Diseases of the

Small Intestine
KATHRYN CECILLE R. UMALI-GOMEZ, MD, FPCS, FPSGS

AUF - SCHOOL OF MEDICINE

06 November 2020
ANATOMY REVIEW
 SMALL INTESTINE
• Principle site of nutrient digestion &
absorption

• Largest reservoir of
immunologically-active & hormone-
producing cells

• largest organ of immune system &

endocrine system

• extends from pylorus → cecum

• est. length = 4-6 meters

• SNS = Splanchnic nerves

• PNS = vagus nerve

 ARTERIAL VENOUS
PARTS BORDERS FEATURES
SUPPLY DRAINAGE

Celiac Plexus
(D1)
Most proximal segment
Pylorus →
Retroperitoneal
DUODENUM Ligament of
Adjacent to head & inferior
Treitz
border of pancreatic body

Larger circumference
Superior
Ligament of Thicker wall
Mesenteric
JEJUNUM Treitz → Longer vasa recta Superior
Vein
proximal 40% More plicae circulares Mesenteric
less fatty mesentery Artery

Smaller circumference
Thinner wall
Distal 60% —>
ILEUM Shorter vasa recta
Ileocecal Valve
Lesser plicae circulares
(+) PEYER’ S PATCHES
 Contents
• Volvulus

• Intestinal Polyps
• Diverticular Disease:

• Infections:

• Meckel’s Diverticula

• Intestinal • Acquired Diverticula

Tuberculosis

• Inflammatory Bowel
Disease:

• Amoebic Colitis

• Crohn’s Disease

• Typhoid Enteritis
• Ulcerative Colitis
INTESTINAL POLYPS
 INTESTINAL POLYPS
• Present in 0.2-0.3%

• Majority are asymptomatic

• Benign = 30-50%

• Only 1.1 - 2.4% of all GI cancers

• Most common = Duodenum

• ADENOMA - most common

benign neoplasm

• others: fibromas, lipomas,

hemangiomas, lymphangiomas,
neurofibromas
 Intestinal Polyps
• PRIMARY SMALL BOWEL CA:

• Rare, 5th-6th decade

• ADENOCARCINOMA - most
common (50%), arise from pre-
existing adenomas

• CARCINOID TUMORS (20-40%)

• LYMPHOMAS (10-15%)

• GIST - most common

mesenchymal tumor in SI
(leiomyomas, leiomyosarcomas,
smooth muscle tumors)
 Intestinal Polyps
• SI are frequently affected by
metastasis / local invasion from other
CA

• RISK FACTORS:

• Eating red meat

• Eating smoked / cured food

• Crohn’s Disease

• Celiac Sprue

• HPNCC

• FAP (100% Lifetime risk)

• Peutz-Jehger’s Syndrome
 Reasons for ↓ Frequency of SI
Neoplasms
• Dilution of environmental carcinogens in liquid chyme present in small
intestinal lumen

• Rapid transit of chyme, ↓ contact time between carcinogens &

intestinal mucosa

• Relatively ↓ concentration of bacteria in chyme → ↓ concentration of

carcinogenic byproducts of bacterial metabolism

• Mucosal protection by secretory IgA and hydrolases that may render

carcinogens ↓ active

• Efficient epithelial cellular apoptotic mechanisms → eliminates clones

harboring genetic mutations
 Intestinal Polyps: Clinical Presentation

• HISTORY:

• Most are asymptomatic until large

• Most common Sx: Partial SBO,

crampy abdominal pain, distention,
nausea & vomiting

• 2nd most common: Indolent

hemorrhage

• Obstruction 2º to luminal narrowing /

intussusception
 Intestinal Polyps: Clinical Presentation

• PE:

• Palpable abdominal mass (25%)

• Intestinal obstruction (25%)

• FOBT (+)

• Jaundice 2º to biliary
obstruction / hepatic metastasis

• Cachexia, hepatomegaly, ascites

= advanced disease
 Intestinal Polyps: Diagnosis

• LAB TESTS:

• ↑ 5-HIAA - in Carcinoid
Syndrome

• CEA - ↑ in SI AdenoCA only if (+)

liver metastasis
 Intestinal Polyps: Diagnosis
• IMAGING:

• Contrast Radiography

• Enteroclysis

• Upper GI Series + Follow Through Exams

• CT Scan

• Angiography / RBC Tagging

• EGD

• Endoscopic Ultrasound (EUS)

• Colonoscopy

• Intraoperative Enteroscopy

• Capsule Endoscopy & Double Balloon

Endoscopy
 Intestinal Polyps: Diagnosis
• IMAGING:

• Contrast Radiography - may

demonstrate benign & malignant
lesions

• Enteroclysis - > 90% sensitive,

test of choice for tumors in distal
SI

• Upper GI Series + Follow

Through Exams - 30-40%
sensitive

• CT Scan - ↓ sensitive for

intramural / mucosal lesions

• for large tumors, staging CA

 Intestinal Polyps: Diagnosis

• IMAGING:

