1

LOWER GASTRO-INTESTINAL TRACT

DR. K. DILEEPA BANAGALA

Clinical Surgery
2
A 50 year old male patient presents with colicky central abdominal pain, associated with vomiting and abdominal distension. He has not opened bowel since day
before yesterday.
What is the most likely diagnosis?

Classification and Definitions

Classification
Dynamic/Mechanical
Vs.
Adynamic (no mechanical obstruction)1:1280
Simple Vs. Strangulated1:1285
Complete Vs. Incomplete1:1285
Small bowel Vs. Large bowel1:1285
Definitions
• 1:1280
Peristalsis works against an obstruction
• No peristalsis
o Paralytic Ileus1:1297
§ Post-operative (after any abdominal procedure): Self-limiting (24-72 hours)
§ Intra-abdominal infection
§ Reflex ileus: Due to fractures of spine, ribs, retroperitoneal haemorrhage
§ Metabolic: Uraemia, hypokalaemia
• Non propulsive waves
o Pseudo-obstruction: Smooth muscle myopathy or neuropathy of GIT1:1297
o Mesenteric vascular occlusion
• Blood supply is intact
• Interference of blood flow to the affected bowel
• Lumen of the bowel is completely obstructed
• Lumen of the bowel is only partially obstructed
• High: Duodenum, jejunum
• Low: Ileum
• From ascending colon to rectum

Causes of Dynamic IO1:1280

Intraluminal1:1282 Intramural Extramural

• Faecal impaction • Carcinoma: Large bowel3:252 • Bands/Adhesions
• Round worms • Stricture1:1282 • Hernia
• FB o Crohn’s disease
• Bezoars/ Phytobezoar: Indigestible material o Radiation enteritis
• Gallstones: Gallstone ileus • Tuberculosis
• Intussusception
• Volvulus

Clinical Surgery
 3
Pathophysiology

Bowel distal to the obstruction1:1280 Bowel proximal to the obstruction1:1280-1281

• Peristalsis continues • Vigorous increase in peristalsis
• Digestion continues o To overcome the obstruction
• Absorption continues o Colicky abdominal pain1:1286 and vomiting
Until it becomes empty and collapses o Bowel sounds are exaggerated1:1286

Leads to, • Cessation of peristalsis

• Absolute constipation5 o Pain disappears1:1286

• Dilates
o Fluid
§ Shift of fluids due to the osmotic gradient formed by the products of
fermentation of bacteria (transudation)
§ Accumulation of intestinal secretions
§ Fluid does not get absorbed

o Gas
§ Accumulation of swallowed air5
§ Anaerobic bacteria
§ Coliforms

• Oedema
o Impairs venous return

• Ischaemia of the bowel wall

o Compression of the arteries

• Necrosis of the bowel wall

• Bacterial translocation
o Portal venous circulation
o Systemic circulation

Clinical Surgery


What is a close loop obstruction? What is SIRS?5

• Bowel is obstructed at both proximal and distal ends1:1281 • Systemic Inflammatory Response Syndrome
o Malignancy with competent ileo-caecal valve: Distended
Presence of 2 or more of the following:
colon cannot decompress itself into the small bowel
• Temperature: < 36 °C or > 38 °C
o Volvulus
• HR: > 90/min
• RR: > 20/min or PaCO2<32 mmHg
• WBC: < 4x109/L (< 4000/mm³) or > 12x109/L (> 12,000/mm³), or
10% Bands (immature neutrophils)

What is sepsis?

• SIRS with documented infection1:51

What is severe sepsis?1:51

• Sepsis with at least ONE end organ dysfunction

• End organs: Brain, heart, lungs, liver, kidneys, blood coagulation system

What types of shock can be seen in IO?

• Hypovolaemic shock: Due to,1:1281 What is MODS?

o Accumulation of fluid in the intestinal lumen TWO or more end organ dysfunction1:15
o Defective intestinal absorption
o Vomiting
o Reduced intake What is septic shock?
• Septic shock: Due to,1:1285
o Bacterial translocation Patients with sepsis, who, despite adequate fluid resuscitation, require
vasopressors to maintain a mean arterial pressure > 65 mmHg5
o Leads to sepsis and septic shock

Leads to MODS and death5 (BP of < 90/60 mmHg)

