Bowel Disorders

Suufi
INTESTINAL OBSTRUCTION
• Bowel obstruction is when the normal flow of contents moving
through the intestines is interrupted. 

• The causes of bowel obstruction can be either mechanical or

functional, also called ileus. 

• Obstruction of the gastrointestinal tract may occur at any level, but

the small intestine is most often involved because of its relatively
narrow lumen.
• Mechanical obstruction is caused by actual blockages in the large or 
small intestine, and it can be defined as partial or complete. 
• Partial obstruction is when gas or liquid stool can pass through the
point of narrowing, while complete obstruction is when nothing can
pass. 
• Functional causes disrupt peristalsis, which are the waves of
contraction that move through the smooth muscles of the bowel wall
that pushes food through the intestines. 
Causes of mechanical obstruction
• The most common cause in the small intestine is postoperative
adhesions. 
• After a surgery, the scar tissue that forms during the healing process
can form fibrous bands that cause organs to attach to the surgical site
or to other organs, causing the lumen of the bowel to get kinked or
pinched tight in certain spots. 
• Another cause of small intestinal obstruction is hernias, and they can
occur when a portion of the bowel protrudes out of the abdominal
cavity and can get trapped or tightly pinched at the point where it
pokes out. 
• Mechanical causes for large bowel obstructions, on the other hand, are
most often due to a volvulus,
• which is when a loop of intestine twists upon itself, kinking off the
lumen. 
• Sometimes the volvulus can occur around a mass like in 
colorectal cancer.
• So, when there's a bowel obstruction, whatever the cause, the bowel
 contents distal to the obstruction get passed; but after that happens,
proximal to the obstruction, gas and stool start to accumulate, causing
the bowel to dilate, and therefore, the overall abdominal cavity to
distend. 
• Over time, all this gas and stool causes pressure inside the bowel
 lumen to increase, so the intestinal contents push towards the 
intestinal wall, compressing the mucosal blood and lymphatic vessels. 
• Since the walls of veins and lymphatics are weaker and easier to 
compress compared to arteries, venous and lymphatic drainage are the
first ones to get blocked. 
• The pressure pushes the water in these vessels into the surrounding
tissue, leading to mucosal edema. 
• If pressure inside the lumen gets even higher, it also compresses
mucosal arteries, leading to  ischemia or reduced blood flow to the 
intestinal wall. 
• In turn, ischemia causes  hypoxia, or low oxygen supply. 
• if this pressure becomes high enough, even larger arteries get
compressed, meaning that the arterial supply to more layers of the 
bowel wall is compromised. 
• In other words, bowel ischemia and infarction extend from just the
mucosa to all layers bowel wall, known as a transmural infarction. 
• This may result in perforation, so there’s basically a hole in the bowel
 wall that connects the lumen to the peritoneal cavity. And all the
bacteria that have been accumulating inside the lumen, can now easily
leak out, causing peritonitis. 
• Now, since the layers of the peritoneum are very rich in blood vessels,
large numbers of bacteria from the peritoneal cavity can sneak into the
bloodstream, triggering a massive inflammatory response called sepsis
. 
• In sepsis, blood vessels throughout the body can get leaky, letting the
water in blood escape into the interstitial space. 
• If too much fluid is lost, blood volume drops and so does the 
blood pressure. This leads to a decrease in the amount of blood
reaching vital organs to deliver oxygen and we call this shock.
Ultimately, this can cause organ failure and death.
Intussusception
• Intussusception is a condition that occurs when a part of the intestine
 folds into another section of intestines, resulting in obstruction.
• Intussusception is the most common cause of intestinal obstruction in
infants and young children, with about two-thirds of them happening
among infants under one year of age, though adults can occasionally
have intussusception too. 
• Now, intussusception usually happens in the ileocecal region of the 
intestines, which is where the ileum of the small intestine and cecum
 of the large intestine meet, and almost all intussusceptions happen
when the ileum folds, or telescopes, into the cecum. 
• In adults, telescoping is usually caused by an abnormal growth in the 
intestine, like a polyp or a tumor, which serves as a lead point or
leading edge. 
• What happens is that the normal wave-like contractions of the 
intestine, called peristalsis, grab this leading edge and pull it into the
part of the bowel ahead of it.
• Although these are well known mechanisms for intussusception, the
majority of cases are considered idiopathic, meaning that they happen
without a clear cause.
• Risk factors include
• having had one previously or
• having a sibling with intussusception,
• as well as having intestinal malrotation - which is a condition where
the intestine doesn't rotate correctly during fetal development.
Symptoms
• the first sign is intermittent abdominal pain that worsens with
peristalsis, sometimes causing a child to guard their abdomen—for
example, they may swat away the hands of a caretaker—or draw their
knees up toward the chest. 