• Angiography / RBC Tagging -

tumors with bleeding

• EGD - tumors in duodenum

• Endoscopic Ultrasound (EUS) -

for duodenal tumors, can see SI
wall layers involved in lesion

• Colonoscopy - for tumors in

distal ileum
 Intestinal Polyps: Diagnosis

• IMAGING:

• Intraoperative Enteroscopy -
directly visualize SI tumors
beyond reach of standard
endoscopy

• Capsule Endoscopy & Double

Balloon Endoscopy
 Intestinal Polyps: Treatment

• BENIGN TUMORS:

• If symptomatic → Surgical
resection / endoscopic
removal

• DUODENAL TUMORS:

• Biopsy all tumors

Intestinal Polyps: Treatment
DUODENAL TUMORS MANAGEMENT

Symptomatic tumors Must be surgically removed due to malignant potential

& Adenomas Do surveillance EGD after (can recur)

Tumors < 1 cm Endoscopic polypectomy

Do EUS → if tumor limited to mucosa → do Endoscopic

Tumors 1-2 cm
Polypectomy

Surgical Removal: 1. Transduodenal Polypectomy

Tumors > 2 cm
2. Segmental Duodenal Resection
 Intestinal Polyps: Treatment
• DUODENAL TUMORS IN FAP:
FAMILIAL ADENOMAL
POLYPOSIS

• Screening EGD started during

2nd-3rd decade of life

• Endoscopic removal of all

detected adenomas

• Surveillance endoscopy in 6
months → annually

• If Surgery Required:
Pancreaticoduonenectomy
Intestinal Polyps: Treatment
DUODENAL TUMORS MANAGEMENT

In D2 near Ampulla of
Vater

Duodena AdenoCA Pancreaticoduodenectomy (Whipple’s)

AdenoCA in D3 or D4
 Intestinal Polyps: Types

• MALIGNANT TUMORS:

• ADENOCARCINOMA

• CARCINOID TUMORS

• LYMPHOMA

• GIST
 Intestinal Polyps: Types
• ADENOCARCINOMA:

• Cell of origin: Epithelial cell

(Adenomas)

• Frequency: 35-50%

• Site: Duodenum

• except in Crohn’s Disease

(found in ileum)

• Features:

• Periampullary lesions = earlier

diagnosis than lesions in distal
bowel
 Intestinal Polyps: Treatment
JEJUNAL /
MANAGEMENT
ILEAL CA

Symptomatic
Wide local resection of intestinal
tumors &
segment harboring lesion
Adenomas

Adenocarcin Wide load resection + mesentery to

oma achieve regional lymphadenectomy

Adenocarcin
Palliative intestinal resection /
oma (Locally
Bypass

advanced /
Chemotherapy = no proven efficacy
metastasis
 Intestinal Polyps: Types
• CARCINOID TUMORS:

• Cell of origin: Enterochromaffin cell

• Frequency: 20-40%

• Site: Ileum

• Features:

• Usually diagnosed after

metastasis

• ↑ aggressive than appendiceal

carcinoids

• 20-50% of patients with liver metz

will develop Carcinoid Sydrome
Intestinal Polyps: Treatment
CARCINOIDS MANAGEMENT

Resection of all visible disease

Segmental intestina resection +

regional lymphadenectomy

Localized
Examine entire SI prior to
planning extent of resection
(can be multiple in 30%)

TUMOR DEBULKING -
associated with ↑ long-term
survival & ↓ symptoms of
carcinoid syndrome

CHEMOTHERAPY = (+)
Metastatic response rates of 30-50% →
Doxorubicin, 5-FU,
Streptozocin

OCTREOTIDE - for
management of Carcinoid
Syndrome
 Intestinal Polyps: Types
• LYMPHOMA

• Cell of origin: Lymphocyte

• Frequency: 10-15%

• Features:

• May involve SI 1º or as part of

systemic disease

• Partial SBO ← most common

presentation

• 10% = will have bowel

perforation
Intestinal Polyps: Treatment
LYMPHO
MANAGEMENT
MA

Segmental resection of involved intestine

Localized
+ adjacent mesentery

Diffuse CHEMOTHERAPY - primary treatment

 Intestinal Polyps: Types
• GIST

• Cell of origin: Interstitial cell of

Cajal

• Frequency: 25% - 35%

• Features:

• 2nd most common site of GIST

• 1st = stomach

• ↑ presentation with overt

bleeding
 Intestinal Polyps: Treatment
GIST MANAGEMENT

SEGMENTAL INTESTINAL
RESECTION

IMATINIB - tyrosine kinase inhibitor

Localized with activity vs tyrosine kinase IT

GOOD PROGNOSIS: Low grade

tumors (↓ mitotic index < 10/HPF),
diameter < 5 cm

IMATINIB - 80% have (+) benefit

Unresectable
50-60% with objective evidence of ↓
/ Metastatic
reduction in tumor volume

Resistant to SUNITINIB - alteratlive tyrosine kinase

Imatinib inhibitor

PALLIATIVE RESECTION / BYPASS

Metastatic
(except in most advanced cases)

CA affecting
SYSTEMIC THERAPY (if effective
SI
chemotherapy exists)
Intestinal Polyps: Prognosis
TUMOR EXTENT OF RESECTION 5-YEAR SURVIVAL RATE