Clinical Surgery

Clinical Features
1:1285-1286

• Depends on,
o Location of the obstruction
o Age of the obstruction
o Underlying cause/ pathology
o Presence/ absence of intestinal ischaemia
• Cardinal clinical features of acute obstruction
o Abdominal pain
o Distension
o Vomiting
o Absolute constipation
• Fever
o Onset of ischaemia
o Intestinal perforation
o Inflammation/abscess associated with the obstructing disease

History1:1285-1286

Dynamic
Feature Adynamic
Small Bowel Obstruction Large Bowel Obstruction
• Predominant • Less severe • Mild and diffuse pain5
• Colicky in nature • Lower abdomen
Pain • Centered on the umbilicus • Occurs every 30 minutes or more2:489
• Occurs every 2-20 minutes, depending on the level of
obstruction2:489
• Early • Late • Effortless vomiting may
• Profuse • Bilious occur1:1297
• Bilious in high small bowel obstruction • Faeculent: Due to bacterial overgrowth
Vomiting
• Brown, thick and foul-smelling (faeculent) in lower
obstruction2:490
• Rapid dehydration
• Central2:490 • Delayed, pronounced3:235 • Marked abdominal
Distension • More in distal obstruction • Peripheral/flanks2:490 distention1:1297
• Visible peristalsis may be present
• Late3:235 • Early3:235 • Early
Constipation
• Incomplete: Absolute constipation is rare2:490
Clinical Surgery

Examination
1:1286,1287

Dynamic Adynamic
• Signs of dehydration • Signs of dehydration
o Dry skin o Dry skin
o Dry tongue o Dry tongue
General Examination
o Sunken eyes o Sunken eyes
o Tachycardia and hypotension3:235 o Tachycardia and hypotension
o Low urine output o Low urine output
• Inspection • Inspection5
o Distension o Distension
o Visible peristalsis o No visible peristalsis
• Palpation • Palpation5
o Tenderness: If localized may indicate site of o No tenderness
impending/established ischaemia
Adominal Examination • Percussion • Percussion1:1297
o No significant finding o Resonant ‘Tympanic abdomen’
• Auscultation • Auscultation1:1297
o Exaggerated bowel sounds o Reduced or absent bowel sounds
• Examination of hernial sites • Examination of hernial sites5
o Irreducible lump o Normal
o No cough impulse
• Faecal impaction1:1296 • Empty rectum
DRE • Rectal carcinoma1:1296
• Blood stained mucous: Red current jelly stools2:502
o Intussusception

What is the next step in the management of this patient?

• Nil by mouth 4:114
• Replacement of fluid losses: IV Crystalloids (Hartman’s/N. Saline)1:1290
• Nasogastric tube1:1290 • Urinary catheter: Input/output chart5
o Stops vomiting • Analgesics5
o Reduces the risk of aspiration • IV broad spectrum antibiotics: Not mandatory1:1290
o Reduces the distension • Monitor: BP, PR, RR, UOP, QHT1:1290
o Assessment of intestinal fluid loss • Thrombo-embolic prophylaxis

Clinical Surgery

How do you confirm your clinical diagnosis?

Small Bowel1:1288 Large Bowel1:1288

• Small bowel • Large intestine
o Dilated loops5: > 2.5cm is diagnostic5 o Dilated loops: > 8cm5
o Straight segments o In the peripheries3:252
o Central3:235 o Haustral folds (not present in the caecum)
o Lie transversely § Do not cross the whole diameter of the bowel
o No gas in the large bowel § Spaced irregularly
o Empty large bowel o Sacculated outline
o Valvulae conniventes in the jejunum
§ Completely pass across the width of the bowel • Caecum
§ Regularly spaced o Dilated caecum > 10cm
§ Concertina or ladder effect o Rounded gas shadow in the RIF

Clinical Surgery

Other Investigations

Radiological Haematological
• CECT scan: Now increasingly done 1:1288
• FBC
• Contrast studies: Gastrografin based5 o Increased haematocrit/PCV1:1286
o Oral contrast: Evidence of gastrografin reaching the colon on the radiography by 24 hours after o WBC/DC
the administration of the contrast is highly predictive of the resolution of adhesive small bowel § Normal or slightly elevated3:235
obstruction without surgical intervention5 § > 20,000 in peritonitis
o Level of obstruction • Blood urea3:235
o Contrast enema: Sigmoid volvulus o Elevated in dehydration
• Serum electrolytes
Why gastrografin based? o Reduced Serum Na+ and Cl- levels5
• Ba might convert a partial obstruction to a complete obstruction § Due to GIT losses
• Gastrografin is water soluble Vs. Ba is insoluble o K , H+ lost due to emesis5
+

