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Basic Science: Small Bowel. Grace Kim, MD June 6, 2007. Basic Anatomy. 270-290 cm from pylorus to cecum Duo 20 cm Jejunum 100 cm Ileum 150 cm. Studying the SB. UGI and SB follow-through Enteroclysis CT Enteroscopy Push enteroscopy (up to 100 cm past LOT)

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Basic science small bowel l.jpg

Basic Science: Small Bowel

Grace Kim, MD

June 6, 2007


Basic anatomy l.jpg
Basic Anatomy

270-290 cm from pylorus to cecum

Duo 20 cm

Jejunum 100 cm

Ileum 150 cm


Studying the sb l.jpg
Studying the SB

  • UGI and SB follow-through

  • Enteroclysis

  • CT

  • Enteroscopy

    • Push enteroscopy (up to 100 cm past LOT)

    • Double balloon enteroscopy (to TI ideally)

  • Capsule endoscopy (beware: obstruction)



Slide8 l.jpg


Small bowel obstruction l.jpg
Small bowel obstruction presents with nausea, vomiting, and abdominal distention x 5 days. Last BM and flatus 2 days ago. AXR as shown on next slide.

  • Etiology

    • Extrinsic

      • Adhesions (#1)

      • Hernias (#3)

      • Abscess

      • Mass

    • Intrinsic

      • Mass (#2)

      • Foreign body (bezoar, gallstone)


Pathophysiology l.jpg
Pathophysiology presents with nausea, vomiting, and abdominal distention x 5 days. Last BM and flatus 2 days ago. AXR as shown on next slide.

  • Hyperperistalsis

  • Bowel dilatation

  • Third-spacing

  • Decrease in mucosal blood flow

  • Bacterial translocation


Presentation l.jpg
Presentation presents with nausea, vomiting, and abdominal distention x 5 days. Last BM and flatus 2 days ago. AXR as shown on next slide.

  • Crampy abdominal pain

  • Nausea

  • Vomiting

  • Obstipation

  • PE: Vitals; Abdominal exam – scars, hernias, bowel sounds, tenderness, peritonitis; Rectal exam


Imaging labs l.jpg
Imaging/Labs presents with nausea, vomiting, and abdominal distention x 5 days. Last BM and flatus 2 days ago. AXR as shown on next slide.

  • AXR

  • +/- CT scan

  • Chem, CBC, lactate


Treatment l.jpg
Treatment presents with nausea, vomiting, and abdominal distention x 5 days. Last BM and flatus 2 days ago. AXR as shown on next slide.

  • Suspicion for strangulation or bowel compromise

    • Resuscitate and operate

  • Simple obstruction

    • Conservative management (NGT decompression, resuscitate, serial exams)

    • Failure or decompensation

      • Operate

  • Operation: Adhesiolysis +/- bowel resection


Slide15 l.jpg


Is the bowel viable l.jpg
Is the bowel viable? secondary to adhesions, you lyse the adhesions and detorse the small bowel. It appears congested and ischemic immediately after devolvulizing. Should this bowel be resected?

  • Warm saline-soaked lap pads

  • Time and patience

  • Doppler

  • Fluorescein fluorescence

  • Planned second look


Slide17 l.jpg

  • Case: 70 yo woman POD#5 from an exploratory laparotomy and lysis of adhesions for SBO secondary to adhesions c/o abdominal distention. She does not tolerate advancement of diet. She has had one flatus since surgery. Labs significant for WBC 13K, K 3.2. She remains on Dilaudid IV PCA and has been minimally ambulatory.

  • Management?


Diverticular disease l.jpg
Diverticular Disease lysis of adhesions for SBO secondary to adhesions c/o abdominal distention. She does not tolerate advancement of diet. She has had one flatus since surgery. Labs significant for WBC 13K, K 3.2. She remains on Dilaudid IV PCA and has been minimally ambulatory.

  • Duodenal diverticula

    • Asymptomatic – no treatment

    • Symptomatic (biliary obstruction, hemorrhage, perforation, diverticulitis, blind loop) – choledochoduodenostomy or choledochojejunostomy vs. resection or duodenal diverticulization

  • Jejunoileal diverticuli

    • Resect if symptomatic (bleeding, perf)


Meckel s l.jpg
Meckel’s lysis of adhesions for SBO secondary to adhesions c/o abdominal distention. She does not tolerate advancement of diet. She has had one flatus since surgery. Labs significant for WBC 13K, K 3.2. She remains on Dilaudid IV PCA and has been minimally ambulatory.