Complete resection (Duodenum) 50-60%

ADENOCA
Complete resection (Jejunum / Ileum) 20-30%

Localized 75-95%
CARCINOIDS
Tumor-derived liver metastasis 19-54%

Intestinal lymphoma 60%

LYMPHOMA
Diffuse Intestinal Lymphoma 20-40%

Complete resection 35-60%

GIST
Recurrence rate after resection 35%
SMALL INTESTINAL
INFECTIONS
 Contents
• Volvulus

• Intestinal Polyps

• Diverticular Disease:

• Infections:
• Meckel’s Diverticula

• Intestinal • Acquired Diverticula

Tuberculosis
• Inflammatory Bowel
Disease:

• Amoebic Colitis
• Crohn’s Disease

• Typhoid Enteritis
• Ulcerative Colitis
Intestinal TB
 INTESTINAL TB (GI TB)
• Mycobacterium tuberculosis
• Obligate aerobe, intracellular with
slow-growth

• acid fast bacillus

• Primarily pulmonary infections

• Infects 1/3 of world population

• Previously 70% of patients with

PTB → GI TB

• Currently = < 1% progress to GI TB

• Invade GIT through swallowing /

contaminated foods or implements
 Intestinal TB
• MDR-TB - resistance to at least 2
of the 1st line anti-mycobacterial
drugs (INH, Rifampin)

• RR-TB - Rifampin-resistant but

INH-susceptible

• XDR-TB - Extensively Drug-

Resistant TB, rare

• resistant to INH, Rifampin,

Fluoroquinolones, Capreomycin,
Amikacin, Kanamycin
 Intestinal TB
• PATHOGENESIS:

• Invades lymphoid tissue of

GIT

• ↑ in Peyer Patches &

terminal ileum

• Most Common Sites: Distal

Ileum & Cecum

• 2 TYPES:

• ULCERATED

• HYPERTROPHIC
 Intestinal TB: Types
• ULCERATED TYPE:

• More common

• Lymphoid follicles of a Peyer

Patch invaded → ulceration
develops

• necrotic base forms in ulcer →

Perforates

• Multiple nodules form around

the ulcer → spread to
peritoneum
 Intestinal TB: Types
• HYPERTROPHIC TYPE:

• Lymphoid follicles of a Peyer

Patch invaded → extensive
granular formation & fibrosis

• NAPKIN RING Formation

• Mimics carcinoma

• TUBERCULOUS PERITONITIS -
from dissemination / direct
extension

• CASEATING GRANULOMAS -
characteritic
 Intestinal TB: Clinical
• HISTORY:

• Abdominal pain

• Fever, anorexia, diarrhea, weight

loss, constipation, bloating,
hemorrhage

• DIAGNOSIS:

• Biopsy through EGD /

laparoscopy

• DIFFERENTIALS: Crohn’s Disease,

Lymphoma, CA, Diverticulitis, AP,
Yesinia, CMV, etc.
 Intestinal TB: Clinical
• DIAGNOSTIC CRITERIA:

• Growth of the organism from

infected tissue

• Histologic demonstration of M.
tuberculosis in tissue

• Histologic demonstration of
granulomas with caveating
necrosis

• Typical gross pathologic findings in

bowel

• Histologic findings of granulomas

with caseation necrosis in
associated LN
 Intestinal TB: Treatment

• ANTIMYCOBACTERIAL
THERAPY

• same as PTB

• INH, Rifampin Pyrazinamide ±

ethambutol / streptomycin x 6
months

• PROGNOSIS:

• May be fatal in HIV patients

Amoebic Colitis
 AMOEBIC COLITIS
• Entamoeba histolytica

• 3rd most common parasitic

disease

• Spread: Fecal-Oral Route

(contaminated food & water)

•↑ infection rates in countries with

poor sanitation

• takes 1 cyst to cause infection

• Entamoeba dispar - non-invasive,

limited to intestine

• infection rate is 7-10x ↑

 Amoebiasis
• Fecal-Oral Route

• most common = Intestinal Disease

• Ingestion of cysts → trophozoites

released from cysts → spread
through colonic mucosa → Portal
Circulation:

• Liver → LIVER ABSCESS

• most common = Right Lobe

• Vascular Tree → BRAIN

ABSCESS, Lung abscess, etc.
 Amoebiasis: Clinical
• HISTORY:

• Only 10% are symptomatic

• Diarrhea (mild / full blown colitis)

• Bloody BM, tenesmus, cramps

• Fever (40%)

• FULMINANT TOXIC COLITIS - can

cause colonic perforation

• LIVER ABSCESS - most common

complication, can rupture in 2-5%

• PLEUROPULMONARY
COMPLICATIONS - 10%
 Amoebiasis: Diagnosis

• FECALYSIS - cysts / trophozoites

in patient’s stool

• may be normal in patients with

extraintestinal disease

• SEROLOGIC TESTING - accurate

in 85-95%

• ↑ titer = ↑ length of disease

 Amoebiasis: Treatment
• ACUTE COLITIS / SYMPTOMATIC
DISEASE:

• METRONIDAZOLE 750 mg x 7-10

days

• AMEBIC LIVER ABSCESS:

