د.منذر العبيدي
SURGERY
SURGERY OF SMALL INTESTINE
Surgical anatomy
It start from the D.J. junction to ileo caecal valve. It is 5m long. derived from the mid gut. It consist of jejunum 2/5 and ileum 3/5 the wall of the jejunum is thicker, lumen is wider than the ileum , jejunum is redder than ileum . jejunum has 2 series of arterial arcade while the ileum has more than 2 arterial arcade . jejunum lies in the upper part of infracolic compartment while the ileum lies in the lower part and the pelvis. While the large intestine have taeniae coli and appendices epiploice.
Blood supply : Superior mesenteric artery
Nerve supply :
1) Parasympathetic secretomotor .
2) Sympathetic inhibitor to muscle wall and inhibit peristalsis & sensory fiber to C.N.S.
3) Peritoneal pain somatic in nature more precise localized to the site of organ.
4) Visceral pain.
Investigation :
1) Plain X-ray abdomen erect and supine can diagnose intestinal obstruction by finding multiple fluid and gas shadow .
2) Barium fallow through can diagnose polyp , diverticulum , tumor .
3) Jejunal biopsy .
4) Selective superior mesenteric artery angiogram .
5) Abdominal ultrasound . 6) CT. 7) M.R.I. 8) blood tests.
Diseases of small intestine
Congenital malformation
1- Congenital atresia or stenosis feature of intestinal obstruction do X-ray abdomen treatment by laparotomy resection plus anastamosis .
2- Arrested rotation : the caecum remain in the left hypochondrium there is a congenital band running from caecum to right abdomen ,feature of intestinal obstruction do laparotomy and cut the band.
3- volvulus neonatorum due to congenital band between caecum at lt. Hypochondrium and right abdomen do lap. Undo the volvulus it is in the clock wise in direqtion also cut the band.
4- meconium ileus terminal ileum filled with viscid pancreatic secretion it will be thick and give Int. obs. . do lap. Resection with anastamosis .
5- haemengioma capillary of cavernous , causes bleeding might lead to shock usually at middle age differentiate it from tumour or diverticulitis or ulcerative colitis . do selective angio can see the site of bleeding treatment resuscitation plus lap. + resection+ anastomosis.
6- failure of descent of the caecum, It remain high up near the Liver.
Diverticula of small intestine
it occur from stomach down to recto sigmoid junction :
1-congenital all three coats of the bowel are present in wall .
2-required the wall. of diverticulum lack of mucosa and muscle layers .
Jejunal diverticula : solitary or multiple . Either
symptoms less or give rise to abdominal pain , flatulence and
borborygmi or produce malabsorption syndrome this will lead
to anaemia , steatorrhoea, hypoproteinaemia and avitaminosis .
diagnosis by barium fallow through .
Treatment
1- conservative
2- surgical. By resection + anastamosis .
Ileal diverticula : congenital or acquired. Solitary or multiple.
Meckel diverticilum :
Arise from anti mesenteric border 2% of population , 2 feet away from ileo caecal valve , 2 inches in diameter . it is one of the differential diagnosis of acute abdomen.
Complication :
1- meckelian diverticulitis
2- gastric mucosa a. bleeding b. Chronic Peptic Ulcer c. perforation
d. intussuseption e. intestinal obstruction by band .
Treatment:
Do laparotomy With resection either wedge or excision with anastamosis.
Traumatic rupture of the small intestine:
1- By open wound e.g. bullet or stab wound .
2- Closed injury e.g. blow on the abdomen or crush injury of the intestine against the promontory of the sacrum , or a fixed part S.I. at D.J. flexure. or at ileo Caecal region.
3- Rupture of small Intestine. In irreducible inguinal Hernia symptom . History abdominal pain signs . feature of acute abdomen + hemorrhage + peritonitis .
Investigation :
Chest X-Ray , X-Ray abdomen , Blood test , Blood transfusion.
Treatment:
Laparotomy
1-Simple closure to the perforation .
2-Laceration to the mesentry : suture it
3-If a segment of small intestine is damaged : Do resection.
TB intestine
1.Ulcerative TB : Is secondary to pulmonary TB and arise
as a result of swallowing the tubercle bacilli , its characterized
by presence of multiple ulcers in the terminal ileum , its
complications is rupture and stricture formation .
