Small Intestine Part 1 Flashcards by joseph dizon

Embryology

The duodenum arises from the

Junction of the foregut and midgut

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Embryology

The jejunum and upper part of the ileum develop from

Proximal limb of the midgut loop

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Embryology

The distal ileum develops from the

Caudal limb of the midgut loop

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Microscopic anatomy

Mucosa

Epithelium
Muscularis mucosa
Lamina propia

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Microscopic anatomy

Submucosa

Blood vessels
Lymphatics
Myenteric meissners plexus

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Microscopic anatomy

Produce an alkaline secretion to protect against acidic gastric chyme

Duodenal brunners gland

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Microscopic anatomy

Lymph node aggregates called___________ are most prevalent in the ileum

Peyers patches

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Layers of the small intestine

Muscularis

Inner - circular
Outer - longitudinal layers
Between - myenteric auerbach’s plexus

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Layers of the small intestine

Single layer of mesoepithelial cells lining the exterior of the SI

Serosa

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Layers of the small intestine

Mucosa

Epithelium
Lamina propria
Muscularis mucosa

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Layers of the small intestine

Sub mucosa

Meissners plexus

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Layers of the small intestine

Muscularis propria

Circular muscle
Auerbach’s plexus
Longitudinal muscle

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Layers of the small intestine

The strongest layer of the small intestine
This should be included when performing intestinal anastomoses

Submucosa

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Specific cells

Arise from pluripotential cells in the crypts of Liberkuhn and migrate to the tips of villi

Enterocytes

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About 95% of the epithelial cells are enterocytes and it is specialized for

Digestion and absorption of dietary nutrients

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Specific cells

Found at the base of the crypts of lieberkuhn
Function include, phagocytosis
Mucosal defense
Regulation of intestinal flora
Secretion of variety antimicrobial peptides

Paneth cells

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Specific cells

Located above the peyers patches
Specialized for antigen presentation

Microfold M cells

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Specific cells

Specialized for mucous secretion

Goblet cells

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Specific cells

Specialized to produce and secrete hormones

Entero endocrine cells

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Properties of small intestine

Mucosal folds visible upon gross inspection
Also visible radio graphically and help in the distinction from the colon, which not contain them.
More prominent in the proximal intestine than in the distal small intestine.

Plicae circulares or valvulae conniventes

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Properties of small intestine

Seen on gross examination of the small intestinal mucosa follicles.
Located in the ileum, are the most prominent and designated peyers patches

Aggregates of lymphoid follicles

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Helpful both upon gross inspection in the OR and on abdominal x rays, to differentiate between the small and large bowel

Plicae circulares

Colon doesn’t have

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Describe jejunum

Larger diameter
Thicker wall
More prominent plicae circulares
Few arcade 1-2
Long vasa recta

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Describe ileum

Many aracades
Short vasa recta
Fatty messentery

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Innervation Para sympathetic innervation

Vagus

Innervation Sympathetic innervation

Splanchnic nerves

Innervation Provides enteric nervous system innervation

Meissners and Auerbach plexuses

The entire small bowel is supplied by branches of the SMA except the

Proximal duodenum Supplied by celiac trunk

Small bowel obstruction Foreign bodies Gallstones Meconium

Intraluminal

Small bowel obstruction Tumors Chronhs

Intramural

Small bowel obstruction Adhesion Hernias Carcinomatosis

Extrinsic

Small bowel obstruction The most common causes of small bowel obstruction are

``` Hernia Adhesions Volvolus Intussusception Crohns Gallstone ileus SMA syndrome Neoplasm ```

Small bowel obstruction Related to prior abdominal surgery account for up to 75% of the cases of small bowel obstruction

Intra abdominal adhesion

Small bowel obstruction Commonly due to extrinsic or invasion by advanced malignancies arising in organs other than the small bowel.

Cancer related SBO

Small bowel obstruction Should not be forgotten when considering the differential diagnosis of adult patients with acute or chronic symptoms of small Boswell obstruction, especially those without a history of prior abdominal surgery

Intestinal Malrotation | Midgut volvulus

Small bowel obstruction Rare etiology of obstruction Compression of third portion of duodenum by the superior mesenteric artery Considered in young asthenic individuals who have chronic symptoms suggestive of proximal small bowel obstruction

Superior messenteric artery syndrome

Small bowel obstruction Pathophysiology

Onset of obstruction Gas and fluid accumulate Intestinal activity increases

Pathophysiology of SBO Most of the gas that accumulates originates from

Swallowed air

Pathophysiology of SBO The fluid consist of

Swallowed liquids | GI secretions

Pathophysiology of SBO

``` Gas and fluid accumulate in lumen Intaluminal and intramural pressure rise Decrease intestinal motility Changes in luminal flora and small bowel Translocation of bacteria Impaired microvascular perfusion Intestinal ischemia Necrosis Strangulated obstruction ```

Small bowel obstruction Only portion of intestinal lumen is occluded Strangulation is less likely