  • True diverticulum

  • Rule of 2’s: 2% population, symptomatic in 2%, 2 years of life, 2 feet from ICV

  • Rx:

    • Bleeding: Small bowel resection

    • Diverticulitis: ?SBR vs. diverticulectomy

    • Incidental finding in child: Diverticulectomy

    • Incidental finding in adult: Diverticulectomy if low risk


Slide20 l.jpg


Crohn s disease l.jpg
Crohn’s Disease presumed acute appendicitis in a 20 yo woman. You find thickened, inflamed ileum with extensive fat creeping. The cecum is uninvolved, and the appendix is normal.

  • Can involve GI tract from mouth to anus

    • 40% ileocolic, 30% SB only, 30% colon or anorectum only

  • Transmural inflammation, non-caseating granuloma formation

  • Skip lesions

  • Usually spares rectum

  • Medical and surgical treatment is palliative


Slide22 l.jpg

  • 3-7/100,000 presumed acute appendicitis in a 20 yo woman. You find thickened, inflamed ileum with extensive fat creeping. The cecum is uninvolved, and the appendix is normal.

  • Highest incidence in N. America and Europe

  • Bimodal distribution (20-30s and 60s)

  • Etiology unclear

  • Increased risk of developing SB adenocarcinoma (100x)


Presentation23 l.jpg
Presentation presumed acute appendicitis in a 20 yo woman. You find thickened, inflamed ileum with extensive fat creeping. The cecum is uninvolved, and the appendix is normal.

  • Relapsing/remitting abdominal pain and diarrhea with weight loss

  • Extra-intestinal manifestations (30%)

    • Skin lesions (erythema nodosum and pyoderma gangrenosum)

    • Arthritis and arthralgias

    • Uveitis and iritis

    • Hepatitis and pericholangitis

    • Aphthous stomatitis


Diagnosis l.jpg
Diagnosis presumed acute appendicitis in a 20 yo woman. You find thickened, inflamed ileum with extensive fat creeping. The cecum is uninvolved, and the appendix is normal.

  • Barium study of small bowel (linear ulcers, transverse sinuses, and clefts)

  • Endoscopy (discrete ulcers,cobblestoning, skip lesions

  • Adjunctive labs: ASCA positive/pANCA negative


Medical management l.jpg
Medical Management presumed acute appendicitis in a 20 yo woman. You find thickened, inflamed ileum with extensive fat creeping. The cecum is uninvolved, and the appendix is normal.

  • Aminosalicylates (Pentasa, Asacol)

  • Antibiotics (Flagyl, cipro)

  • Corticosteroids

  • Immunosuppresive drugs (6-MP, aza)

  • Anti-TNFα (Infliximab)


Surgery l.jpg
Surgery presumed acute appendicitis in a 20 yo woman. You find thickened, inflamed ileum with extensive fat creeping. The cecum is uninvolved, and the appendix is normal.

  • Reserved for complications and failures of medical management (75%)

  • Indications

    • 1 – Obstruction

    • 2 – Fistula

    • 3 – Perforation/Abscess

    • 4 – Perianal disease

    • 5 – Toxic megacolon


Slide27 l.jpg


Surgical options l.jpg
Surgical options to that segment of bowel involved with the complication and no attempt should be made to resect more bowel even though grossly evident disease may be apparent.

  • Small bowel resection

  • Ileocolic resection

  • Strictureplasty

    • Take mucosal bx first


Small bowel tumors l.jpg

Small Bowel Tumors to that segment of bowel involved with the complication and no attempt should be made to resect more bowel even though grossly evident disease may be apparent.


Slide31 l.jpg

  • Represent 2% of all GI malignancies to that segment of bowel involved with the complication and no attempt should be made to resect more bowel even though grossly evident disease may be apparent.

  • Presentation: intermittent or partial SBO, bleeding, pain, perforation, weight loss

    • Malignant lesions usually will cause sx – based on tumor infiltration

    • Benign lesions may/may not cause sx – based on intussusception

  • Dx: SBFT, enteroclysis, CT, enteroscopy


Benign lesions l.jpg
Benign Lesions to that segment of bowel involved with the complication and no attempt should be made to resect more bowel even though grossly evident disease may be apparent.

