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Small Bowel Disorders

Mamuka Zakalashvili
Bowel obstruction
Hernias
Vascular disorders
Small bowel diverticula
Sigmoid colon diverticular disease
Bowel obstruction
1. Small bowel (SB) is the most common site for obstruction.
Due to the small lumen when compared to the large bowel
2. Radiographic findings
a. Bowel distention
b. Air-fluid levels with a step-ladder appearance
c. Absence of air distal to obstruction
3. Clinical findings
a. Colicky pain
Severe pain alternating with pain-free intervals
b. Abdominal distention
c. No rebound tenderness
d. Tympanitic to percussion
e. High-pitched tinkling sounds
4. Treatment is surgery
Small and Large Bowel Obstruction
ETIOLOGIC DISORDER DISCUSSION
Adhesions MCC of small bowel obstruction (60% of cases). Adhesions from previous surgery (most
common), metastasis to the small bowel (second MCC), endometriosis, radiation
Crohn disease Lumen in terminal ileum is narrow because of full-thickness inflammation of bowel
adhesions
Duodenal atresia Atresia is distal to entry of the common bile duct. Association with Down syndrome
History of maternal polyhydramnios. Vomiting of bile-stained fluid at birth. Double bubble
sign: air in stomach and air in proximal duodenum

Gallstone ileus Occurs in elderly women with chronic cholecystitis and cholelithiasis
Fistula develops between gallbladder and small bowel. Stone lodges at the ileocecal valve
causing obstruction. Radiograph shows air in the biliary tree

Hirschsprung disease Absence of ganglion cells in Meissner and Auerbach causes localized aperistalsis.
Male dominant in 80% of cases; occurs in 10% of Down syndrome patients
Usually involves the distal sigmoid and rectum; Clinical findings: chronic constipation;
absent stool on the examining finger, because there is no stool in the rectal vault.
Complication: enterocolitis of dilated bowel (danger of perforation)
Diagnose with rectal suction biopsy; Treatment: surgical resection of affected segment
ETIOLOGIC DISORDER DISCUSSION
Indirect inguinal Second most common cause of small bowel obstruction
hernia Bowel becomes trapped in the inguinal canal
Femoral hernia Highest rate of bowel incarceration
Intussusception Peak incidence ages 15; In children, the terminal ileum invaginates into the cecum
Hyperplastic lymphoid tissue in Peyer patches that project into the lumen serves as the
nidus for the intussusception; may occur with rotavirus oral vaccine
Combination of obstruction and ischemia
Clinical findings: colicky pain with bloody diarrhea; an oblong mass is palpated in the
midepigastrium (Dance sign); usually self-reduces without intervention
May require air reduction under fluoroscopy or ultrasound
In adults, a polyp or cancer is the nidus for intussusception
Meconium ileus Complication of newborn with cystic fibrosis
Meconium lacks NaCI and obstructs the bowel lumen
Volvulus Bowel twists around mesenteric root producing obstruction and strangulation
Sigmoid colon is most common site in elderly
Cecum is the most common site in young adults
Risk factors: chronic constipation (most common), pregnancy, laxative abuse
Case 1
A 3 month old male infant was born at term with no congenital anomalies. His mother has
noted marked abdominal enlargement along with infrequent bowel movements for the
past week. On physical examination his abdomen is distended but there does not appear to
be appreciable tenderness. A plain film abdominal radiograph reveals marked colonic
dilation. What pathologic finding is most likely to be present in this infant?

A Rhabdomyosarcoma - Bowel obstruction from neoplasia is rare in infancy and


childhood.
B congenital bowel malrotation - usually occurs when there has been an abdominal wall
defect (omphalocele or gastroschisis)
C Cecal volvulus - Volvulus in infants usually involves the small intestine with twisting of
the mesentery. Cecal volvulus is more characteristic for adults.
D Ileal intussusception - Lack of bowel movements, vomiting of bilious material, and
abdominal tenderness would be more typical for intussusception.
E Meconium ileus - This condition is typically present at birth, usually in association with
cystic fibrosis, and most often involves the small bowel.
F Aganglionic colonic segment - Hirschsprung disease - submucosal and myenteric
plexuses lack ganglion cells.
Hernias
1. Mechanisms predisposing to acquired hernias
a. Increased intra-abdominal pressure (e.g., coughing, heavy weight lifting)
b. Weakness in the abdominal wall
HERNIA DISCUSSION
Direct Hernia Hernia bulges through floor of triangle of Hesselbach. Bulge disappears when patient
reclines.
Small bowel cannot enter scrotal sac; therefore, there is no obstruction or incarceration
Treatment: sutured mesh covering inguinal canal and Hesselbach triangle

Indirect heria Most common. Pathogenesis in children: persistence of peritoneal connection between
inguinal canal and tunica vaginalis. Pathogenesis in adults: protrusion of new peritoneal
process into inguinal canal
Complications: incarceration or strangulated obstruction (hemorrhagic infarction)
Treatment: Surgical

