GENERAL

SURGERY

Small Intestine • 1.5 L enters the colon
Dr. Vequilla o if less than 1.5 L enters the colon → constipation
th
Schwartz’s 10 Edition, Lecture notes, Pacis transcription (FEU
NRMF) SMALL BOWEL OBSTRUCTION
October 12, 2018 • 75% of SBO cases are secondary to post-operative adhesions
NOTE: MAJORITY OF THE LECTURE WOULD REVOLVE AROUND SBO. THUS, • Obstructing
MAJORITY OF THE EXAM QUESTIONS WILL BE TAKEN FROM THAT PART.
Extrinsic
SMALL INTESTINES 1. Adhesions
ü Most common cause of SBO
• Site of nutrient digestion and absorption i. Most common cause of bowel obstruction in
• Largest reservoir of immunologically active and hormone producing patients 20-40 years old? Answer- Post
cells operative adhesion (SBO)
• Largest organ of immune and endocrine system ii. Most common cause of bowel obstruction in
o Produces 75% of our body’s immune system non operative patients? Answer-
• Diseases are relatively infrequent Incarcerated inguinal hernia
o Infrequency due to the environment and immune cells ü Approximately 90% of SBO in patients with prior
o Exception- Small Bowel Obstruction abdominal surgery are due to adhesions or internal
herniation through a surgically created defect
2. Hernia
nd
GROSS ANATOMY ü 2 most common cause of obstruction
ü But the most common cause in patients without prior
• Tubular structure extending from pylorus to cecum
abdominal surgery
• Measures 4-6m
ü Incarcerated hernia requires immediate surgery
• 3 segments: 3. Carcinomatosis
o duodenum

o jejunum Intraluminal
o ileum v Foreign bodies, gallstones, or meconium


Duodenum Intramural

• Most proximal segment v Tumors
ü Leiomyoma
• Retroperitoneum
ü Liposarcoma
o Duodenum needs to be lifted from the retroperitoneal area
v Crohn’s disease-associated obstructions
in order to do surgery

• Demarcated from the
Conditions that mimic the clinical picture of SBO
o Stomach by the pylorus
v Colonic obstruction
o Jejunum by the ligament of Treitz
ü Right colonic obstruction near the ileocecal valve
§ In order to appreciate this, you need to lift the
§ Right sided colonic tumor: presents with
transverse colon and the omentum
dilatation and bowel obstruction of small
• Blood supply: Celiac and Superior Mesenteric Arteries
intestine rather than the large bowel
• 4 parts:
st v Adynamic Ileus
o 1 part: Superior
nd ü Seen in post operative patients
o 2 part: Descending
rd
o 3 part: Inferior/Horizontal
th Mechanical Ileus
o 4 part: Ascending
Onset Often sudden Insidious

Pain Colicky None
Jejunum and Ileum Distention Present Present

• Within the perioneal cavity Vomiting Present Present
• Broad based mesentery (blood supply) Bowel sounds Hyperactive Absent/Present
• Proximal 40% → Jejunum Fluid status With dehydration Not characteristic
• Distal 60% → Ileum (dehydration)
• It is hard to differentiate the two Shock Maybe significant Not present
• Ileum with thinner walls making it more prone to iatrogenic injury Radiograph Gas to site of Gas throughout the
during surgery obstruction bowel
• Mechanical obstruction- do surgery
JEJUNUM ILEUM • Ileus- do not operate on the patient
Largest circumference Smallest circumference
Thicker walls Thinner walls
Less fatty mesentery More fatty mesentery Diagnosis

Longer vasa recta Shorter vasa recta I. Diagnosis
II. Physical examination
III. Laboratory examinations
IV. Radiographs
PHYSIOLOGY

• 8-9 L of fluid/ day A. History
o 2 L comes from oral intake; the rest comes from salivary, 1. Age
gastric, biliary, pancreatic and intestinal secretions § Neonate - consider meconium ileus,
• normally → 80 % absorbed Hirschprung's, malrotation, intestinal atresias