• Other classic findings include

• vomiting, and
• the presence of a hard sausage-like mass in the abdomen.
Diagnosis
• In children, intussusception can sometimes be felt by finger while
doing a digital rectal examination, but a definite diagnosis often
requires imaging techniques. 

• An ultrasound, X-ray or computerized tomography (or CT) scan can

reveal a classic bull's-eye, which represents the telescoped intestine
 shown on end, as well as signs of intestinal obstruction.
Treatment
• Intussusception can develop suddenly and because of the possibility
of intestinal ischemia, rapid treatment is necessary.
• A barium or air enema, can be used to unfold the intussusception,
especially in children. 
• If it doesn’t work or if there’s a complication, then surgery may be
necessary. 
• During surgery, the portion of the telescoped intestine is freed, any
obstruction is cleared, and any tissue that died is removed.
Hirschsprung disease
• Hirschsprung disease is also known as congenital aganglionic
megacolon,
• so Hirschsprung’s is a disease that’s present since birth, in which a
ganglion, or cluster of nerves is missing, which ultimately leads to a
blocked colon, causing it to enlarge.
• Well during fetal development, there are cells called neural crest cells, which
are basically a group of fetal cells that migrate away and differentiate into a
variety of different cell types. 
• In this case, some of them become neuroblasts, and eventually the nerve fibers
of the plexuses in the gut. 
• Starting from the mouth, the neuroblasts start migrating toward the anus. 
• Around week 8 of development the neuroblasts get to the proximal colon of
the gut, and pass through the distal colon, and around week 12 they finally the
reach rectum. 
• A disruption of that neuroblast journey in that time window, means that nerve
fibers don’t develop in the rectum and parts of the colon.
• For diagnosis, an abdominal X Ray with contrast dye might shows an
enormous megacolon full of stool that can’t be easily pushed out, but a
definitive diagnosis is by rectal suction biopsy of the narrowed area in
the colon, where both the mucosa and submucosa are extracted, as
opposed to a normal biopsy where just the mucosa is taken. 
• Remember that those plexuses are in the muscle layer or submucosal
layer, so a normal biopsy with just the mucosa wouldn’t cut it, you
need a sample of submucosa to see if the submucosal plexus is there or
not.
• Treatment is typically
surgical resection of the
area that’s lacking the nerve
fibers, and then the healthy
end is connected to the
anus.
Abdominal Hernias
• Abdominal hernias, also called external hernias, are when an
abdominal organ, or part of an abdominal organ protrudes through the
abdominal wall, usually at a site of weakness.
• They can be classified into midline hernias and groin hernias. 
• Most frequent types of midline hernias are the epigastric and 
umbilical hernias, while groin hernias can further be classified into
inguinal and femoral hernias. 
• There’s also incisional hernias, which is when contents herniate
through an incisional scar from a previous abdominal surgery
Midline hernias
• Midline hernias include the epigastric hernia, which is when
abdominal organs herniate through the linea alba, or the part of the
midline between the xiphoid process and the umbilicus. 
• With umbilical hernias, on the other hand, the organ protrudes through
the umbilicus.
Groin hernias
•  groin hernias, which can be classified into inguinal hernias, the more
common type, and 
• femoral hernias. 
• With inguinal hernias, the contents of the abdominal cavity, usually fat
or part of the small intestine, protrude through the inguinal canal.
INGUINAL HERNIAS
• inguinal hernias can be classified
• indirect, or