Femoral Most common in women


Bulge located below inguinal ligament
Highest rate of incarceration of small bowel
Umbilical Most common hernia in adults with ascites (cirrhosis), pregnancy, or obesity
Most common hernia in black newborns
Peritoneal protrusion extends into a fascial defect containing remnants of umbilical cord
Incarceration more likely in adults than children
Ventral Hernia develops in weakened area of previous surgical excision
Obesity most common cause
Vascular disorders

Blood supply of the small and large bowel

a. Areas of bowel supplied by the superior


mesenteric artery
(1) Most of the small bowel
(2) Ascending and transverse colon up to the
left colic flexure (splenic flexure)
(3) SMA and inferior mesenteric artery (IMA)
overlap at the splenic flexure.
Splenic flexure is a watershed area .

b. Areas of bowel supplied by the IMA


(1) Descending and sigmoid colons
(2) Proximal rectum
(3) Upper half of the anal canal
Vascular disorders
Types of infarctions
a. Transmural
(1) Full-thickness hemorrhagic infarction
Usually involves all or part of the small bowel
(2) Usually due to thrombosis of the SMA
b. Mural and mucosal infarctions
Usually occur in hypoperfusion states (e.g., shock)
Vascular disorders
Causes of acute ischemia involving small bowel

Acute mesenteric ischemia (50% of cases)


(1) Embolism from the left side of the heart to the SMA
(a) Atrial fibrillation is the most common predisposing arrhythmia.
(b) SMA has the greatest velocity of blood flow and the most acute angle off the aorta
(2) Thrombosis of the SMA
Nonocclusive ischemia (25% of cases)
(1) Hypotension secondary to heart failure (most common)
(2) Hypovolemic shock
(3) Patient taking digitalis (vasospasm)
Mesenteric vein thrombosis (25% of cases)
(1) Thrombosis states
(a) Polycythemia vera
(b) Antiphospholipid syndrome
(2) Extension of renal cell carcinoma into the vena cava
Vascular disorders
Clinical and radiographic findings of small bowel Treatment
infarction

(1) Surgery for embolic disease


Sudden onset of diffuse abdominal pain
(2) Thrombotic disease
Pain is disproportionate to the physical findings
Anticoagulation and surgery if
Bowel distention necessary
Bloody diarrhea
Absent bowel sounds (ileus)
No rebound tenderness (peritonitis) early in
infarction
Profound neutrophilic leukocytosis
Positive stool guaiac
Radiographic findings
(1) Thumbprint sign due to edema in bowel wall
(2) Bowel distention with air-fluid levels similar to
bowel obstruction
Abdominal CT scan has 90% sensitivity.
Vascular disorders
Ischemic colitis

Splenic flexure of the large bowel is involved.


Watershed area where the SMA distribution ends and the IMA distribution begins
Atherosclerotic narrowing of SMA causes mesenteric angina.
(1) Severe pain occurs in the splenic flexure shortly after eating.
(2) Patient loses weight for fear of pain related to eating.
Clinical findings
(1) History compatible with mesenteric angina
(2) Pain localized to the splenic flexure
Accompanied by bloody diarrhea due to mucosal or mural infarction
(3) Barium study shows thumbprinting of the colonic mucosa.
Due to edema of the mucosa
Normal repair of infarction site may result in fibrosis.
Common cause of ischemic strictures and obstruction in the colon
Vascular disorders
Angiodysplasia

a. Dilation of mucosal and submucosal venules in cecum and right colon


(1) Usually occurs in elderly individuals
(2) Vascular ectasias in the cecum increase with age.
b. Increased wall stress in the cecum stretches the venules.
Recall that the cecum has an increased diameter, increased diameter increases wall stress.
c. Clinical findings
(1) Hematochezia
(2) More likely to bleed if patient has coagulopathy
d. Diagnose with colonoscopy and angiography
e. Treatment
(1) Colonoscopy
(a) Cautery of lesions
(2) Angiography localizes the disease
(3) Right hemicolectomy
(4) Correction of aortic stenosis (if present)
Bleeding often abates
Case 2
62-year-old man has worsening dyspnea and swelling of his legs for the past month. On
physical examination he has pitting edema to the hips as well as sacral edema. Diffuse
wheezing are present in all lung fields. He is afebrile and normotensive. A chest
radiograph shows a markedly enlarged heart along with pulmonary edema and
bilateral pleural effusions. He develops abdominal pain. His stool is positive for occult
blood. Which of the following is most likely to produce this finding in his bowel?