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 GENERAL SURGERY

§ 2 - 24 months - consider intussusception, 2. Abdominal PE
Hirschprung's § Distention
§ Young adults - hernia, inflammatory bowel ü Minimal in proximal obstruction
disease ü Marked on prolonged distal
§ Adults - hernia, neoplasms, diverticular obstruction
disease § Presence of surgical scars
§ Elderly - neoplasms, diverticular disease, § Tenderness
hernia, Ogilvie's ü Mild tenderness is common
ü Localized tenderness, rebound
2. Nausea, vomiting, obstipation tenderness, guarding suggest
§ In proximal obstruction, bilious vomiting may peritonitis and likelihood of
occur early and the patient may have a little strangulation or perforation
abdominal distention
§ The patient may continue to pass stool and 3. Rectal exam
flatus as the bowel distal to the obstruction is § Rectal vault is empty
evacuated. ü Determined if the whole anal canal is
§ In distal obstruction, the patient initially hugging your finger
complain of obstipation and distention prior to § Fecal impaction can be ruled out
the onset of vomiting of feculent materials ü Scybalous stools- hardened feces; do
finger fracturing to break the feces
3. Pain within
§ Proximal Obstruction § Guaiac positive stool suggest an alimentary
ü Crampy mucosal lesion, as may occur with cancer,
ü Referred primarily to the periumbilical intussusception, or mesenteric infarction
area § Extrinsic pelvic masses as well as intrinsic colon
ü Mostly upper abdomen lesions can be diagnosed
§ Distal Obstruction
ü Referred primarily to the lower C. Laboratory examinations
abdomen 1. WBC
ü Mostly generalized § Normal in uncomplicated SBO
§ Elevated in strangulation or inflammatory causes
4. Past surgical history § Markedly elevated late with mesenteric
§ Adhesions infarction
§ Internal herniation
2. Hematocrit
5. Past medical § Often increased due to hemoconcentration
§ History of severe atherosclerosis, cardiac § Anemia – colon carcinoma
arrhythmias, prior myocardial infarction, chronic
CHF, and atrial fibrillation may suggest intestinal 3. Electrolyte imbalance
ischemia
§ Previous history of inflammatory bowel disease D. Radiographs
or diverticulitis may suggest mechanical ü Essential to confirm clinical diagnosis
obstruction ü Define more accurately the site of obstruction
§ Gallstone ileus
1. Chest X-ray upright
6. Medications § Pneumoperitoneum- surgical emergency
§ Digitalis – intestinal ischemia
§ Narcotics – adynamic ileus 2. Abdominal flat and upright
§ Anticholinergics, ganglion blockers, § Small bowel can be distinguished from large
antipsychotics, drugs for Parkinson’s – adynamic bowel by the presence of valvulae conniventes
ileus § Step Ladder Pattern
§ Polypharmacy – Ogilvie’s (Pseudo obstruction) § If the cecal diameter is >10 cm = increased risk of
perforation
B. Physical Examination § Obstruction Triad:
1. Vital signs ü Dilated small bowel loops (<3
§ Fever cm)
ü Usually absent in uncomplicated ü Air fluid level
obstruction ü Paucity of air in the colon
ü If present, consider inflammatory (interserosal spaces)
process or strangulation if associated
with leucocytosis and localized 3. Contrast enema
tenderness § Most commonly used to rule out colonic
§ Tachycardia obstruction
ü May be secondary to dehydration/ § Must be done in low pressure
hypovolemia § Barium
a. Dehydration due to third § Water soluble contrast
spacing
ü Cardinal signs of strangulation if
associated with leucocytosis and
localized tenderness

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 GENERAL SURGERY

Treatment
• Most common electrolyte imbalance- Hypokalemia
• 6 Ns in Treating SBO:
o NPO (Nothing per orem)
o NSS → IV fluid hydration Clinical Presentation

o NGT ü
Inability to tolerate liquids and solids by mouth
o aNtacids ü Nausea
o aNtibiotic ü Lack of flatus or bowel movements
o iNwelling Folley Catheter ü Vomiting and abdominal distention
ü Bowel sounds are characteristically diminished or absent
A. Resuscitation
1. Rehydration Diagnosis
§ Rapid volume repletion with NSS until adequate urine
output is established ü
Ileus beyond 3-5 days postoperatively or occurs in the absence of
2. Correction of electrolyte abnormalities abdominal surgery, diagnostic evaluation is needed
3. Indwelling foley catheter to monitor urine output ü Opiates impair intestinal motility
ü Serum electrolytes
B. Nasogastric intubation- for decompression ü Abdominal radiographs/ CT scan
C. Perioperative antibiotics- to prevent further sepsis
Therapy
D. Surgery
§ Conservative treatment vs. operative management
ü Limiting oral intake
ü Correcting the underlying inciting factor
ü Vomiting or abdominal distention are prominent – NGT
a. Operative treatment in SBO ü IV fluids and electrolytes
ü SBO is a surgical emergency and should be ü TPN, early ambulation
treated by laparotomy ü Administration of NSAIDS such as ketorolac
b. Non-operative treatment in SBO ü Reduction in opioid dosing
ü Conservative therapy in the form of NG
decompression and fluid resuscitation is the
initial recommendation for:
1. Partial small bowel obstruction
2. Obstruction occurring in the early
postoperative period
3. Intestinal obstruction due to Crohn’s
disease
4. Carcinomatosis- already indicates that it is
in Stage IV; no need for any radical
intervention


