Intestinal Resection Ileal resection Vitamin B12 & Bile salt malabsorption. Watery diarrhea & Fat malabsorption. Lithogenic bile formation: Gallbladder stones. Oxalate renal stones. Investigations Barium Follow through. Tests for B12 & Bile acid absorption. Treatment Parenteral Vit.B12 supply. Colystyramine or Aluminium Hydroxide for diarrhea.
Ileal resectionUsually occurred following surgery for Crohnss disease.
Massive Resection ( Short Bowel Syndrome ) Etiology: • Children: 1-Congenital anomalies ( Artesia ,Volvulus ). 2-Necrotizing Enterocolitis. • Adults: 1- Crohns disease. 2-Mesenteric infarction. 3-Radiation Enteritis. 4-Volvolus.
MAIN TYPES OF SHORT BOWEL SYNDROME • Jejunal resection with intact ileum: This is uncommon & nutritional support is rarely needed. • Jejunum-colon patient ( Jejuno-ileal resection with jejunocolicanastamosis). • Jejunostomy patients (Jejuno-ileal resection& colectomy)
Effects of short bowel syndrome Jejunum-colon Jejunostomy • Clinical gradual diarrhea, weight loss Rapid fluid loss • Water/electrolytes depletion: +/- ++ • Malabsorption nutrients: ++ +++ • D-lactic acidosis: +/- - • Oxalate renal calculi: ++ - • Pigment gallstones: ++ ++ • Gut adaptation: + - • Impact on quality of life: diarrhea High output , Dehydration Parenteral nutrition
Clinical features: • Diarrhea & Steatorrhea Fluid loss. • Dehydration & Signs of hypovolemia. • Weight loss, loss of muscle bulk. Management: • Nutritional assessment. • Monitoring of fluid & electrolytes balance. • Adequate calories & protein intake. • Replacement of Vit.B12 , Calcium , vit. D , Magnesium , Zinc & Folic acid. • Anti-diarrheal agents ex. Loperamide , Codeine phosphate, Octeriotide s.c injection.
Radiation Enteritis & Proctocolitis Clinical features: A-Acute phase: • Nausea , vomiting , cramping abdominal pain & diarrhea. • Rectal involvement: rectal mucus , tenesmus & bleeding . B-Chronic complications: • Proctocolitis. • Small bowel stricture. • Fistulae: Recto-vaginal ,colo-vesical. • Adhesions. • Malabsorption: Bacterial overgrowth, bile salt malabsorption ( Ileal damage ).
Investigations: In acute phase rectal changes at sigmoidoscopy: like ulcerative proctitis. Barium follow through: Small bowel stricture, ulcer & fistulae. Management: • Anti- diarrheal agents. • Local steroid enemas. • Antibiotic. • Nutritional supply. • Colystyramin ( 4 g ). • Endoscopic laser therapy. • Surgery for complications.
Motility disordersChronic intestinal pseudo-obstruction Causes: • Primary or Idiopathic: 1-Rare familial visceral myopathies or neuropathies. 2-Congenital aganglionosis. • Secondary: 1- Drugs: ex. Opiates ,TCA , Phenothiazines. 2-Smooth muscle disorders: ex. Scleroderma. 3-Myenteric plexus disorders : ex. Paraneoplastic syndrome. 4-CNS disorders: ex. Parkinsonism. 5-Endocrine & Metabolic disorders: ex. hypothyroidism.
Clinical features: • Recurrent episodes of nausea , abdominal discomfort & distension. • Alternating constipation & diarrhea. • Weight loss from malabsorption, fear of eating . • Dysphagia. • Bladder dysfunction. Investigations: • Plain abdominal X-Ray: Distended loops of the bowel + air fluid level. • Barium studies: No mechanical obstruction. • Laparotomy: to exclude obstruction & to obtain full thickness biopsies of the intestine. • Electron microscopy, Histochemistry & especial stain for deficiency of rare & specific syndromes. Management: • Treatment of underlying cause. • Prokinetic agents ( Domperidone ). • Antibiotic. • Nutritional & psychiatric support.
Whipple,s disease • Characterized by infiltration of intestinal mucosa by (foamy macrophages) which stain +ve with Periodic Acid Shiff ( PAS ) reagent. • Multisystem involvement. • EM: G +ve Bacilli ( Tropheryma whippelli) within the macrophages. • Villi are widened & flattened . • Obstruction of lymphatic cause fat malabsorbtion.
Management • Is often fatal if not treated. • Respond to co-trimoxazole & to lesser degree to Tetracycline. • Symptoms resolve within a week & biopsy changes revert to normal in few weeks. • Long term follow up is essential. relapse usually occur in CNS which treated by:2 weeks of parenteral ceftriaxone, followed by 6-12 months of oral co-trimoxazole.