A Adenocarcinoma - typically do not compromise circulation


B Venous thrombosis - can occur in the presence of sepsis and hypercoagulable states
C Volvulus - Volvulus can cause ischemia, but it does not occur frequently, and it has
an acute onset with bowel obstruction
D Incarcerated hernia - can cause ischemia in the segment of trapped bowel, but it is
also likely to present as bowel obstruction
E Ischemia - ischemic enteritis and/or ischemic colitis. Heart disease (probably a
dilated form of cardiomyopathy) led to reduced cardiac output with reduced tissue
perfusion.
Small bowel diverticula
Meckel diverticulum

a. Vitelline (omphalomesenteric) duct remnant


(1) True diverticulum (all layers present)
(2) Mnemonic: 2 inches long, 2 feet from ileocecal valve, 2% of population, 2% symptomatic
b. Contains pancreatic rests and heterotopic gastric mucosa
Increase the risk for bleeding
c. Clinical findings
(1) Newborn finding
Fecal material in umbilical area due to persistence of vitelline duct
(2) Bleeding (most common finding)
(a) Common cause of iron deficiency in newborns and young children
(b) Symptoms usually arise during the first and second year of life
(3) Diverticulitis
Clinically impossible to distinguish Meckel diverticulitis from appendicitis
d. Diagnosis
99mTc nuclear scan identifies parietal cells in ectopic gastric mucosa.
e. Treatment is surgery.
Small bowel diverticula

Small bowel pulsion diverticula

a. Duodenum is most common site.


Wide-mouthed diverticula suggests systemic sclerosis.
b. Complications
(1) Diverticulitis (danger of perforation)
(2) Bacterial overgrowth
May produce bile salt deficiency and vitamin B12 deficiency
Sigmoid colon diverticular disease

Epidemiology
a. Definitionherniations of mucosa and submucosa through the muscularis
b. Incidence in the general public is 35% to 50%.
c. Incidence increases with age.
d. Sigmoid colon is the most common site for diverticula in the entire gastrointestinal
tract.
e. Diverticula are located on the mesenteric border where the vasa recta penetrates
the muscle wall (anatomic weakness site).
Pathogenesis
a. It is due to a low-fiber diet with increased constipation.
b. Area of weakness is where vasa recta penetrate the muscular propria.
Diverticulum is juxtaposed to a blood vessel.
Associations
(1) Marfan syndrome
(2) Ehlers-Danlos syndrome
(3) Adult polycystic kidney disease
Sigmoid colon diverticular disease

Clinical findings

Diverticulitis - most common complication.


(1) Caused by stool impacted (fecalith) in diverticulum sac
Produces ulceration and ischemia
(2) Clinical findings
(a) Fever
(b) Diarrhea initially followed by constipation
(c) Left lower quadrant pain (left-sided appendicitis)
(d) Tender mass is palpated in some cases
(3) Best diagnosed with CT scan or water-soluble barium study
(4) Increased risk for perforation and abscess formation
(5) Most common cause of fistula formation (connection between hollow structures)
Sigmoid colon diverticular disease
Clinical findings

Diverticulosis
(1) Painless bleeding (hematochezia), is characteristic.
Usually caused by erosion of juxtaposed vessel by a fecalith
(2) Bleeding stops spontaneously in 60% of cases.
(3) Sigmoid diverticulosis is the most common cause of hematochezia.
Scarring of the juxtaposed vessel in recurrent attacks of diverticulitis prevents bleeding.
Treatment
a. Nonpharmacologic
Increase fiber in diet to prevent constipation
b. Antibiotics for acute disease
c. Colonic resection in selected cases
Examplesrepeated episodes of diverticulitis; bleeding that does not stop; abscess/fistula formation;
obstruction
Case 3
A 4-year-old girl has the sudden onset of abdominal pain and
vomiting. She has a oblong mass in the right lower quadrant and
hyperactive bowel sounds. Which of the following is the most likely
diagnosis?

(A) Appendicitis
(B) Intussusception
(C) Meckel diverticulum
(D) Necrotizing enterocolitis
(E) Strangulated hernia
The most important points
SB obstruction: bowel distention; air/fluid levels; colicky pain; adhesions from previous
surgery
Hernias: Increased intra-abdominal pressure; weakness in the abdominal wall; Indirect
inguinal hernia - MC hernia
SMA and IMA junction: watershed area
Occlusion SMA (thrombus/embolus): MCC SB infarction
SB infarction: sudden onset diffuse abdominal pain, bloody diarrhea; distention, absent
bowel sounds, no rebound tenderness;
Ischemic colitis: splenic flexure pain after eating fear of eating and weight loss
Angiodysplasia: dilation of cecal submucosal venules; 2d MCC of hematochezia; more
likely to bleed if genetic/acquired vWD present;
Meckel diverticulum - Vitelline duct remnant; 2s rule; mimics acute appendicitis
SB diverticula: duodenum MC site
Sigmoid diverticular disease: herniation mucosa/submucosa through muscularis;
mesenteric border; area of weakness where vasa recta penetrate; constipation MCC;
Sigmoid diverticulitis MC complication; left-sided appendicitis; CT scan best for Dx
Sigmoid diverticulosis: MCC hematochezia and fistulas