• METRONIDAZOLE 750 mg TID x

7-10 days → fever resolves in few
days, abscess resolves in few months

• PERCUTANEOUS ASPIRATION -

• large abscesses / superinfection

• Refractory to medical therapy

• Abscesses in L lobe than may

rupture into pericardium
Typhoid Enteritis
 TYPHOID ENTERITIS

• a.k.a. Typhoid Fever / Enteric

Fever

• Salmonella typhi
• Purely human disease

• Transmission: Human feces / urine,

transmitted from flies / shellfish

• 30% in developing countries

 Typhoid Enteritis: History
• 1st WEEK: Fecal-Oral Route →
filtered through Peyer Patches & LN
of SI → Incubation period of 7-14
days

• High fever, headache, abdominal

pain

• Bradycardia

• Abdominal pain 2º to swollen

Peyer Patches & LN:

• Periumbilical, RLQ, or Diffuse

• Splenic enlargement, palpable

• Diarrhea (50%)
 Typhoid Enteritis: History
• 1st WEEK:

• ROSE SPOTS - develop on chest /

abdomen (30%)

• 2nd WEEK:

• High fever

• Patient is debilitated

• 3rd WEEK:

• Severe anorexia, dehydration,

debilitation

• PEA SOUP STOOL

• Abdominal distention, pain

 Typhoid Enteritis: History

• 4th WEEK: (In untreated patients)

• Gradual Improvement

• Temperatures ↓

• Untreated severe disease = 4

weeks to a month

• May be fatal in 30%

 Typhoid Enteritis: History

• COMPLICATIONS: Usually in 3rd -

4th week

• INTESTINAL PERFORATION -
occurs at site of ulceration from
infected lymphoid tissue

• Endocarditis, pericarditis, liver &

splenic abscesses, spontaneous
splenic rupture

• CHRONIC CARRIER STATE -

1-14%
 Typhoid Enteritis: Diagnosis

• BLOOD / STOOL / URINE

CULTURE - isolate S. typhi (50%)

• BONE MARROW ASPIRATION -

for severe anemia / leukopenia

• PUNCH BIOPSIES of Rose Spots

• CULTURE TESTING (Zero-WIDAL

Test) - ↑ in 2nd - 3rd week of
illness
 Typhoid Enteritis: Treatment

• CHLORAMPHENICOL - ↓
mortality to 1% & ↓ fever duration
to 3-5 days

• For resistant organisms:

• Ciprofloxacin, Amoxicillin,
Quinolone, 3rd Gen
Cephalosporins
 Contents
• Volvulus
• Intestinal Polyps

• Diverticular Disease:

• Infections:

• Meckel’s Diverticula

• Intestinal • Acquired Diverticula

Tuberculosis

• Inflammatory Bowel
Disease:

• Amoebic Colitis

• Crohn’s Disease

• Typhoid Enteritis
• Ulcerative Colitis
VOLVULUS
 VOLVULUS

• Air-filled segment of Intestine twists

about its mesentery

• In Sigmoid, Cecum, & Transverse

colon

• May reduce spontaneously

• Bowel obstruction → strangulation

→ gangrene → perforation

• Up to 40% Risk of Recurrence

 Volvulus
• TYPES:

• Small Intestine:

• MALROTATION

• INTERNAL HERNIATION

• Colon:

• CECAL VOLVULUS

• TRANSVERSE COLON
VOLVULUS

• SIGMOID VOLVULUS
SI Volvulus
 INTESTINAL MALORATION
• Incomplete rotation of midgut in 6th
week AOG

• Leads to MIDGUT VOLVULUS

• occurs at any age

• most common = first weeks of

life

• Assoc:

• BCL6 Gene - malrotation, situs

inversus

• FOXF1 Gene - formation of

dorsal mesentery
 Intestinal Malrotation
• CHARACTERISTICS:

• Cecum in Epigastrium

• LADD’S BANDS - extend from

cecum → across duodenum →
lateral abdominal wall

• fix the cecum & duodenum to

retroperitoneum

• Narrow pedicle suspending all

branches of SMA & entire midgut
→ MIDGUT VOLVULUS
 Intestinal Malrotation
• MIDGUT VOLVULUS

• occurs in clockwise direction

• needs high index of suspicion

• Early surgical intervention:

• LADD’S PROCEDURE

• Detort volvulus in
Counterclockwise direction

• Divides Ladd’s Bands

• Brings Duodenum into RLQ &

Cecum into LLQ

• Appendectomy - to eliminate
diagnostic errors later in life
 INTERNAL HERNIATION
• Loop of SI enters a peritoneal /
mesenteric aperture

• Congenital

• Iatrogenic defects (s/p gastric

bypass / liver transplant)

• Symptomatic / asymptomatic

• CLASSIFICATION:

• Paraduodenal Hernia

• Pericecal Hernia

• Intersigmoid Hernia

• Transmesenteric Hernia
 Internal Herniation
• PARADUODENAL HERNIAS

• most common

• Left-sided in 75%

• herniate into Fossa of

Landzert (left of D4)