  • Adenomas

  • Lipomas

  • Hemangiomas

  • Hamartoma

  • Usually asymptomatic

  • Should be excised or resected


Malignant tumors l.jpg
Malignant Tumors to that segment of bowel involved with the complication and no attempt should be made to resect more bowel even though grossly evident disease may be apparent.

  • Metastatic Disease (cervix, ovaries, renal, stomach, colon pancreas, melanoma)

  • Adenocarcinoma

  • Carcinoids

  • Malignant GIST

  • Lymphoma


Adenocarcinoma l.jpg
Adenocarcinoma to that segment of bowel involved with the complication and no attempt should be made to resect more bowel even though grossly evident disease may be apparent.

  • 50% SB tumors

  • More frequently proximal SB

  • Treatment: Wide resection with 10-cm margins, ?adjuvant

  • Prognosis poor – usually late stage when diagnosed


Carcinoids l.jpg
Carcinoids to that segment of bowel involved with the complication and no attempt should be made to resect more bowel even though grossly evident disease may be apparent.

  • From Kulchitsky cells – enterochromaffin cells

  • Produce 5-HIAA, chromogranins, neuropeptide K, substance P

  • 80% found within 2’ of TI

    • AIR: Appendix (45%), Ileum (28%), Rectum (16%)

  • 10% have carcinoid syndrome (diarrhea, blushing, bronchospasm, hypotension, endocardial fibrosis – R heart failure)

    • Metastatic carcinoid or tumors that bypass the portal system

  • Fibrotic, desmoplastic reaction in mesentery



Slide37 l.jpg


Carcinoids38 l.jpg
Carcinoids presumably from a carcinoid tumor. During induction of general anesthesia, she develops SVT, hypotension, and elevated peak airway pressures.

  • Treatment: Segmental resection

  • Beware: Carcinoid crisis with general anesthesia (Rx: somatostatin, hydrocortisone, antihistamine)

    • prep all patient with preoperative octreotide

  • Adjuvant: doxo, 5-FU, streptozocin, chemoembolization bulky liver disease

  • Palliative for carcinoid syndrome: octreotide

  • Experimental: radionuclide somatostatin agonists “smart bomb”


Last two l.jpg
Last two… presumably from a carcinoid tumor. During induction of general anesthesia, she develops SVT, hypotension, and elevated peak airway pressures.

  • Lymphoma

    • Ileum

    • Risk factors: immunodeficiency, celiac disease

    • Rx: Wide resection with nodes

  • GIST

    • Jejunum/ileum

    • Segmental resection


Vascular l.jpg

Vascular presumably from a carcinoid tumor. During induction of general anesthesia, she develops SVT, hypotension, and elevated peak airway pressures.


Acute mesenteric ischemia l.jpg
Acute Mesenteric Ischemia presumably from a carcinoid tumor. During induction of general anesthesia, she develops SVT, hypotension, and elevated peak airway pressures.

  • Acute-onset pain, out of proportion to exam, fever, Heme (+) stool

  • MI, A-fib, mural thrombus, mitral valve disease

  • Dx: CT scan (good for bowel, large vessels), angiogram, MRA


Slide43 l.jpg

Embolus presumably from a carcinoid tumor. During induction of general anesthesia, she develops SVT, hypotension, and elevated peak airway pressures.

Acute onset without antecedent sx

Lodge distal to middle colic and jejunal branches of SMA

Sparing of proximal jejunum and R colon

Thrombus

Antecedent intestinal angina

Origin of vessel

Entire SB and R colon affected


Nonocclusive mesenteric ischemia nomi l.jpg
Nonocclusive Mesenteric Ischemia (NOMI) presumably from a carcinoid tumor. During induction of general anesthesia, she develops SVT, hypotension, and elevated peak airway pressures.

  • Optimize fluid resuscitation

  • Improve CO

  • Eliminate vasopressors

  • Selective vasodilatory injection (papaverine)

  • Bowel resection for frankly necrotic bowel


Mesenteric embolic disease l.jpg
Mesenteric Embolic Disease presumably from a carcinoid tumor. During induction of general anesthesia, she develops SVT, hypotension, and elevated peak airway pressures.