• Gastrografin has an osmolarity 6 times that of the ECF

• It activates the movement of water into the small bowel lumen by osmosis
• Decreases oedema of the small bowel wall
• Enhances smooth muscle contraction too
• These effects act to generate effective peristalsis, enabling small bowel to overcome the adhesive
obstruction
•
It has been proven to result in quicker resolution and shorter hospital stay5

Treatment1:1290

“The sun should not both rise and set on a case of unrelieved intestinal obstruction”

Dynamic
Adynamic1:1297
Small Bowel Large Bowel
• Adhesions • Carcinoma1:1294 Paralytic ileus
o Non-operative for up to 72 hours o Surgery • Non-operative
o > 72 hours: Surgery • Treat the underlying cause
• Obstruction of external hernia o Eg: Uraemia, hypokalaemia
o Surgery Pseudo-obstruction
• Volvulus • Non-operative
o Go to section on volvulus
• Intussusception
o Discussed in Paediatric surgery
Clinical Surgery

Volvulus
Introduction1:1284 Clinical Features5
• Twisting of portion of bowel about its mysentery • Pain
o >180° torsion: Obstruction of the lumen o Usually continuous and severe, with a superimposed colicky
o >360° torsion: Vascular occlusion in the mysentery component during peristalsis
• Closed loop obstruction • Nausea, abdominal distension, constipation
• Types • Vomiting usually several days after the onset of symptoms
o Primary: Following congenital malrotation of gut, abnormal • Elderly: >50 years
mysenteric attachments, congenital bands o Sigmoid volvulus: Mean age 70 years at presentation5
§ Volvulus neonatarum: Congenital malrotation of the gut • Male > Female
o Secondary (more common): Rotation around an acquired adhesion • Previous abdominal surgery1:1284
or stoma • History of chronic constipation and laxative abuse
o Sigmoid volvulus: 80% • Psychiatric and geriatric hospitalization
§ Nearly always anti-clockwise • Psychiatric drugs
o Caecal volvulus: 15%

Risk Factors1:1284-1285 Investigations5

• 5:
Long sigmoid colon Chronic faecal overloading from constipation may • Plain abdominal X-ray - Omega / Coffee bean sign
cause elongation • Dilated loop in the right side of the abdomen
• Excessively mobile colon5 • Contrast enema: Bird's beak sign
• Constipation
• Adhesions
• Long pelvic mesocolon
Treatment1:1295
• Narrow root of pelvic mesocolon • Non-Operative (especially for sigmoid volvulus5)
o Flexible/ rigid sigmoidoscopy and decompression
o Insertion of flatus tube

• Operative (for caecal or midgut volvulus5)

o Laparotomy and untwisting of the loop
o If non-viable: Resection and end-to-end anastomosis

Clinical Surgery

During non-operative management, the patient’s pattern of pain changed During non-operative management, the patient develops severe continuous
from colicky to continuous. The patient is febrile. abdominal pain with obliteration of liver dullness.

What is the most likely diagnosis? What is the most likely diagnosis?

Clinical Features
1:1286-1287
Clinical Features2:488
• Fever • Fever
• Colicky abdominal pain becomes continuous • Colicky abdominal pain becomes continuous2:501
• Tachycardia2:488 • Tachycardia
• Shock • Obliteration of liver dullness5 :Percussion over the liver is tympanitic
• Signs of peritonitis • Signs of peritonitis
o Generalized tenderness o Generalized tenderness
o Rebound tenderness o Rebound tenderness
o Guarding o Guarding
o Rigidity o Rigidity

• If obstruction was due to hernia: Examination of hernial site Investigations

o Tense, tender, irreducible lump • Erect Chest X-ray: Free air under the diaphragm5
o No expansile cough impulse
o Recent increase in size Treatment
o Skin changes • Surgery2:488
§ Erythema, purplish discolouration o Laparotomy: Hartmann’s procedure

Investigations What is a Hartmann’s procedure? 1:1295

• Emergency procedure when perforated
*Clinical Diagnosis* • Resect perforated segment
• Suture the distal end
• Increased WBC count3:235 • Proximal end is brought out as a colostomy

Treatment Which part of the bowel has the highest risk of perforation?
• Surgery 1:1291
• Caecum and Rectum
o Laparotomy: Relieve the obstruction • ‘r’ (radius) is high, therefore tension is high
o If non-viable: Resect and re-anastomose • P = 2T/r
Clinical Surgery

A 20 year old female presents with blood and mucous diarrhea for the past 6 A 30 year old female presents with anaemia, right lower quadrant abdominal
months with associated tenesmus. pain. She has also noted blood and mucous diarrhea.
What is the most likely diagnosis? What is the most likely diagnosis?