• Right sided in 25%

• herniate Mucoparietal fossa of

Waldeyer (inferior to D3)
Colonic Volvulus
 Cecal Volvulus
• Involved in < 20%

• from non-fixation of the R Colon

• Rotation around Ileocolic vessels →

early vascular impairment

• CECAL BASCULE - (10-30%), Cecum

folds upon itself

• DIAGNOSIS:

• Mass in RLQ

• X-RAY - Kidney-shaped air-filled

structure in LUQ (opposite
obstruction)

• GASTROGRAFIN ENEMA - confirms

obstruction at level of volvulus
Cecal Bascule
 Transverse Colon Volvulus

• Extremely rare

• Non-fixation of the colon + chronic

constipation with megacolon

• DIAGNOSIS:

• SFA X-RAY - resembles sigmoid

volvulus

• GASTROGRAFIN ENEMA -
shows more proximal obstrution
 Sigmoid Volvulus
• Most common (90%)

• DIAGNOSIS:

• SFA X-RAY - BENT INNER

TUBE / COFFEE BEAN SIGN

• convexity of loop lies in RUQ

opposite side of obstruction

• GASTROGRAFIN ENEMA -
BIRD’S BEAK NARROWING at
site of volvulus
 Volvulus
• TREATMENT:

• Resuscitation

• SIGMOID VOLVULUS:

• ENDOSCOPIC DETORTION - if
(-) signs of gangrene / perforation

• Insert Rigid Proctoscope →

decompress → Insert Rectal
Tube to maintain
decompression

• do Elective Sigmoid
Colectomy / Ileocecal
resection after patient is
stabilized
 Volvulus
• TREATMENT:

• SIGMOID VOLVULUS:

• EXPLORATORY
LAPAROTOMY +
DETORSION - in unstable
patients or with gangrene /
perforation

• HARTMANN’S RESECTION -
Removal of Sigmoid Colon +
Double barrel Colostomy
 Volvulus
• TREATMENT:

• CECAL VOLVULUS:

• RIGHT HEMICOLECTOMY +
END TO END ANSTOMOSIS

• treatment of choice, prevents

recurrence

• DETORSION + CECOPEXY -
40% recurrence rate (not
encouraged)
 Contents
• Volvulus

• Intestinal Polyps

• Diverticular Disease:

• Infections:

• Meckel’s Diverticula

• Intestinal • Acquired Diverticula

Tuberculosis

• Inflammatory Bowel
Disease:

• Amoebic Colitis

• Crohn’s Disease

• Typhoid Enteritis
• Ulcerative Colitis
DIVERTICULAR
DISEASE
MECKEL’S DIVERTICULUM
• Most common congenital anomaly
of the GIT

• affects 2% of population

• in ileum, within 100 cm of ileocecal

valve

• 60% contain heterotypic mucosa

• gastric mucosa > pancreatic acini >

Brunner’s glands > pancreatic islet
cells, colonic mucosa,
endometriosis, HBT tissues

• RULE OF 2: 2% prevalence, 2:1 male

predominance, 2 feet proximal to
ileocecal valve, 50% of symptomatic
are < 2 years old
 Meckel’s Diverticulum
• PATHOPHYSIOLOGY:

• Failure / incomplete obliteration of

Omphalomesenteric / Vitelline Duct

• Other conditions:

• Omphalomesenteric fistula

• Enterocyst

• Fibrous band connecting to

umbilicus

• Remnant of left vitelline artery

→ MESODIVERTICULAR
BAND tethering Meckel’s
Diverticulum to ileal mesentery
 Meckel’s Diverticulum
• PRESENTATION: as Complications

• 4-6% lifetime risk, does not

change with age

• BLEEDING - from ileal mucosal

ulceration from heterotopic
gastric mucosa

• most common presentation

in Pedia (>50%)

• rare in patients > 30 y/o

 Meckel’s Diverticulum
• PRESENTATION:

• INTESTINAL OBSTRUCTION -
most common presentation in
adults

• volvulus of intestine around

fibrous band attaching
diverticulum to umbilicus

• Entrapment of intestine by
mesodiverticular band

• Intussusception with
diverticulum acting as lead point

• Stricture 2º to chronic
diverticulitis
 Meckel’s Diverticulum
• PRESENTATION:

• DIVERTICULITIS - present in
20% of symptomatic patients

• same presentation as Acute

Appendicitis

• NEOPLASMS - most common =

CARCINOID TUMOR

• in 0.5-3.2% of symptomatic
resected diverticula

• LITTRE’S HERNIA - in inguinal /

femoral hernia sacs →
strangulation
 Meckel’s Diverticulum
• PRESENTATION:

• Incidental finding on imaging,

endoscopy, or surgery

• CT SCAN - Low accuracy

• ENTEROCLYSIS - 75% accurate

but N/A during acute complications

• RADIONUCLIDE SCAN - (+) when

diverticulum contains ectopic gastric
mucosa

• (+) 90% of pedia cases, < 50% of

adults

• ANGIOGRAPHY - for sites of

bleeding during hemorrhage
 Meckel’s Diverticulum
• TREATMENT:

