DISEASES OF THE SMALL

INTESTINE
 CLASSIFICATION:-
• Anatomically the small bowel includes the
duodenum, jejunum and ileum
Congenital anomalies
Intestinal obstructions
Ischaemic bowel disease
Inflammatory bowel disease
Infective enterocolitis
Intestinal tumours

@patrick macharia MKU

 I: CONGENITAL ANOMALIES:
 INTESTINAL ATRESIA.
 Congenital absence of the lumen
 Most commonly affects ileum or
duodenum
 The proximal segment has a blinded end
which is separated from distal segment
freely or the two segment are joined by
fibrous cord
@patrick macharia MKU
 Congenital anomalies cont--
INTESTINAL STENOSIS.
 Congenital narrowing of the lumen
affecting a segment of the small intestine
 The intestinal segment above the level of
obstruction is dilated and that below is
collapsed

@patrick macharia MKU

 Congenital anomalies cont--
MECKEL’S DIVERTICULUM
 Is the most common congenital anomaly
of GIT
 Occurs in about 2% of the population
 It is more common in males
 It is commonly located on the
antimesenteric border of the ileum about 1
meter from the ileocaecal valve
@patrick macharia MKU
 Meckle’s diverticulum cont--
 It is an outpouching containing ALL LAYERS of
the intestinal wall in the normal orientation
 It is almost always lined by intestinal type of
epithelium
 The lining may at times contain heterotopic
islands of GASTRIC and COLONIC MUCOSA
and ectopic pancreatic tissue
 Embryologic origin is from incomplete
obliteration of vitellointestinal ducts

@patrick macharia MKU

 Meckel’s diverticulum cont--
 Complications:
 Perforation
 Haemorrhage
 Inflammation- Diverticulitis
 Vesiculodiverticular fistula
 Peptic ulceration –ectopic gastric mucosa
 Intussusception
 Intestinal obstruction
 Carcinoid tumour and other rare tumours
DD: Acute appendicitis

@patrick macharia MKU

 MD

@patrick macharia MKU

 II: INTESTINAL OBSTRUCTION:
• These are conditions which interfere with propulsion of
contents in the intestine.
• CAUSES:-
 Mechanical obstruction.
 Internal obstruction (in the wall or lumen):
 Inflammatory strictures
 Congenital stenosis or atresia
 Imperforated anus
 Tumours
 Round worms
 Gall stones etc.

@patrick macharia MKU

 Intestinal obstruction cont--
 External compression (forms 80%):
 Peritoneal adhesions
 Strangulated hernias
 Intussusception
 Volvulus
 Intra-abdominal tumours

@patrick macharia MKU

 Intestinal obstruction cont--
NEUROGENIC OBSTRUCTION.
 Occurs due to paralytic ileus of muscularis
of intestine as a result of shock after
abdominal operation or acute peritonitis
VASCULAR OBSTRUCTION.
 Obstruction of superior mesenteric artery
or its branches may result in infarction
causing paralysis. The causes may be
@patrick macharia MKU
 Superior mesenteric artery
obstrustion - causes
• Thrombosis
• Embolism
• Accidental ligation

 HERNIA:
• Is a protusion of portion of a viscus
through an abnormal opening in the wall of
its natural cavity
@patrick macharia MKU
 HERNIA cont--
- External hernia – is the protrusion of the
bowel through a defect of weakness in the
peritoneum
- Internal hernia – is the term applied for
herniation that DOES NOT PRESENT on
the external surface

@patrick macharia MKU

Types of hernias

@patrick macharia MKU

Strangulated inguinal hernia-small
bowel seen in the centre

@patrick macharia MKU

Umbilical hernia

@patrick macharia MKU

Epigastric hernia
 FORMATION OF HERNIA:
 Factors involved in the formation of hernia
are:-
• Local weakness;
 These weaknesses may be congenital at;
- The umbilicus
- The inguinal canal
- The femoral canal
 In surgical scars- called “incisional hernia”

@patrick macharia MKU

Factors in formation of hernia cont-
• Increased intra-abdominal pressure;
 This may be produced by coughing, straining
and exertion
 Inguinal hernia is more common, followed in
decreasing frequency by femoral and umbilical
hernias
 Inguinal hernia may be;
- Direct –when hernia passes MEDIAL to
INFERIOR EPIGASTRIC ARTERY and
- It appears through the external abdominal ring
@patrick macharia MKU
 Inguinal hernia cont--
-Indirect – when it follows the INGUINAL
CANAL LATERAL TO the INFERIOR
EPIGASTRIC ARTERY
When blood flow in the intestine is
obstructed it results in STRANGULATED
HERNIA, this may lead to INFARCTION or
GANGRENE of the affected loop.