Partial SBO

Small bowel obstruction Dangerous form of bowel obstruction Obstructed both proximal and distal (volvolus) Rapid progression to strangulation

Closed loop obstruction

Clinical presentation of SBO More prominent symptom with proximal obstructions than distal

Vomiting More feculent more establish obstruction

Clinical presentation of SBO Continue passage of flatus and or stool beyond 6-12 hours after onset of symptoms

Obstipation More on partial than complete obstruction

Clinical presentation of SBO Abdominal distention most pronounced if the site of obstruction is in the

Distal ileum

Clinical presentation of SBO Abdominal distention May be absent if the site of obstruction is in the

Proximal small intestine

Clinical presentation of SBO Bowel sound may be

Hyper active initially | But minimal bowel sounds in late

Clinical presentation of SBO Laboratory findings Reflect intravascular volume depletion

Hemocencentration Electrolyte abnormalities Mild leukocytes is is common

Features associated with strangulated SBO include

``` Tenderness Tachycardia Fever Elevated WBC Acidosis ```

Diagnosis of SBO Goals

Mechanical vs ileus Etiology Partial vs comple Simple vs strangulated

Symptoms of small bowel obstructions are

Colicky abdominal pain Nausea Vomiting Obstipation

Diagnosis of SBO Important elements to obtain on history

Prior abdominal operations | Presence of abdominal disorders

Diagnosis of SBO PE Search for

Hernias | Abdominal scars

Diagnosis of SBO LABS Full labs

Normal at initial stage Progression Leukocytosis Hemocencentration Electrolyte abnormalities

Diagnosis of SBO The stool should be checked for gross or occult blood

Presence of strangulation

Diagnosis of SBO Confirmed by

Radiographic examination

Diagnosis of SBO | Abdominal series of Radiographic evaluation

Abdomen - supine Abdomen - upright Chest - upright

Diagnosis of SBO Radiographic Triad

Dilated stool bowel loos >3 cm Air fluid levels Paucity of air

Diagnosis of SBO Radiographic Sensitivity range from

70-80%

Diagnosis of SBO Radiographic Specificity is low because

Mimic small bowel obstruction

Diagnosis of SBO CT scan Sensitivity and specificity

Sensitive - 80-90% | Specific - 70-90%

Diagnosis of SBO CT scan Findings

Discrete transition zone, dilation of bowel proipximally, decompression distally Intra luminal contrast that dose not pass beyond transition zone Colon containing little gas or fluid

Closed loop obstruction CT scan Is suggested by the presence of

U shaped or C shaped dilated bowel loop

Closed loop obstruction CT scan Depend on 2 things

Length of bowel segment | Orientation of the loop

Closed loop obstruction CT scan If we have a short closed loop oriented with the plane of imaging, we will see a

U or C shaped loop of bowel

Strangulated obstruction CT scan The cause of this radiologic finding was intestinal ischemia Patient was taken emergently to the operating room

Intestinal pneumatosis

Limitation of CT scan Detection of grade or partial small bowel obstruction

Low sensitivity

Other limitation of CT scan Subtle transition zone may be difficult to identify in the

Axial images obtained during CT scan

Standard small bowel series Although barium can be used water soluble contrast agents, such as _____________ should be used if the possibility of intestinal perforation exists.

Gastrografin

An x ray examination of the small intestine that looks at how the liquid contrast material moves through the small intestine

Enteroclysis

Enteroclysis Double contrast technique used for better assessment of

Mucosal surface and detection of small lesions

Enteroclysis 200 - 250 ml of barium followed by 1-2 L of a solution of ___________ in water is instilled into the proximal jejeunum via a___________

Methylcellulose | Long nasoenteric catheter

Treatment of SBO Trial of non operative mangy

NPO Isotonic fluid NGT Foley catheter

Treatment of SBO May be necessary to assist with fluid management, particularly in patients with underlying cardiac disease.

Central venous or pulmonary artery catheter monitoring

Treatment of SBO Given by some because of concerns that bacterial translocation may occur in the setting of small bowel obstruction;

Broad spectrum antibiotics

Treatment of SBO Standard therapy for complete SBO has been

Surgery

Treatment of SBO The goal is

Operate before the onset of irreversible ischemia

Treatment of SBO Others note, however, that a period of observation and NG decompression , providing

No tachycardia No tenderness No increase in white cell count

Conservative treatment of SBO Partial SBO Do not improve within 48 hours after initiation of non operative therapy should

Undergo surgery

Conservative treatment of SBO Partial SBO Patients undergoing non operative therapy should be closely monitored for signs suggestive of

Peritonitis

Conservative treatment of SBO Obstruction in early post operative period Greater risk for developing

PT undergoing pelvic surgery

Conservative treatment of SBO Obstruction in early post operative period Should considered if symptoms of intestinal obstruction occur