  • Surgical embolectomy

    • Exposure of SMA

    • Transverse or longitudinal arteriotomy (vein patch)

    • 3 and 4-Fr Fogarty embolectomy


Acute mesenteric thrombotic disease l.jpg
Acute Mesenteric Thrombotic Disease presumably from a carcinoid tumor. During induction of general anesthesia, she develops SVT, hypotension, and elevated peak airway pressures.

  • Bypass

    • Antegrade or retrograde

    • Conduit: autologous greater saphenous vein (acute situation)

    • Inflow: supraceliac aorta, infrarenal aorta, iliac artery


Outcome l.jpg
Outcome presumably from a carcinoid tumor. During induction of general anesthesia, she develops SVT, hypotension, and elevated peak airway pressures.

  • Perioperative mortality 62%

    • MODS, ischemia/reperfusion insult

  • Long-term TPN 31%


Chronic mesenteric ischemia l.jpg
Chronic Mesenteric Ischemia presumably from a carcinoid tumor. During induction of general anesthesia, she develops SVT, hypotension, and elevated peak airway pressures.

  • Chronic post-prandial abdominal pain in a vasculopath

  • Dx: Duplex, angiogram


Management l.jpg
Management presumably from a carcinoid tumor. During induction of general anesthesia, she develops SVT, hypotension, and elevated peak airway pressures.

  • Visceral Bypass

    • One or two-vessel bypass

    • Inflow: supraceliac, infrarenal

    • Conduit: Vein or PTFE/Dacron

  • Endovascular

    • PTA

    • *not many studies supporting management


Outcome50 l.jpg
Outcome presumably from a carcinoid tumor. During induction of general anesthesia, she develops SVT, hypotension, and elevated peak airway pressures.

  • Mortality 8%, morbidity 30% (includes acute)

  • Primary patency 89% at 72 months

  • 5-yr survival 64%, 3-yr symptom-free rate 81%

  • Endovascular approaches promising – more recent studies: similar symptom-free rate with lower morbidity and mortality


Slide51 l.jpg


Enterocutaneous fistula l.jpg

Enterocutaneous Fistula who presented with an SBO secondary to a strangulated incisional hernia. She is slow to regain bowel function. On POD#6, her wound appears erythemaous. You open it at the bedside, and purulent, feculant material is returned.


Slide53 l.jpg


Initial management l.jpg
Initial Management perioperative hemodynamics, bowel prep

  • Resuscitate

  • Imaging

  • Consider abx

  • Nutritional support

  • Control of fistula drainage

  • Skin care

  • Consider somatostatin


Impediments to closure l.jpg
Impediments to closure perioperative hemodynamics, bowel prep

  • High output (>500 mL/24 hr)

  • Severe disruption of intestinal continuity (>50% of bowel circumference)

  • Active inflammatory bowel disease of bowel segment

  • Cancer

  • Radiation enteritis

  • Distal obstruction

  • Undrained abscess cavity

  • Foreign body in the fistula tract

  • Fistula tract <2.5 cm in length

  • Epithelialization of fistula tract


Secondary management l.jpg
Secondary Management perioperative hemodynamics, bowel prep

  • Fistulogram (one week later)

    • Define anatomy

    • Rule out distal obstruction

  • Failure of conservative management

    • Operate: small bowel resection


Short gut l.jpg

Short Gut perioperative hemodynamics, bowel prep


Short bowel l.jpg
Short bowel perioperative hemodynamics, bowel prep

  • Less than 200 cm healthy small intestine

  • Downside of TPN

    • Liver failure

    • Cholelithiasis

    • Line sepsis

    • Venous thrombosis

  • Adaptive response: 1-2 years


Medical therapy l.jpg
Medical Therapy perioperative hemodynamics, bowel prep

  • Diarrhea: Immodium, lomotil, opiods

  • Bile salt-induced diarrhea: cholestyramine

  • Electrolyte losses: replete IV/PO

  • Hypergastrinemia: H2 blocker or PPI

  • Vitamin/Mineral deficiencies: Monitor and replete

  • Bacterial overgrowth: Flagyl, tetracycline

  • Enteral nutrition with supplemental TPN


Surgical therapy l.jpg
Surgical Therapy perioperative hemodynamics, bowel prep

  • Reanastomose

  • Gastrostomy over jej

  • Intestinal valves (iatrogenic intussusception

  • Reversed segment

  • Tapering enteroplasty (Bianchi procedure)

  • Intestinal tranplantation