Intestinal Resection Ileal resection Vitamin B 12 Bile

Intestinal Resection Ileal resection ØVitamin B 12 & Bile salt malabsorption. ØWatery diarrhea & Fat malabsorption. ØLithogenic bile formation: Gallbladder stones. ØOxalate renal stones. Investigations ØBarium Follow through. ØTests for B 12 & Bile acid absorption. Treatment ØParenteral Vit. B 12 supply. ØColystyramine or Aluminium Hydroxide for diarrhea.

Ileal resection Usually occurred following surgery for Crohnss disease.

Massive Resection ( Short Bowel Syndrome ) Etiology: Ø Children: 1 -Congenital anomalies ( Artesia , Volvulus ). 2 -Necrotizing Enterocolitis. Ø 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. Ø Ø Jejunum-colon patient ( Jejuno-ileal resection with jejunocolic anastamosis). Ø Jejunostomy patients (Jejuno-ileal resection& colectomy)

Effects of short bowel syndrome Jejunum-colon gradual diarrhea, weight loss Jejunostomy Ø Clinical Rapid fluid loss Ø Water/electrolytes depletion: Ø Malabsorption nutrients: Ø D-lactic acidosis: +/- Ø Oxalate renal calculi: ++ - Ø Pigment gallstones: ++ ++ Ø Gut adaptation: + - Ø Impact on quality of life: +/- ++ ++ diarrhea +++ - High output , Dehydration Parenteral nutrition

Clinical features: Ø Diarrhea & Steatorrhea Fluid loss. Ø Dehydration & Signs of hypovolemia. Ø Weight loss, loss of muscle bulk. Management: Ø Nutritional assessment. Ø Monitoring of fluid & electrolytes balance. Ø Adequate calories & protein intake. Ø Replacement of Vit. B 12 , Calcium , vit. D , Magnesium , Zinc & Folic acid. Ø Anti-diarrheal agents ex. Loperamide , Codeine phosphate, Octeriotide s. c injection.

Radiation Enteritis & Proctocolitis Clinical features: A-Acute phase: Ø Nausea , vomiting , cramping abdominal pain & diarrhea. Ø Rectal involvement: rectal mucus , tenesmus & bleeding. B-Chronic complications: Ø Proctocolitis. Ø Small bowel stricture. Ø Fistulae: Recto-vaginal , colo-vesical. Ø Adhesions. Ø 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: Ø Ø Ø Ø Anti- diarrheal agents. Local steroid enemas. Antibiotic. Nutritional supply. Colystyramin ( 4 g ). Endoscopic laser therapy. Surgery for complications.

Motility disorders Chronic intestinal pseudo-obstruction Causes: v Primary or Idiopathic: 1 -Rare familial visceral myopathies or neuropathies. 2 -Congenital aganglionosis. v 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: q q q Recurrent episodes of nausea , abdominal discomfort & distension. Alternating constipation & diarrhea. Weight loss from malabsorption, fear of eating. Dysphagia. Bladder dysfunction. Investigations: q q 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: q q 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 Ó Is often fatal if not treated. Ó Respond to co-trimoxazole & to lesser degree to Tetracycline. Ó Symptoms resolve within a week & biopsy changes revert to normal in few weeks. Ó 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: Lactose Lactase Glucose + galactose Primary ( Racial ). o Secondary ( Lactase deficiency ): 1 -Coeliac disease. 2 -Viral gastroenteritis. o Clinical features: Asymptomatic. o Colicky abdominal pain, abdominal distension, diarrhea. o Picture like IBS. ** Lactose hydrogen breath test s useful non invasive confirmatory test ** o Treatment: lactose exclusion. Ø Commercial lactase preparations supply. Ø

Food allergy: Immune mediated disorders due to Ig. E Ab & 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. Ø Lesions >2 cm : local extension & metastasis to the liver. Ø In the rectum & appendix usually benign. Carcinoid syndrome Systemic symptoms produced when secretory products of the neoplastic enterochromafin cells reach the systemic circulation ( 5 HT, serotonin) Bradykinin are released by hepatic metastasis.

Clinical features F Small bowel obstruction. F Intestinal ischemia. F Hepatic metastasis: pain , hepatomegaly. F Flushing & wheezing. F Diarrhea. F Cardiac involvement: TR, PS & Heart failure. F Facial telangectasia.

Management Surgical resection. Treatment of Carcinoid syndrome is palliative. Surgical resection of the primary & hepatic secondaries. Octeriotide 200 Mg 8 h.

Lymphoma Non Hodgkin's lymphoma occur with increased frequency in patients with Coeliac disease , AIDS & other immune deficiency states. Æ Mostly B cell origin , while in Coeliac Enteropathy associated T –cell lymphoma. Ê Presentations: Æ Æ Æ 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 q Acute Small Bowel Ischemia: ØOcclusive: Emboli from the heart. ØNon-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: Í Increased WBC count. Í Metabolic acidosis. Í Hyperphosphetemia. ÍIncreased S. Amylase. ÍPlain XR: Thumb printing. ÍMesenteric Angiography:

Treatment Resuscitation. Correction of heart disease. IV antibiotics. Laprotomy. Embolectomy & vascular reconstruction. Small bowel transplantation.

q 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 Ø Caused by mycobactium Tuberculosis , which is swallowed after coughing. Ø Many patients have no pulmonary symptoms & a normal CXR. Ø Ileocaecal region is the most commonly affected area. Ø The presentation & radiological findings may be very similar to those of crohns disease.

Ø Abdominal pain can be acute or chronic but diarrhea less than in Crohns disease. Ø Low grade fever is common but not invariable. Ø Like Crohns disease TB can affect any part of GIT & perianal disease with fistula is recognized. Ø Peritoneal TB may result in peritonitis with exudative ascites associated with abdominal pain & fever. Ø Granulomatous hepatitis occurs.

Diagnosis: Ø Elevated ESR Ø Raised serum alkaline phosphatase concentration suggest hepatic involvement. Ø Histological confirmation by endoscopy , laparoscopy or liver biopsy ( caseation granuloma , Acid & alcohol fast bacilli ) may be seen. Ø Culture may take 6 weeks , Diagnosis is now possible on biopsy specimens using PCRbased techniques.

Management Ø When the presentation is very suggestive of abdominal TB chemotherapy with 4 drugs INH , Rifampicin , Pyrazinamide & Ethambutol should be commenced.