2.Hyoerplastic TB : It affect iliocecal region , the
causative , bacteria is mycobacterium bovis , this cause
thickening to the wall of intestine and then narrowing of its
lumen , the regional lymph nodes involvement which may
caseat , if not treated it will cause complete or partial intestinal
obstruction.
Clinical feature of TB intestine : poor health ,
weight loss, abdominal pain , diarrhea , distended abdomen ,
mass RIF .
radiography:
Ba-Follow through: shows narrow lumen ileum , caecum , ascending colon with filling defects.
Treatment :
1- Anti-TB drug + good diet : may cure this condition .
2- Surgery : indicated if there is intestinal obstruction, do laporarotomy+ Rt. Hemicolectomy or Do ileotransverse
anastomosis .
Surgical Complications of Typhoid Fever
1-paralytic ileus .
2-Hemorrhage.
3-Perforation.
4-acute cholecystitis.
5-phlebitis.
6-genitourinary.
7-joints & bone.
Crohn’s disease ( regional enteritis )
Described by Crohn in 1932 describing young adult with chronic inflammation of the ileum , no causative organisms has been found , it's a granulomatous disease affect the GIT from the mouth down to the anus but the most common area affected is the terminal ileum and the colon.
Pathology: There is fibrotic thickening of the intestinal wall with narrow lumen with ulceration to the mucosa with stricture formation , the intestine proximal the stricture will be dilated then will be adhesions and fistula formation into adjacent organ's. There is thickening to the mesentry with enlarged mesentric lymph nodes , the condition discontinue with inflammed area separated from normal intestine it is called skip lesions and it is a premalignant condition.
Types :.
1-Acute Crohn’s disease : occur only in 5% of the disease , symptoms and signs are similar to acute abdomen , if the abdomen is opened on the mistake of diagnosis of acute abdomen & found the condition is crohn's disease , do not do appendicectomy otherwise external fistula will result .
2-Chronic Crohn’s disease : there is historv of diarrhea and intestinal colic , pain RIF , there may be tender mass RIF , fever , anemia , Wt. Loss , perianal abscess and fistula, fissure .
Then as the disease progress it will lead to acute or chronic intestinal obstruction also there will be fibrosis , adhesion , and stenosis .
Investigations :
1-Ba meal & follow through : cobblestone appearance with lack of normal mucosa and stricture formation called String sign of Kantor .
2-Sigmoidoscopy & Colonoscopy with biopsy.
Treatment:
1-Medical : By giving Steroid , salazopyrine ,azathioprine , antibiotic. Treat anemia and hypoproteinemia.
2-Surgical : It does not cure the condition but to treat its complication , and these complication are :
1- Recurrent intestinal obstruction.
2- Bleeding.
3- Perforation.
4- Failure of medical treatment.
5- Intestinal fistula.
6- Malignant changes.
a) Rt. Hemicolectomy.
b) segmental resection.
c) colectomy .
Tumours of small intestine
1-Benign : ( Liomyoma , lipoma , polyps , Peutz-Jegher's its a familial intestinal polyposis with melanin spots on the lips of the patients , it causes bleeding and intussusception .Malignant changes rarely occur ,resection if there is bleeding .
2-Maligmant : lymphoma [ 3 types : (1) Western type of lymphoma (2) Primary lymphoma (3) Meditenanean lymphoma.
Clinical feature : malabsorption , diarrhea, wt. Loss , anemia , hypoproteinemia, avitaminosis, perforations , intestinal obstruction and bleeding.
Treatment : ( Surgical + Chemotherapy )
3-Carcinoma : clinical feature and treatment same as lymphoma.
4-Leiomyosarcoma .
Carcinoid ( Argentaffin Tmour )
Occur in GIT , bronchus , testis and ovary , The commonest site is appendix 65 % , ileum 25%, they arise from the neuroendocrine cells at the base of intestinal crypts . The primary is small and metastasis to the liver, carcinoid is yellow in color , it secrete 5-hydroxy tryptamine ( serotonin ) causing reddish blue cyanosis , flushing attack, diarrhea, borborygmi , asthmatic attack , pulmonary or tricuspid stenosis.
Treatment :
(1) Rt. Hemicolectomy ,
(2) partial hepatectomy
(3) somatostatin analogue which reduce flushing and diarrhea
(4) octreotide to prevent carcinoid crises.
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