CROHN’S DISEASE
ILEUS
ü
Chronic, idiopathic transmural, inflammatory disease
ü Impaired intestinal motility ü Propensity to affect distal ileum
ü Signs and symptoms of intestinal obstruction in the absence of a ü Any part can be involved
lesion-causing mechanical obstruction ü Slightly more prevalent in females than in males
ü Ileus is a temporary motility disorder that is reversed if corrected ü Third decade
ü Intestinal motility return to normal within the first 24 hours after ü Higher socioeconomic status
laparotomy ü Breastfeeding to be protective
ü Gastric and colonic motility returning to normal by 48 hours and 3-5 ü More prevalent among SMOKERS
days respectively ü Fatty layer of the small intestine goes beyond the borders of the
ü Intra-abdominal abscesses or electrolyte abnormalities small intestine- Fat wrapping
§ Post-operative: consider intra-abdominal abscess →
drain the abscess
§ Percutaneous (UTZ guided): single
§ Open-technique: multiple or near the major blood
vessels

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 GENERAL SURGERY

Clinical Presentation

ü
Abdominal pain, diarrhea, weight loss INTESTINAL FISTULA

ü Depends on which segment of the GIT is affected ü
Fistula – abdominal communication between two epithelialized
ü Patients with Crohn’s disease can be classified by their surfaces
predominant clinical manifestation as having primarily ü Internal Fistula (e.g., enterocolonic fistula or colovesicular fistula)
a. Fibrostenotic disease ü External Fistula (e.g., enterocutaneous fistula or rectovaginal
b. Fistulizing disease fistula)
c. Aggressive inflammatory disease o Low-output fistulas – drain less than 200mL of fluid per
§ 90% of the time associated with poor day
prognosis o High-output fistulas – drain more than 500mL of fluid
ü Affects the small bowel in 80% of cases, and colon alone 20% per day; need to be closed surgically
ü Iatrogenic, post-operative complications, Crohn’s disease or
cancer
Therapy

ü NO curative therapies Diagnosis
ü Goal of treatment is to palliate symptoms
ü Medical therapy is used to induce and maintain disease remission ü CT
ü Surgery is reserved for specific indications o Contrast enhanced (oral, rectal, IV)
o Surgery for Crohn’s disease is very specific due to the o All 3 needed to be done for tumors involving the
fragile nature of the small intestine abdomen; triple contrast enhanced
ü Nutritional support enteral regimens or parenteral nutrition o Fistula- oral and rectal only
o Needed for patient to recovery properply ü Intra-abdominal abscess should be sought and drained
percutaneously
ü Small bowel series
ü Fistulogram

Therapy

ü
Treatment proceed sequence of steps
1. Stabilization → fluid and electrolyte, nutrition is provided,
antibiotics, drainage, ostomy appliances or fistula drains
2. Investigation → diagnosis
3. Decision → available treatment
ü Timing and Surgical Intervention
§ 2-3 months of conservative therapy

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 GENERAL SURGERY

§ 90% of fistulas that are going to close
ü If fistulas fails to resolve during this period → surgery Therapy

ü
Benign symptomatic neoplasm → Surgically resected or removed

endoscopically
SMALL BOWEL NEOPLASM ü EGD → Lesions should be biopsied

ü
Adenomas, most common benign neoplasm
ü Other benign tumors include fibromas, lipomas, hemangiomas, ü In general:
lymphangiomas, and neurofibromas o <1cm → Endoscopic polypectomy
ü Lesions are most frequently encountered in the duodenum during o Lesions >2cm → Removed surgically
EGD ü Surgical Options:
ü Benign neoplasms account for 30 to 50% of small bowel tumors o Transduodenal polypectomy and segmental
and include adenomas, lipomas, hemartomas, and hemangiomas duodenalresection
ü Primary small bowel cancers are rare o Pancreaticoduocenectomy (Whipples)
ü Adenocarcinomas comprise 35-50% of all cases, carcinoid tumors ü The surgical therapy of jejuna and ileal malignancies → Wide local
comprising 20-40% of cases, and lymphomas 10-15% of cases resection
ü Adenocarcinomas → Wide excision of corresponding
Diagnosis ü mesentery
ü Locally advanced or metastatic disease → Palliative intestinal
ü
Rarely diagnosed preoperatively (mostly incidental findings). resection or bypass
Laboratory tests are nonspecific with the exception of the
following:
o Elevated serum 5-hydroxyindole acetic acid (5-HIAA)
levels in patients with carcinoid syndrome RADIATION ENTERITIS