• Symptomatic Diverticula →
DIVERTICULECTOMY +
removal of associated bands

• Bleeding Diverticula / Inflamed /

Perforated base → Segmental
Ileal Resection + adjacent
peptic ulcer

• Asymptomatic →
PROPHYLACTIC
DIVERTICULECTOMY esp. with:

• narrow base, attached to

bands
ACQUIRED DIVERTICULUM
• False diverticula

• Walls = Mucosa + submucosa, (-)

complete muscularis

• cause: acquired abnormalities of

intestinal smooth muscle /
dysregulated motility → herniation
of mucosa & submucosa through
weakened areas of muscular

• Asymptomatic unless (+)

complications (6-10%)
 Acquired Diverticulum

• ASSOCIATED WITH: Bacterial

Overgrowth, leading to:

• Vitamin B12 Deficiency

• Megaloblastic anemia

• Malabsorption

• Steatorrhea
 Duodenal Diverticula
• most common

• Location: Near ampulla

(PERIAMPULLARY /
JUXTAPAPILLARY / PERIVATERIAN)

• 75% in medial wall of duodenum

• Prevalence: 23%, rare in patients <

40y/o

• Complications:

• Distend with intralumina debris →

compress CBD → obstructive
jaundice / pancreatitis

• Cholangitis, choledocholithiasis
 Duodenal Diverticula

• DIAGNOSIS:

• Incidental finding on EGD /

Surgery

• ULTRASOUND - can be mistaken

for pancreatic pseudocysts, fluid
collections, biliary cysts, etc.

• UPPER GI X-RAY - best diagnosis

 Jejunoileal Diverticula
• Location:

• 80% = jejunum (large, multiple,

mesenteric side)

• 15% = ileum (small, solitary)

• 5% = both jejunum & ileum

• Prevalence: 1-5%, ↑ with age

• mean age = 6-7th decades

• Complications:

• Intussusception, SBO, abdominal

pain, flatulence, diarrhea, diverticulitis,
constipation, hemorrhage, perforation,
malabsorption
 Jejunoileal Diverticula

• DIAGNOSIS:

• Incidental finding on imaging,

EGD, surgery

• ENTEROCLYSIS - most sensitive

 Acquired Diverticulum
• TREATMENT:

• Asymptomatic - no treatment

• Bacterial Overgrowth - Antibiotics

• Bleeding / Diverticulitis:

• Jejunoileal → Segmental intestinal

resection

• Lateral Duodenal →
Diverticulectomy

• Medial Duodenal → Non-operative

(if possible)

• Lateral Duodenotomy +
Oversewing + Wide Drainage
 Contents
• Volvulus
• Intestinal Polyps

• Diverticular Disease:

• Infections:
• Meckel’s Diverticula

• Intestinal • Acquired Diverticula

Tuberculosis

• Inflammatory Bowel
Disease:
• Amoebic Colitis

• Crohn’s Disease
• Typhoid Enteritis
• Ulcerative Colitis
INFLAMMATORY
BOWEL DISEASE
 INFLAMMATORY BOWEL DISEASE
(IBD)
• Includes: CROHN’S DISEASE,
ULCERATIVE COLITIS, &
Indeterminate Colitis

•↑ in US, Northern Europe

•↓ in Asia, Africa, South America

• ETIOLOGY:

• Autoimmune disease / defect in

intestinal immune system

• 30-50% hereditary

• defect in gut mucosal barrier → ↑

exposure to intraluminal bacteria,
toxins → ↑ intestinal inflammation
INFLAMMATORY BOWEL DISEASE
(IBD)
Crohn’s Disease
 CROHN’S DISEASE
• Chronic, idiopathic transmural
inflammatory disease

• Can involve any part of GIT, but ↑

in distal ileum

• Small bowel = 80%, (ileocecal)

• Small bowel alone = 15-30%

• Colon alone = 20%

• Perianal & anorectal = 5-10%

• Rare sites: esophagus,

duodenum, stomach
 Crohn’s Disease

• PREVALENCE:

• ↑ in females, bimodal (3rd & 6th

decades of life)

• 15x ↑ chance if (+) affected 1st

degree relative

• ↑ in smokers

• IBD1 locus chr 16 = NOD2 gene

 Crohn’s Disease

• PATHOLOGY:

• Sustained GIT inflammation

2º to abnormal epithelial
barrier function / immune
dysregulation

• Hallmark = focal transmural

inflammation of intestine

• Pathognomonic feature = FAT

WRAPPING
 APTHOUS ULCER
- earliest characteristic lesion
- superficial ulcer ≤ 3 mm
surrounded by halo of erythema
- arise over lymphoid aggregates
GRANULOMAS
- (+) in 70%
- Non-caseating, in areas of active
disease, any layer of bowel wall &
mesenteric LN
 APTHOUS ULCER GRANULOMAS
- earliest characteristic lesion - (+) in 70%
- superficial ulcer ≤ 3 mm - Non-caseating, in areas of active
surrounded by halo of erythema disease, any layer of bowel wall &
- arise over lymphoid aggregates mesenteric LN

APTHOUS ULCERS coalesce

STELLATE SHAPED ULCERS:

LINEAR / SERPIGINOUS ULCERS - multiple ulcers coalesce & fuse longitudinally
COBBLESTONE APPEARANCE - from transverse coalescence of ulcers