@patrick macharia MKU

 INTUSSUSCEPTION
DEFINITION

• Telescoping of a proximal
segment of the intestine
(intussusceptum) into a distal
segment (intussuscipiens)

@patrick macharia MKU

 INTUSSUSCEPTION.
• Is the telescoping (Invagination) of a
segment of intestine into the segment
below due to peristalsis
 The telescoped segment is called
INTUSSUSCEPTUM and the lower
receiving segment is called
INTUSSUSCIPIENS.

@patrick macharia MKU

 INTUSSUSCEPTION
EPIDEMIOLOGY
• Incidence 2 - 4 / 1000 live births
• Usual age group 3 months - 3 years
• Greatest incidence 6-12 months
• Male predominance (1.5-2 : 1)
• No clear hereditary association
• No seasonal distribution
• Frequently preceded by viral infection
– URI, ADENOVIRUS

@patrick macharia MKU

INTUSSUSCEPTION
ANATOMIC LOCATIONS
• ILEOCOLIC
– MOST COMMON IN CHILDREN
• ILEO-ILEOCOLIC
– SECOND MOST COMMON
• ENTEROENTERIC
– ILEO-ILEAL, JEJUNO-JEJUNAL
– MORE COMMON IN ADULTS
– MAY NOT BE SEEN ON BARIUM
ENEMA
• CAECOCOLIC, COLOCOLIC
– MORE COMMON IN AFRICAN
@patrick macharia MKU

CHILDREN
 Intussusception cont--
• The condition occurs in more commonly in
the infants and young children
• The condion occurs more often in the
ILEOCAECAL region where the portion of
the ileum invaginates into the ascending
colon without affecting the position of the
ileocaecal valve

@patrick macharia MKU

Intussusception

@patrick macharia MKU

Intussusception

@patrick macharia MKU

 INTUSSUSCEPTION
ETIOLOGIES
• Majority of pediatric intussusceptions idiopathic (85-90%)
– LYMPHOID HYPERPLASIA POSSIBLE ETIOLOGY
• Mechanical abnormalities may act as “lead points”
– congenital malformations (meckel’s diverticulum,
duplications)
– neoplasms (lymphoma, lymphosarcoma)
– polyposis (juvenile, familial)
– trauma (post-surgical, hematoma)
– miscellaneous (appendicitis, parasites)
– illnesses ( cystic fibrosis)

@patrick macharia MKU

 INTUSSUSCEPTION
PATHOPHYSIOLOGY
• Precipitating mechanism unknown
• Obstruction of intussusceptum
mesentery
• Venous and lymphatic obstruction
• Third spacing of fluid into bowel wall
• Ischemic necrosis occurs in both
intussusceptum and intussuscipiens
@patrick macharia MKU
 INTUSSUSCEPTION
PATHOPHYSIOLOGY
• Majority occur in the region of the
ileocecal valve (80%)
– DISPROPORTIONATE DIAMETERS OF
ILEUM AND CECUM
– ILEOCECAL VALVE PROTUDES INTO
CECUM
– LYMPHOID AGGREGATES MORE
NUMEROUS IN TERMINAL ILEUM
– ILEOCECAL REGION ANATOMIC
@patrick macharia MKU

NEURAL TRANSITION ZONE

 INTUSSUSCEPTION
CLINICAL CHARACTERISTICS

• Early Symptoms
– PAROXYSMAL ABDOMINAL PAIN
– SEPARATED BY PERIODS OF APATHY
– POOR FEEDING AND VOMITING
• Late Symptoms
– WORSENING VOMITING, BECOMING BILIOUS
– ABDOMINAL DISTENTION
– HEME POSITIVE STOOLS
– FOLLOWED BY “CURRANT JELLY” STOOL
– DEHYDRATION (PROGRESSIVE)
• Unusual Symptoms
– DIARRHEA
@patrick macharia MKU
 Complications of intussusception:
• Intestinal obstruction
• Infarction of the bowel
• Gangrene
• Intestinal perforation
• Peritonitis

@patrick macharia MKU

 Volvulus
• Is the twisting of loop of intestine on itself
through 180 degrees or more
• This leads to obstruction of the intestine
• Also leads to cutting of the blood supply to
the affected loop

@patrick macharia MKU

• Colon twists on its own mesenteric
axis
• venous congestion and infarction
• Gangrene

• Arterial supply comprised

• Ischemia

@patrick macharia MKU

 Distribution
• Sigmoid colon : Most common
• Cecum
• T-Colon
• Splenic flexure

@patrick macharia MKU

 Sigmoid Volvulus
• Prevalence
: 3% ~ 30% in large bowel obstruction

@patrick macharia MKU

 Pathogenesis
• The pathogenesis is obscure
• Chronic constipation
• High fiber diet
• Chronic medical or psychiatric
problem
• Precipitating factor
: pregnancy, abdominal surgery
@patrick macharia MKU
 Symptoms and Signs
• Colicky abdominal pain
• Constipation
• Failure to pass flatus
• Abdominal distension
• Nausea
• Vomiting
@patrick macharia MKU
Caecal volvulus