• direct. .
Indirect inguinal hernias
• Indirect inguinal hernias occur when the processus vaginalis fails to close
during after the testes have passed through it, so this is considered a
congenital hernia. 
• Due to the congenital aspect associated with it, indirect inguinal hernia
 typically occurs in infants and children, but it can also be discovered in
adulthood. 
• When the processus vaginalis remains open, intra-abdominal organs, like the 
intestines, can herniate through the inguinal canal. 
• Specifically, with indirect inguinal hernias, the organs herniate lateral to the
inferior epigastric vessels, through the internal and external rings of the 
inguinal canal, and end up in the scrotum
Symptoms
• small hernias can be asymptomatic,
• but larger hernias appear with pain and a visible, palpable bulge. 
• Incarceration may also interrupt passage of contents through the 
intestines, causing symptoms of bowel obstruction like nausea,
vomiting and fever. 
• With strangulation, there may also be redness, because blood is
trapped in the hernial sac.
VASCULAR DISORDERS OF BOWEL
• The largest portion of the gastrointestinal tract is supplied by the
celiac, superior mesenteric, and inferior mesenteric arteries. As they
approach the intestinal wall, the superior and inferior mesenteric
arteries fan out to form the mesen- teric arcades.

• acute compromise of any major vessel can lead to infarction of

several meters of intestine.
Ischemic bowel disease
• Ischemic damage to the bowel can range from mucosal infarction,
extending no deeper than the muscularis mucosa; to mural infarction
of mucosa and submucosa; to transmural infarction involving all three
layers of the wall.
• infarction becomes more severe as the damage extends from just the
mucosal layer, called a mucosal infarct, to all layers, known as a
transmural infarction.
• Early on bowel ischemia can make the bowels simply not work -
resulting in an ileus - where food lingers and doesn’t get pushed
along. 
• Severe damage to the small intestines can also cause a break in the
epithelial lining of the small intestines, allowing bacteria in the lumen
to get into the blood vessels in the wall. 
• Alternatively, bacteria can completely cross the small intestinal wall
and get into the peritoneal space, and from there get into lymphatics or
blood vessels.
• Ultimately, if bacteria get into the bloodstream then it can lead to a
massive inflammatory response called sepsis. 
• In sepsis, blood vessels throughout the body can get leaky, and if
enough fluid moves from the blood vessels into the interstitial space, it
can lead to septic shock, which is where organs throughout the body
 get insufficient blood. 
• And this can lead to organ failure and death.
Diarrheal Diseases
• Diarrhea is defined as an increase in stool mass, fre- quency, or fluidity, typically
to amounts greater than 200 grams per day.
• It can be classified into four major categories:
• Secretory diarrhea is characterized by isotonic stool and persists during fasting.
• Osmotic diarrhea, such as that occurring with lactase defi- ciency, is due to
osmotic forces exerted by unabsorbed luminal solutes.
• Malabsorptive diarrhea caused by inadequate nutrient absorption is
associated with steatorrhea and is relieved by fasting.
• Exudative diarrhea is due to inflammatory disease and characterized by
purulent, bloody stools that continue during fasting.
• Diarrhea can also be classified as either inflammatory or non-
inflammatory. 
• Inflammatory diarrhea causes inflammation of the gastrointestinal
epithelium and this usually happens with invasive pathogens or as a
result of a chronic inflammatory bowel disease, and usually there are
systemic symptoms like fever. 
• In contrast, non-inflammatory diarrhea can be either secretory or 
osmotic, and neither one usually causes systemic symptoms like
fever. 
Secretory and osmotic diarrhea
• With secretory diarrhea, there’s increased water and electrolyte
secretion and decreased absorption. 

• With osmotic diarrhea, some of the ingested nutrients aren’t fully

absorbed, and they remain in the intestinal lumen and pull in water
through the process of osmosis!
Chronic Diarrhea
•  there’s chronic diarrhea, and the causes vary a bit based on the socio-
economic status of the population. 
• In low-income countries, chronic diarrhea is mostly caused by
infectious organisms such as Giardia, whereas in high-income
countries, chronic diarrhea is mostly caused by 
inflammatory bowel disease, and malabsorption syndromes like 
celiac disease or lactose intolerance.