Ulcerative Colitis Crohn's Disease

Ulcerative Colitis Vs. Crohn's Disease

Feature Ulcerative Colitis1:1267 Crohn's Disease1:1241-1242

Introduction • Relapsing and remitting type of chronic inflammation5 • Relapsing and remitting type of chronic inflammation5
• Unknown • Unknown
• ? Products from the bacterial flora5 • Genetic: 10% patients have a first degree relative with IBD
Aetiology • ? Autoimmune • Environmental
• Genetic predisposition: 10-20% patients have a first degree relative o Products from bacteria
with IBD o Rare in developing countries

• Most commonly diagnosed between 20-40 years • Bimodal distribution

Age • Can occur at any age o 25 – 40 years
o 70 years
• Can occur at any age
• Men = Women in early life • Female > Male
Sex
• Male > Female in later life5
• 95% starts in the rectum and spreads proximally in continuity • Any part of the GI tract: Lips to the anal margin
Location • Secondary inflammation of the terminal ileum: ‘Backwash • Rectum often spared
ileitis4:392 • Common site: Terminal ileum: 65%
Geography • Commonest in Caucasians • Commonest in Caucasians
Smoking • Protective effect • Increases the risk
• Increased risk (pre-malignant condition) • Increased risk (pre-malignant condition)
Cancer risk
• Acute • Acute
o Toxic megacolon o Toxic megacolon (less common)1:1272
o Perforation o Perforation1:1247
o Haemorrhage o Haemorrhage1:1247
Complications
• Chronic • Chronic1:1247
o Cancer o Fistula
§ Colon o Stenosis: Intestinal obstruction
§ Cholangiocarcinoma o Cancer4:394
Clinical Surgery

Inflammatory Bowel Disease (IBD)
Ulcerative Colitis1:1267 Crohn's Disease1:1243
• Proctitis • Acute disease
o Formed or semi-formed stools o Fever
o Tenesmus o Diarrhoea: Blood and mucous4:394
o Urgency5 o Gross bleeding is less frequent than in UC (except in Crohn's
o Rectal bleeding, mucous discharge colitis)5
o No systemic features o Right lower quadrant pain4:394
o No effect on growth in children • Chronic disease
o Extraintestinal manifestations are rare o Right lower quadrant pain4:394
o Fatigue
• Colitis o Anaemia
o Diarrhoea o Weight loss
§ Active disease proximal to the rectum o Chronic mild diarrhoea
§ Blood and mucous o Ill-defined mass in the abdomen (para-enteric abscess
§ Up to 20 times/day formation)4:394
o Associated with o Anal disease4:394
§ Anaemia § Atypical severe anal fissures
§ Hypoalbuminaemia § Fistula in ano
§ Hypokalaemia4:392 § Anal mucosal thickening
§ Dehydration3:247 § Discoloration: Bluish perianal skin
o Systemic features common § Peri-anal abscess
§ Fever o Fistulation
§ Anorexia § Into adjacent bowel loops: Entero-enteric
§ Loss of weight3:247 § Into the bladder: Entero-vesical)
§ Tachycardia • Rcurrent UTI
o Affects growth in children § Into the female genital tract: Entero-vaginal
o Extra-intestinal manifestation + • Passage of gas, faeces through the vagina
§ To the skin: Entero-cutaneous: Bowel contents drain to
the skin

Disease Severity In Ulcerative Colitis1:1267

Mild Moderate Severe

• Less than 4 motions per day • > 4 motions per day • > 6 bloody motions per day
• No systemic signs • Few systemic signs • Systemic signs + (fever, tachycardia)
o eg:- mild anaemia • Hypoalbuminaemia, weight loss

Clinical Surgery

Extraintestinal Manifestations of IBD1:1244, 1267

In which IBD are these more common? In Crohn’s disease

Eyes Skin Musculoskeletal Hepato-Billiary Others
• Conjunctivitis5 • Erythema nodosum • Polyarthritis: Knees, • Primary billiary cirrhosis • Nephrotic syndrome
• Uveitis • Pyoderma gangrenosum ankles, elbows and wrists • Sclerosing cholangitis (rare • Pancreatitis
o Iritis • Aphthous stomatitis/ulcers • Sacroiliitis in CD) • Venous and arterial
o Episcleritis (UC) (CD) • Ankylosing spondylitis • Chronic active hepatitis thromboembolism5
(CD) • Renal calculi (CD)
• Liver failure
• Gall stones (CD)