@patrick macharia MKU

ISCHAEMIC BOWEL DISEASE
• Depending on the extent of severity of
ischaemia
• 3 patterns of pathologic lesion can occur
Transmural infarction
Mural infarction
Ischaemic stenosis

@patrick macharia MKU

 TRANSMURAL INFARCTION.
• Ischaemic necrosis of the full-thickness of the
bowel wall
• Etiopathogenesis:-
 Mesenteric arterial thrombosis
 Atheroclerosis (most common)
 Aortic aneurysm
 Fibromuscular hyperplasia
 Use of contraseptives
 Invasion by the tumor
 Arteritis of various types

@patrick macharia MKU

 Etiopathogenesis cont--
 Mesenteric arterial embolism;
 Intestinal sepsis (e.g. Appendicitis)
 Portal venous thrombosis
 Tumour invasion
 Use of contraceptives
 Miscellaneous
 Strangulated hernia
 Torsion etc

@patrick macharia MKU

 PATHOLOGICAL CHANGES:
 Gross.
• Haemorrhagic infarction (red type)
• Oedematous thickened wall
• Marked congestion
• Pale surface coated by fibrinous exudate
• Gangrene of bowel
 Microscopically.
• Coagulative necrosis
• Ulceration of the mucosa

@patrick macharia MKU

Pathologic changes-microscopically
cont--
• Submucosal haemorrhage
• Inflammatory infiltrate (later)
Clinical features.
 Acute abdominal pain
 Nausea and vomiting
 Diarrhoea
 The disease is rapidly fatal with 50-70%
mortality rate

@patrick macharia MKU

 MURAL AND MUCOSAL
INFARCTION
• Known as haemorrhagic
gastroenteropathy
• Is limited to superficial layers of the bowel
wall
• It spares the deeper layer of the
muscularis and the serosa

@patrick macharia MKU

 ETIOPATHOGENESIS:
 Results from conditions causing non-
occlusive HYPOPERFUSION, these are;
 Shock
 Cardiac failure
 Infections
 Drugs causing vasoconstriction e.g
digitalis, norepinephrine

@patrick macharia MKU

 Pathologic changes.
Gross.
 Red or purple of the affected segment
without haemorrhage
 Oedematous mucosa
 Mucosal ulceration

@patrick macharia MKU

 INFECTIVE ENTEROCOLITIS
• Acute and chronic inflammatory lesions of
small intestine and/or colon caused by
microorganisms (bacteria, viruses, fungi,
protozoa and helminths)
 Bacteria causing infective enterocolitis.
Entero invasive bacteria
 Tuberculosis
 Salmonella
@patrick macharia MKU
 Entero invasive bacteria cont--
 Campylobacter jejune
 Shigella
 E. coli
 Yersinia entercolitis
Enterotoxin producing bacteria.
 Vibrio cholerae

@patrick macharia MKU

 Entero- invasive bacteria.
Primary Tuberculosis.
 Tubercle bacilli –ingestion of un-
pasteurized milk
GROSSLY:
• Lymphnodes enlarged, matted and
caseous
• Healing by fibrosis and calcification

@patrick macharia MKU

 GROSSLY TB cont--
• Ghon focus (primary complex) is in intestinal
mucosa
• Granulomatous reaction with caseation
• TB peritonitis
 Haemorrhagic fluid
 Pathologic changes:-
GROSS;
 Patchy and LONGITUDINAL mucosal ulceration

@patrick macharia MKU

 Secondary TB:
• Follows swallowing of sputum in patients
with active PTB
• Lymphadenopathy is more extensive (not
only regional as in primary TB)
• GROSS:
 Ulceration of mucosal ulcers are
TRANSVERSE to long axis of the bowel

@patrick macharia MKU

 ENTERIC FEVER (TYPHOID).
• Caused by salmonella typhi
• Bacilli ingested through contaminated water or
food- and follows the sequence as under;
 Bacilli invade lymphoid tissue & payer’s patches
of small intestine and proliferate
 Bacilli invade blood stream (Bacteremia)
 Eventually bacteria localized in lymphoid tissue
in intestine
 Haemologic lymphadenitis (in mesenteric
lymphnode).
@patrick macharia MKU
 Pathologic changes-typhoid.
GROSS:
• Oval ulcers with axis along the length of
the bowel and payer’s patches
• Regional lymphadenopathy
MICROSCOPICALLY:
 Hyperaemia
 Oedema