Transmural inflammation → serosal adhesions between inflamed loops of bowel &

adjacent organs → fibrosis with stricture formation → intraabdominal abscesses →
fistulas → peritonitis
Crohn’s Disease
• SKIP LESIONS - inflammation
affecting discontinuous portions
of intestine, separated by
normal-appearing intestine

• FAT WRAPPING -
pathognomonic

• encroaching mesenteric fat

onto serial surface of bowel

• helps identify affected

segments of intestine
 Crohn’s Disease: Clinical Presentation

• CLINICAL PRESENTATION:

• depends on:

• Which segment is affected

• intensity of inflammation

• ± Specific complications

• Insidious onset with waxing &

waning course

• Pedia: weight loss, fever, ↓

growth
 Crohn’s Disease

• CLASSIFICATION:

• FIBROSTENOTIC DISEASE

• FISTULIZING DISEASE

• AGGRESSIVE
INFLAMMATORY DISEASE
 Crohn’s Disease
• CLASSIFICATION:

• DERMATOLOGIC - Erythema
nodosum, pyoderma gangrenosum

• RHEUMATOLOGIC - peripheral
arteritis, ankylosing spondylitis,
sacroileitis

• OCULAR - conjunctivitis, uveitis / iritis,

episcleritis

• HBT - hepatic steatosis, cholelithiasis,

1º sclerosing cholangitis,
pericholangitis

• UROLOGIC - urolithiasis

• MISCELLANEOUS: thromboembolic
disease, vasculitis, osteoporosis,
endocarditis, myocarditis,
pleuropericarditis
 Crohn’s Disease
• DIAGNOSIS:

• clinical assessment +
confirmatory findings +
pathologic tests

• CLINICAL PRESENTATION:

• Acute / chronic abdominal

pain in RLQ

• Chronic diarrhea

• Intestinal inflammation on
radiography / endoscopy

• Bowel stricture / fistula

• Granulomas / inflammation
 Crohn’s Disease
• DIAGNOSIS:

• COLONOSCOPY +
INTUBATION OF TERMINAL
ILEUM - main diagnostic tool

• Focal ulcerations adjacent

to normal appearing
mucosa

• Cobblestone appearance

• Skip lesions (20%)

• Pseudopolyps
 Crohn’s Disease
• DIAGNOSIS:

• CONTRAST EXAMS - structures,

ulcers, tissues

• CT SCAN - intraabdominal
abscesses

• EGD - for disease of the proximal

alimentary tract

• CAPSULE ENDOSCOPY

• ANTIBODY TESTING - ASCA (+),

pANCA (-)
 Crohn’s Disease
• MEDICAL TREATMENT:

• goal = palliative

• induce & maintain disease remission

• ANTIBIOTICS - adjunct for

infectious complications, perianal
disease (metronidazole,
ciprofloxacin)

• AMINOSALICYLATES
(Mesalamine, 5-ASA, Sulfasalazine)

• CORTICOSTEROIDS - mild to
moderate disease, induce
remission but don’t prevent relapse
 Crohn’s Disease
• MEDICAL TREATMENT:

• IMMUNE MODULATORS - for

steroid-resistant cases

• THIOPURINE ANTIMETABOLITES
(Azathioprine, 6-Mercaptopurine)

• METHOTREXATE

• INFLIXIMAB - for pxs resistant to

standard tx, taper steroid dosage,
↑ closure of ECF

• drug of choice for fistulas

• ADALIMUMAB (Humira)
 Crohn’s Disease

• SURGICAL TREATMENT:

• for patients unresponsive to aggressive

medical tx or develop complications

• CONDUCT:

• Thorough exam of entire bowel

• Look for signs of active disease

• Note length of normal small intestine

Indications for Surgery
ACUTE ONSET OF FAILURE OF MEDICAL DISEASE
SEVERE DISEASE THERAPY COMPLICATIONS

Persistent symptoms
Obstruction

despite long-term steroid

use

Perforation

Crohn’s Colitis

Recurrence of symptoms
Toxic Megacolon
Complicated fistulas

when high-dose steroids are

tapered

Hemorrhage

Drug-induced complications
Risk of CA
(Cushing’s disease, HPN)
 Crohn’s Disease
• SURGICAL TREATMENT:

• Intra-abdominal Abscesses → CT-

GUIDED Percutaneous Drainage

• Chronic Fibrosis → Resection /

Stricturoplasty

• Fistula → Segmental Resection

• Hemorrhoids / Skin Tags → Don’t

excise unless symptomatic! Won’t
heal!