Adverse Food Reaction Food intolerance Lactose intolerance: LactoseGlucose + galactose • Primary ( Racial ). • Secondary ( Lactase deficiency ): 1-Coeliac disease . 2-Viral gastroenteritis. Clinical features: • Asymptomatic. • Colicky abdominal pain, abdominal distension, diarrhea. • Picture like IBS. ** Lactose hydrogen breath test s useful non invasive confirmatory test ** Treatment: • lactose exclusion. • Commercial lactase preparations supply. Lactase
Food allergy: • Immune mediated disorders due to IgEAb & type 1 hypersensitivity reaction. • Culprits: are peanuts , milk, Soya …. Etc. Clinical manifestations: • Trivial – Life threatening or even fatal anaphylaxis. • Oral allergy syndrome: Urticaria & angioedema. • Allergic gastroenteropathy. • Gastrointestinal anaphylaxis. ** Double blind placebo- controlled food challenges are the gold standard ** Treatment: • Elimination of offending antigen. • Antihistamines. • Disodium cromoglycate. • Treatment of anaphylaxis.
Tumours of the small intestine Benign Tumours: Adenoma , Leiomyoma , Lipoma & Hamartoma Adenoma usually occur in preampullary area. Usually asymptomatic , occult bleeding , obstruction due to intussusceptions , may be multiple ( FAP ). Hamartoma occur in Peutz-Jegher syndrome ( non malignant )
Malignant tumours Adenocarcinoma , Carcinoid , Liemyosarcoma, Lymphoma , Kaposi sarcoma in AIDS patients. Adenocarcinoma: FAP Coeliac disease Peutz-Jeghers syndrome Investigations: Barium Follow through Small bowel enema. Enteroscopy Mesenteric angiography CT scan
Carcinoid tumours Derived from enterochromafin cells & most common in ileum. • Lesions >2cm :local extension & metastasis to the liver. • In the rectum & appendix usually benign. Carcinoid syndrome Systemic symptoms produced when secretory products of the neoplastic enterochromafin cells reach the systemic circulation ( 5HT, serotonin) Bradykinin are released by hepatic metastasis.
Clinical features • Small bowel obstruction. • Intestinal ischemia. • Hepatic metastasis: pain , hepatomegaly. • Flushing & wheezing. • Diarrhea. • Cardiac involvement: TR, PS & Heart failure. • Facial telangectasia.
Management • Surgical resection. • Treatment of Carcinoid syndrome is palliative . • Surgical resection of the primary & hepatic secondaries. • Octeriotide 200 Mg 8h.
Lymphoma • Non Hodgkin's lymphoma occur with increased frequency in patients with Coeliac disease , AIDS & other immune deficiency states. • Mostly B cell origin , while in Coeliac Enteropathy associated T –cell lymphoma. Presentations: • Abdominal pain. • Malabsorption. • Obstruction. • Weight loss. • Perforation • Hepatosplenomegaly is rare.
Investigations: • Small bowel biopsy. • Barium follow through. • CT scan. Treatment: • Surgical resection. • Radiotherapy + Combination chemotherapy. Prognosis: • Stage at diagnosis. • Cell type. • Patient age. • Presence of B symptoms
Ischemic Gut Injury • Acute Small Bowel Ischemia: • Occlusive: Emboli from the heart. • Non-occlusive: Decrease BP HF Arrhythmia. Sudden blood loss Pathology:Transient alteration of bowel function. Transmural haemorrhage: Gangrene.
Clinical features • Abdominal pain+ • Abdominal distension + • Signs of peritonitis. Investigations: • Increased WBC count. • Metabolic acidosis. • Hyperphosphetemia. • Increased S. Amylase. • Plain XR: Thumb printing. • Mesenteric Angiography:
Treatment • Resuscitation. • Correction of heart disease. • IV antibiotics. • Laprotomy. • Embolectomy & vascular reconstruction. • Small bowel transplantation.
Chronic Mesenteric ischemia Atherosclerosis of 2 or more Celiac axis branches. Clinical features: Post brandial pain. Weight loss. Diarrhea. O/E: Signs of generalized arterial disease Abdominal bruit. Mesenteric angiography confirm the diagnosis. Treatment: Vascular reconstruction.
Abdominal Tuberculosis • Caused by mycobactium Tuberculosis , which is swallowed after coughing. • Many patients have no pulmonary symptoms & a normal CXR. • Ileocaecal region is the most commonly affected area. • The presentation & radiological findings may be very similar to those of crohns disease.
Abdominal pain can be acute or chronic but diarrhea less than in Crohns disease. • Low grade fever is common but not invariable. • Like Crohns disease TB can affect any part of GIT & perianal disease with fistula is recognized. • Peritoneal TB may result in peritonitis with exudative ascites associated with abdominal pain & fever. • Granulomatous hepatitis occurs.
Diagnosis: • Elevated ESR • Raised serum alkaline phosphatase concentration suggest hepatic involvement. • Histological confirmation by endoscopy , laparoscopy or liver biopsy ( caseation granuloma ,Acid & alcohol fast bacilli ) may be seen. • Culture may take 6 weeks , Diagnosis is now possible on biopsy specimens using PCR-based techniques.
Management • When the presentation is very suggestive of abdominal TB chemotherapy with 4 drugs INH , Rifampicin , Pyrazinamide & Ethambutol should be commenced.