@patrick macharia MKU

 Typhoid –microscopic changes
cont--
 Cellular infiltrate consisting of;
 PHAGOCYTIC HISTIOCYTES –showing
characteristic ERYTHOPHAGOCYTOSIS
 Lymphocytes
 Plasma cells
NB: although enteric fever is an example of
acute inflammation, neutrophils are
invariably absent from the cellular infiltrate
@patrick macharia MKU
 Microscopic –Typhoid fever cont--
• Leucopenia with neutropenia and relative
lymphocytosis in the peripheral blood are
characteristic
 Complications:-
 Perforation of the ulcers
 Haemorrhage

@patrick macharia MKU

 BACILLARY DYSENTERY.
• Is the term used for infection by SHIGELLA
species.
• MACRO:- superficial transverse ulceration of the
mucosa
- hyperaemia and oedema
• MICRO:-
- Necrosis overlying lymphoid follicles
- Congestion and oedema
- Neutrophils and lymphocytes
@patrick macharia MKU
 SMALL INTESTINAL TUMOURS:
 BENIGN:- in descending order of frequency are;
 Leiomyoma
 Adenomas
 Vascular tumours (haemangioma,
lymphangioma)
 MALIGNANT:-
 Carcinoid tumour
 Lymphoma
 adenocarcinoma

@patrick macharia MKU

 CARCINOID TUMOURS
(Argentafinoma)
• Tumours originating from endocrine cells
• Belong to APUD cell system
• APUD – Amine Precursor Uptake
Decarboxylation and are therefore called
APUDOMAS.
• The endocrine cells are distributed in the
mucosa of GIT
• The endocrine cells have secretory
granules
@patrick macharia MKU
 Carcinoid tumours cont--
• The secretory granules may stain
POSITIVELY with SILVER SALTS
(aregentaffin granules) or
- may stain positively AFTER ADDITION OF
EXOGENOUS REDUCING SUBSTANCE
(Argyrophil granules)
• Accordingly carcinoid tumours may be
ARGENTAFFIN or ARGYROPHIL in type.
@patrick macharia MKU
 Carcinoid tumours cont--
• Depending on embryologic derivation of
tissues where the tumour is located;
carcinoid tumours are CLASSIFIED as,
- Foregut
- Midgut and
- Hindgut carcinoids

@patrick macharia MKU

 CARCINOIDS cont--
Midgut carcinoids:
 Are seen in terminal ileum and appendix
 Are the most common (60-80%)
 Are more often argentaffin positive
Hindgut carcinoids:
 Occur in rectum and colon
 Are more commonly of argyrophil type
 Comprise about 10-20% of carcinoids

@patrick macharia MKU

 Carcinoids cont--
Foregut carcinoids:
 Are located in the stomach, duodenum
and oesophagus
 Are also of argyrophil type
 Are encountered frequently as in the hind
gut (10-20%)
Other uncommon locations are:-
 Bronchus, trachea, gallbladder and
Meckle’s diverticulum.
@patrick macharia MKU
 Carcinoids cont--
• NB:- Appendix and terminal ileum, the two
MOST COMMON SITES for carcinoid depict
variation in their AGE and SEX INCIDENCE and
BIOLOGIC BEHAVIOUR
 APPENDICEAL CARCINOIDS:-
 Occur more frequently in 3rd and 4th decades of
life
 without sex predilection
 They are solitary
 Behave as locally malignant tumours
@patrick macharia MKU
 Carcinoids cont--
ILEOCARCINOIDS:-
 Are seen more often in later age (7th
decade)
 with female predominance
 Are often multiple
 Behave like metastasizing carcinoids

@patrick macharia MKU

 Carcinoids cont--
CARCINOID SYNDROME:-
 Carcinoid tumours that metastasize
(especially to the liver) are sometimes
associated with carcinoid syndrome
 The syndrome consist of the following
features;
 Episodic waterly diarrhoea
 Abdominal pain
@patrick macharia MKU
Carcinoid syndrome features cont--
 Attacks of dyspnoea –due to
bronchospasms
 Involvement of tricuspid valve and
pulmonary valves leading to right-sided
heart failure
 Secretory products include;
 5-HT (Serotonin)
 Histamine
 Kallikrein and Bradykinin
@patrick macharia MKU
 Secretory products of carcinoid
tumour cont--
• NB: 5-HT and its degradation products 5-
HIAA(5-Hdroxyl-Indole-Acetic-Acid) are
particularly significant in the production of
carcinoid syndrome.

@patrick macharia MKU

Carcinoid tumour small intestine

@patrick macharia MKU

 Small rounded and elevated
carcinoid tumour in submucosa

@patrick macharia MKU