• Abscesses / Anal Fistula → Control

infection, Seton placement, local /
systemic therapy
 Crohn’s Disease
• SURGICAL TREATMENT:

• Segmental Intestinal Resection of

grossly evident disease → 1º anastomosis

• No need to ensure negative margins

• STRICTUROPLASTY - allows preservation

of intestinal surface

• HEINECKE-MICKULICZ - strictures <

12 cm length

• FINNEY TECHNIQUE - strictures 12-25

cm length

• SIDE-TO-SIDE ISOPERISTALTIC
ENTEROENTEROSTOMY - for
strictures 50 cm in length
 Crohn’s Disease
• OUTCOMES:

• Overall complication rate = 30%

• wound infections, post-op abscesses,

anastomotic leks

• ENDOSCOPIC RECURRENCE:

• 70% = within 1 year of resection

• 85% = within 3 years of resection

• CLINICAL (SYMPTOMATIC) RECURRENCE:

• 60% = within 5 years

• 94% = within 15 years

• Re-op needed in 1/3 of patients within 5

years
 Crohn’s Disease

• SURVEILLANCE:

• Annual surveillance colonoscopy +

multiple biopsies for long-standing
Crohn’s Disease (> 7 years)
Ulcerative Colitis
 ULCERATIVE COLITIS (UC)
• Peak age = 3rd to 7th decade

• PATHOPHYSIOLOGY:

• Mucosa & submucosa infiltrated

by inflammatory cells

• atrophic mucosa

• CRYPT ABSCESSES

• inflammatory PSEUDOPOLYPS

• LEAD PIPE COLON - in long-

standing UC, colon is
foreshortened & lacks haustra

• strictures are uncommon

 Ulcerative Colitis (UC)
• PARTS OF GIT AFFECTED:

• Rectum = PROCTITIS

• Rectum + Sigmoid =
PROCTOSIGMOIDITIS

• Rectum + L Colon = LEFT

SIDED COLITIS

• Rectum + Colon = PANCOLITIS

• BACKWASH ILEITIS - when UC

causes inflammatory changes in
distal ileum
 Ulcerative Colitis (UC)
• CLINICAL PRESENTATION:

• Bloody Diarrhea → Anemia

• Crampy abdominal pain

• COMPLICATIONS:

• FULMINANT COLITIS

• TOXIC MEGACOLON

• PERITONITIS

 Ulcerative Colitis (UC)
• RISK FOR CA:

• COLORECTAL CA - in areas of
flat dysplasia

• difficult to diagnose

• DIAGNOSIS:

• COLONOSCOPY + MUCOSAL
BIOPSY

• CHROMOENDOSCOPY

• ANTIBODY TESTING: ASCA (-),

pANCA (+)
CHARACTERISTICS CROHN’S DISEASE ULCERATIVE COLITIS

Layers of bowel wall

Full thickness Mucosa + Submucosa
affected
Continuous

Discontinuous

Longitudinal extent (+) affects the rectum

RECTAL SPARING

ASCA (+)
ASCA (-)

Antibody Testing
pANCA (-) pANCA (+)

Fat wrapping

Skip lesions

Stellate shaped ulcers

Features Serpiginous ulcers

Cobblestone mucosa

Apthous ulcers

granulomas
 Ulcerative Colitis (UC)
• MEDICAL TREATMENT:

• SALICYLATES - ↓ COX & 5-

lipooxygenase in gut mucosa →
↓ inflammation

• Sulfasalazine

• 5-ASA

• Mesalamine

• CORTICOSTEROIDS -
Improvement in 70-90%

• IMMUNOMODULATING AGENTS
- Azathioprine, 5-mercaptopurine,
cyclosporine, methotrexate
 Ulcerative Colitis (UC)
• SURGICAL TREATMENT:

• Curable by surgery

• INDICATIONS FOR ELECTIVE

SURGERY:

• Intractable despite maximum

medical therapy

• ↑ risk of developing major

complications of medical
therapy

• ↑ risk of colorectal CA (20%)

 Ulcerative Colitis (UC)
• ELECTIVE SURGERY:

• Most include rectal resection

• TOTAL PROCTOCOLECTOMY
+ END ILEOSTOMY - gold
standard

• removes entire affected intestine

• avoids functional disturbances

assoc. with ileal pouch-anal
reconstruction
 Ulcerative Colitis (UC)
• ELECTIVE SURGERY:

• RESTORATIVE
PROCTOCOLECTOMY + ILEAL
POUCH-ANAL ANASTOMOSIS
- for patients who want to avoid
permanent ileostomy

• ABDOMINAL COLECTOMY +
ILEORECTAL ANASTOMOSIS

• for patients with indeterminate

colitis & rectal sparing
 Ulcerative Colitis (UC)

• INDICATIONS FOR EMERGENCY

SURGERY:

• Massive hemorrhage

• Toxic Megacolon

• Fulminant Colitis

• Deterioration / failure to improve

over 24-48 hours
 Ulcerative Colitis (UC)
• EMERGENCY SURGERY:

• Fulminant Colitis + Toxic

Megacolon → Total Abdominal
Colectomy + End Ileostomy ±
Mucus Fistula

• Unstable Patient → Loop

Ileostomy + Decompressing
Colostomy

• Massive Rectal Hemorrhage →

Proctectomy + Creation of
permanent ileostomy / ileal
pouch anastomosis
 Ulcerative Colitis (UC)
• SURVEILLANCE

• Colonoscopy with multiple

(40-50) random biopsies to
identify dysplasia

• Magnifying chromoendoscopy

• Annually:

• after 8 years in patient with

Pancolitis

• after 15 years in patient with L-

sided colitis
Thank You!