o Elevated carcinoembryonic antigen (CEA) levels are ü
Radiation-induced injury to the small intestine
associated with small-intestineal adenocarcinomas, but ü Malabsorption is a problem
only in the presence of metastases ü 2 distinct syndromes: Acute & Chronic Radiation Enteritis
ü Contrast radiography ü Acute Radiation Enteritis → Transient, in approximately 75%
ü Enteroclysis ü Chronic Radiation Enteritis → In 5-15%
o 90% sensitivity in the detection of small bowel tumors
o Test of choice, particulary for tumors located in the
distal small bowel

GIT Stromal Tumors (GISTS)

ü
Most common mesenchymal tumors
ü Comprise up to 15% of small bowel malignancies
ü Formerly classified as leiomyomas, leiomyosarcomas, and smooth
muscle tumors
ü Frequent site for metastases
th th
ü 5 or 6 decade of life
ü Reported Risk Factors
o Consumption of red meat Therapy
o Ingestion of smoked or cured foods
ü
Most cases of acute radiation enteritis are self-limited
o Crohn’s disease
o Celiac sprue ü Supportive therapy
ü Rarely reduction in or cessation of radiation therapy
ü Surgery only done if needed → Difficult with high morbidity
Clinical Presentation ü Limited resection of diseased intestine

ü
Most are asymptomatic until they become large
ü Partial SBO
ü Associated signs and symptoms of crampy abdominal pain and
MECKEL’S DIVERTICULUM
distention, N/V
ü Obstruction à Luminal narrowing or intussusceptions ü
Most prevalent congenital anomaly of GIT
ü Hemorrhage, indolent, is 2nd most common presentation § 2% of the general population
ü PE may be unrevealing § 3:2 M:F prevalence ratio
ü Jaundice secondary to biliary obstruction or hepatic metastasis (if § True Diverticula → Contains all layers of normal
duodenal area is affected there will be a painless jaundice) intestine
ü Cachexia, hepatomegaly, and ascites may be present with § Usually found in ileum within 100cm of ileocecal valve
advanced disease § 60% contain heterotopic mucosa → >60% gastric
ü Adenocarcinomas, as well as adenomas are most common in mucosa
duodenum ü RULE OF TWO’s
§ 2% prevalence

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 GENERAL SURGERY

§ 2:1 female preponderance ü Need for continuous nutritional support
§ Location 2 ft proximal to the ileocecal valve in adults ü Defined as the presence of <200cm of residual small bowel
§ ½ of those who are symptomatic are under 2yo ü Functional definition, insufficient intestinal absorptive capacity
results in the clinical manifestations of diarrhea, dehydration, and
malnutrition, is more broadly applicable
ü In adults, acute mesenteric ischemia, malignancy, and Crohn’s
disease
ü In pediatric patient à Intestinal atresias, volvulus, and NEC
ü Treatment: TPN, intestinal transplant, or intestinal transplant

Clinical Presentation

ü Asymptomatic
ü Most common symptoms are bleeding, intestinal obstruction,
and diverticulitis
o Bleeding due to ectopic cells which causes erosion of
the bowel
ü Most common disease associated with Meckel’s diverticulum is
appendicitis

Therapy

ü
Diverticulotomy with removal of associated bands
ü Bleeding, tumor, perforation → Segmental resection
ü Incidentally found (asymptomatic)


INTUSSUSCEPTION

ü becomes drawn into the lumen of
One segment of the intestine
the proximal segment of the bowel
ü Intussusceptum: the one that went in
ü Intussuscipient: where it went in
ü Usually in the pediatric population
ü Cecum intussuscepted into the ileum (ileocolic intussusceptions)
ü Treated nonsurgically by radiologic reduction (barium enema
increases pressure which will force the intussusception to resolve)
ü In adults, need to resect due to lead point


PNEUMATOSIS INTESTINALIS

ü
Presence of gas within the bowel wall
ü Common in the jejunum
ü NOT a disease but merely a sign
ü Association with bowel ischemia and infarction
ü Necessitate emergent surgical intervention

SHORT BOWEL SYNDROME

ü
Extent of resection is great enough

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