Pathology

Feature Ulcerative Colitis1:1267-1268 Crohn's Disease1:1268, 1272

• Diffuse colonic inflammation • Skip lesions
Macroscopy • Strictures are rare • Strictures are more
• Thin wall • Thick wall1:1242
• Perianal disease rare • Perianal disease common

• Inflammation limited to mucosa and superficial submucosa • Transmural inflammation

• Marked pseudopolyps • Less pseudopolyps5

• Crypt abscesses: Inflammatory cells in lamina propria and crypts of • Crypt abscesses -rare
Lieberkuhn
• Superficial, broad-based ulcers • Deep, knife like ulcers1:1242

• No healthy mucosa in between • Healthy mucosa in between ulcers
Microscopy o ‘Cobblestoning’
• Less lymphoid reaction • Marked lymphoid reaction4:394
o Crohn's rosary’
• Less fibrosis • Marked fibrosis4:394

• No granulomas • Non-caseating granulomas are seen

• No fistulae • Fistulae are seen

• No fissuring • Fissuring common

Clinical Surgery

How will you investigate this patient?
Investigations

Ulcerative Colitis Crohn's Disease

1:1268 1:1243-1244

• Sigmoidoscopy and biopsy • Lower GI symptoms5

• Colonoscopy and biopsy o Colonoscopy with ileal intubations and biopsy
o Establish the extent of inflammation • Upper GI symptoms
o Distinguish UC Vs. CD o OGD
o Monitor response to treatment • Chronic gastro-intestinal bleeding
o Assess long standing cases for malignant change o Capsule endoscopy/ Enteroscopy
• Anal disease4:395
• Always test stool for parasites and cysts in any acute presentation to exclude
o EUA
infection4:392 o Anal ultrasound
o MRI scanning
Radiological Other Radiological Options
• X-ray abdomen
• CT Abdomen
o Oedematous colonic mucosa: ‘Thumb-printing’4:392
• Ba meal and follow through5 / Small bowel enema
o Loss of haustrations: Lead pipe appearance
o Mucosal irregularity
o Narrowing
• Ba enema3:247 o String sign of Kantor: Involvement of the terminal ileum
o Loss of haustrations: Lead pipe appearance
• Labelled white cell scan4:395
o Mucosal changes
o Ileal ‘hot spots’
o Stricture due to carcinoma
o Pseudopolyps5 • Fistulography
o Fistulae

Haematological4:392 Haematological
• FBC • FBC
o Low Hb o Low Hb
o Increased WBC o Increased WBC4:395
• Elevated CRP • Elevated ESR
• Low albumin • Elevated CRP
• Low albumin
• Low K+, Mg2+, Ca2+ 3:245

Clinical Surgery

How do you treat IBD?
Treatment
Medical Surgical
1:1245, 1269 1:1270, 1246-1247

Acute Episode • Proctocolectomy

• Steroids o + Ileostomy
o Local: Steroid enema o + Ileo-anal pouch (not in CD1:1272)
o Systemic • Surgery to manage complications of CD
§ Oral: Prednisolone o Fistulae
§ IV: Hydrocortisone o Perianal disease
• +/- ASA (5-aminosalicyclic acid) based on severity o Bowel perforation
o Local o Recurrent intestinal obstruction
o Oral o Stricture (strictureplasty: widening the bowel lumen
• Correct o Malignant change
o Nutrition: High calorie diet
o Fluid balance
o Electrolytes
o Anaemia
• Monitor
o BP, PR, RR
o UOP
o QHT
o Abdominal girth
o Weight
o Stool frequency
• UC: Daily abdominal X-ray to look for dilatation of transverse colon (toxic
megacolon)
• Antibiotics: Metronidazole, ciprofloxacin (especially in perianal disease in
CD)

Long Term Treatment

• Immuno-suppressants: Azathioprine, cyclosporin
• Infliximab (anti-TNF alpha)
o Monoclonal antibody
o For fistulae and cases of moderate to severe CD
o In severe acute attacks of UC
• CD: Quit smoking1:1242
Clinical Surgery