Intestinal Failure and other Small Bowel Problems Flashcards
What is intestinal failure?
Where the gut is no longer able to supply the hydration and nutritional needs of the body
What is acute intestinal failure?
Short term (2 weeks) Type I and II intestinal failure e.g. mucositis post chemo
What is chronic intestinal failure?
Long term
Type III intestinal failure
e.g. short gut syndrome
What is Type I intestinal failure?
Self limiting, short term
Post operative or paralytic ileus
What is Type II intestinal failure?
Prolonged
Accosted with sepsis or metabolic complications
Often related to abdo surgery with complications
What is Type III intestinal failure?
Long term but stable
Home parenteral neutron often indicated
How is Type I intestinal failure managed?
Fluid replacement, correct electrolytes
Parenteral nutrition if unable tolerate food/fluids after a week
Acid suppression: PPIs
Octreotide
Mg preservation (a hydroxycholecalciferol)
Allow some enteral feeding if poss
Which veins are generally used for parenteral nutrition?
Large veins, especially in the neck
What are the complications of parenteral nutrition?
Pneumothorax Arterial puncture Misplacement Sepsis SVC thrombosis Line fracture/leakage/migration Metabolic bone disease Nutrient toxicity/insufficiency Liver disease Metabolic disturbance Psycho-social Inappropriate usage
What are the feeding options for Type II intestinal failure?
Parenteral +/- some enteral feeding
What are the two current options for management of Type III intestinal failure?
Home parenteral nutrition
Intestinal transplantation
What conditions could result in Type III intestinal failure and require HPN?
Short gut syndrome Crohn's disease Neoplasia (not an indication in the UK) Vascular Mechanical Radiation enteritis Dysmotility
What is short bowel syndrome?
A bowel of less than 200cm
Insufficient length to meet nutritional needs without artificial nutrimental support
At what length must the small bowel be in order to indicated HPN?
Less than 50cm + all of colon
Less than 100cm + no colon
What are the main indications for small bowel transplantation?
Loss of venous access for HPN or liver disease
usually combined with liver transplant
Where is the blood supply for the small bowel derived from?
Superior mesenteric artery
What are the causes of small bowel ischaemia?
Mesenteric arterial occlusion =
Mesenteric artery atherosclerosis
Thromboembolism from heart
Non occlusive perfusion insufficiency = Shock Strangulation obstructing venous return Drugs Hyperviscosity
How is acute ischaemia of the small bowel classified?
By degree of infarction caused (mucosal, mural or transmural)
The longer the period of hypoxia, the more severe the ischameia
What are the complications of small bowel ischaemia?
Resolution
Fibrosis, stricture, chronic ischaemia, “mesenteric angina and obstruction
Gangrene, perforation, peritonitis, sepsis and death
What causes Meckel’s Diverticulum?
Incomplete regression of the vitello-intestinal duct
What are the complications of Meckel’s Diverticulum?
Often asymptomatic
May cause bleeding, perforation or diverticulitis which mimics appendicitis
Which types of tumours are more common in the small bowel?
Primary are rare
Metastases from ovary, colon and stomach are more common
What are some primary tumours of the small bowel?
Lymphomas
Carcinoid tumours
Carcinomas
What types of lymphoma occur in the small bowel, and what is their treatment?
All non-Hodgkins in type
Maltomas (b-cell) derived
Enteropathy associated with T-cell lymphomas (associated with coeliacs)
Surgery and chemotherapy
What is the most common site for carcinoid tumours of the small bowel?
Appendix
What are carcinoid tumour of the small bowel like?
Small, yellow, slow growing
Locally invasive
Produce hormone like substances
What are the complications of carcinoid tumours of the small bowel?
Can cause intussusception, obstruction
If metastases to the liver, a carcinoid syndrome occurs, producing flushing and diarrhoea
What is the pathology of acute appendicitis?
Aute inflammation (neutrophils), which MUST involve the muscle coat
Mucosal ulceration
Serosal congestion, exudate
Pus in lumen
What are the complications of appendicitis?
Peritonitis Rupture Abscess Fistula Sepsis and liver abscess
What is coeliac disease?
An abnormal reaction to gluten which damaged enterocytes and reduces absorptive capacity
What does coeliac disease have a strong association with?
HLA-B8
Dermatitis herpetiformis
Childhood diabetes
What is the aetiology of coeliac disease?
Glaidin (component of gluten) is the suspected toxin
Tissue injury may be a bystander effect of abnormal autoimmune reaction to Glaidin
Mediated by T-cell lymphocytes which exist within the small intestinal epithelium
What does the surface epithelium of the small bowel look like in coeliac disease?
Loss of villous structures due to loss of enterocytes from IEL mediated damage
What is the result of the loss of villi in coeliac disease?
Loss of surface area
Reduction in absorption
Flat duodenal muscle
What are the metabolic effects of coeliac disease?
Malabsorption of fats, sugars, amino acids, water and electrolytes
Steatorrhoea
Reduced intestinal hormone production, so reduced pancreatic secretion and bile flow, causing gallstones
What are the effects of malabsorption in coeliac disease?
Unexplained weight loss Anaemia (Fe, Vit B12, Folate) Abdominal bloating Failure to thrive Vitamin deficiencies
Other than malabsorption, what are the complications of coeliac disease?
T cell lymphomas of GI tract
Increased rose of small bowel carcinoma
Galls stones
Ulcerative-jejenoilleitis
