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10- small intestine

10- small intestine

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SMALL INTESTINE AND APPENDIX
Anatomy
The small intestine is divided into three regions: duodenum, jejunum and ileum.
The duodenum is the first part of the small intestine and most of it is deeply
placed on the posterior abdominal wall.
It is situated in the epigastric and umbilical regions. It is a C-shaped tube that
extends from the stomach around the head of the pancreas to join the jejunum.
About halfway down its length it receives the bile and the pancreatic ducts.
The jejunum and ileum measure about 6 m. long, the upper two-fifths of this
length being the jejunum.
The jejunum begins at the duodenojejunal junction and the ileum ends at the
ileocecal junction.

The coils of jejunum occupy the upper left part of the abdominal cavity, while the ileum tends to occupy the lower right part of the abdominal cavity and the pelvic cavity.

The jejunum is larger in diameter, thicker walled, has more prominent plicae
circulares (mucosal folds) and has less mesenteric fat than the ileum.
The arterial supply to the small bowel is primarily from the jejunal and ileal
branches of the superior mesenteric artery.
Layers of the small bowel

The mucosa is composed primarily of columnar epithelium with goblet cells. The absorbtion of nutrients takes place through the mucosa. The mucosa covers the intestinal villi and has an absorption area of 500 m2.

The submucosa is the strongest layer and provides strength to an intestinal anastomosis. It contains nerves, Meissner\u2019s plexus, blood vessels and fibrous and elastic tissue.

The muscularis- the muscle layer is composed of an outer longitudinal layer and
an inner circular layer with Auerbach\u2019s myenteric plexus.
The serosa is the outermost layer and derives embriologically from the
peritoneum.
Physiology

The primary functions of the small bowel are digestion and absorbtion. All ingested food and fluid and also secretions from the stomach, liver and pancreas, reach the small intestine. The total volume may reach 9 l. a day and all but 1-2 l. will be absorbed.

2Motility
Two types of contractions occur following a meal.
To-and-fro motion mixes chyme with digestive juices and provides prolonged
exposure to the absorbative mucosa.
Peristaltic contractions move food distally.
Parasympathetic stimulation promotes contractions while sympathetic
stimulation inhibits them.
Absorbtion
Vitamines, fat, protein, carbohydrates, water and electrolytes are all absorbed in
the small intestine.
Investigations of Small Bowel Disorders
Radiology
Plain erect and supine abdominal films, whilst invaluable in the diagnosis of

acute surgical disorders such as intestinal obstruction and perforations are of limited practical use in the investigation of chronic symptoms referable to the small intestine.

Barium sulphate small bowel follow through(SBFT) is the established

investigation designed to outline the small intestine.The small bowel is radiographed at periodic intervals and fluoroscopically spotted by the attending Radiologist. This type of SBFT can take hours to complete and detail of the lumen cannot be assessed as the loops of small intestine overlap as the barium progresses.

Enteroclysis

A better diagnostic tool would be an enteroclysis small bowel exam. "Entero" is Greek for intestine. "Clysis" is Greek for washing out. Thus, enteroclysis is washing out of the intestine.

With this in mind, an Enteroclysis study of the small bowel is a minimally invasive radiographic procedure of the small intestine, which requires the introduction of a catheter into the small intestine followed by the injection of barium and methylcellulose. The barium coats the intestine and the methylcellulose distends the lumen to give a double contrast. This allows visualization of the entire small bowel.

The enteroclysis study may be helpful in diagnosing almost all diseases that affect the small bowel. It may also be helpful in ruling out diseases in patients with unexplained abdominal complaints. There are several different indications for an enteroclysis study of the small bowel which include:

1. Suspected or known small bowel obstruction
2. Neoplasms (cancers)
3
3. Inflammatory bowel disease
4. Unexplained gastrointestinal bleeding

5. Malabsorption
6. Polyps
7. Adhesive bands

8. Post surgical changes

The Radiologist may not be able to determine a diagnosis of a disease by radiographic findings only. Some diseases cause very subtle changes on radiographs, so it is beneficial to obtain a complete medical history from the patient prior to the exam. When obtaining the patients information it is

recommended to obtain at least the following history:
1. Any abdominal pain, with location and length of symptoms
2. Diarrhea, or change in bowel movements
3. The presence of dark or tarry stools (indication bleeding)
4. Anemia (If possible get the most recent lab test results)
5. Any history of bowel obstructions
6. Weight loss or gain
7. Types and dates of abdominal surgeries
8. Types of previous test including endoscopes, lab tests, and other x-rays

Disadvantages

There are two drawbacks to the enteroclysis small bowel follow through which need to be weighed carefully by the ordering physician and the radiologist. The disadvantages are:

1. The placement of the enteroclysis catheter is the largest disadvantage. It can be uncomfortable for the patient, even with the use of anesthetic spray and Xylocaine jelly or a similar lidocaine product.

2. The patient will receive higher doses of radiation in comparison to the
traditional small bowel follow through exam during this exam.

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