After initial return of bowel function If bowel function fail to return 3-5 days after surgery

Conservative treatment of SBO Obstruction in early post operative period

Ususally partial and rarely strangulation

Conservative treatment of SBO Obstruction in early post operative period Treatment A period of extended non operative therapy 2-3 weeks consisting of

Bowel rest Hydration TPN

Conservative treatment of SBO Obstruction in early post operative period Treatment If complete obstruction is demostrated or if signs suggestive of peritonitis are detected

Re operation should be undertaken without delay

Conservative treatment of SBO Carcinomatosis

Adhesion

Conservative treatment of SBO Carcinomatosis Recurrent malignancy

Palliative resection or bypass

Surgical treatment of SBO The operative procedure for small bowel obstruction varies according to the etiology of obstruction.

Adhesions are lysed Tumors are resected Hernias are reduced and repaired

Surgical treatment of SBO Criteria suggesting viability of bowels

Normal color Peristalsis Marginal arterial pulsations

Surgical treatment of SBO Used to check for pulsation flow to the bowel

Doppler probe

Surgical treatment of SBO Arterial perfusion can be verified by visualizing intravenously administered

Fluorescein dye

Surgical treatment of SBO For hemodynamic ally stable patient Should be resected and primarily anastomosis

Short lenght

Surgical treatment of SBO For hemodynamic ally stable patient The bowel of uncertain viability should be left intact and patient LARGE

Re explored in 24 to 48 hours in a second look operation

Surgical treatment of SBO Success is being reported with greater frequency Quicker recovery and less post operative discomfort Presence of bowel distention and multiple adhesion can cause these procedures

Laparoscopic surgery for SBO.

Prognosis of SBO

Related to the etiology

Prognosis of SBO Majority of patients

Do not require future re admissions

Prognosis of SBO Mortality

5% non strangulating elderly | 8-25% strangulated

Prevention of SBO

Adhesion prevention Laparoscopic surgery Seprafilm

Prevention of SBO Cornerstone of adhesion prevention consists of

Good surgical technique Careful handling of tissue Minimal use and exposure of peritoneum to foreign bodies

Prevention of SBO Hyaluran based agents Reduce incidence of post operative bowel adhesion

Seprafilm

Clinical syndromes caused by impaired intestinal motility | Characterized by SS of intestinal obstruction in the absence of a lesion causing mechanical obstruction

Ileus and intestinal pseudo obstruction

Major caused of morbidity in hospitalized patients

Ileus

Most frequently implicated cause of delayed discharge following abdominal operations

Post operative ileus

A temporary motility disorder that is reversed with time as the inciting factor is corrected

Ileus

Compromises a spectrum of specific disorders associated with irreversible intestinal dysmotility

Chronic intestinal pseudo obstruction

Pathophysiology of ileus Responsible for dysmotility

Surgical stress Inflammatory response Anesthetic or analgesics

Pathophysiology of ileus Post operative return of bowel function varies by

Small intestine - 1 day Stomach - 2 days Large intestine- 3-5 days

Pathophysiology of ileus Not reliable indicator

Bowel sounds

Pathophysiology of ileus More useful indicator

Passing flatus or bowel movement

Pathophysiology of ileus Resolution of ileus may be delayed in the presence of other factors capable of inciting ileus such as

Intra abdominal abscesses | Electrolyte abnormalities

Pathophysiology of ileus | Can caused by a large number of specific abnormalities affecting intestinal smooth muscle,

Chronic intestinal pseudo obstruction

Constitute a group of diseases characterized by degeneration and fibrosis of the intestinal muscularis propria.

Visceral myopathies

Encompasses a variety of degenerative disorders of the myenteric and sub mucosal plexuses

Visceral neuropathies

Chronic intestinal pseudo obstruction Primary causes

Familial types | Sporadic types

Chronic intestinal pseudo obstruction Secondary causes

``` Smooth muscle disorders Neurologic disorders Endocrine disorders Miscellaneous disorders Pharmacologic causes ```

Chronic intestinal pseudo obstruction Familial type

Familial visceral myopathies type 1,2&3 Familial visceral neuropathies type 1&2 Childhood visceral myopathies type 1&2

Clinical presentation Ileus

``` Inability to tolerate liquid Nausea Lack of flatus Vomiting Abdominal distention No bowel sounds ```

Clinical presentation CIPO

Variable degrees of nausea and vomiting | Abdominal pain and distention

Diagnosis Ileus Known to be associated with impaired intestinal motility

Opiates

Diagnosis Ileus Measurement of serum electrolytes abnormalities

Hypokalemia Hypocalcemia Hypomagnesemia Hypermagnesemia

Diagnosis Ileus Distinction between ileus and mechanical obstruction may still be difficult

Abdominal x rays

Diagnosis Ileus Test of choice in post operative setting

Ct scan

Diagnosis CIPO May be required to establish the specific underlying causes

Laparotomy or laparoscopy

Treatment of ileus

Limit oral intake NGT Fluid and electrolytes TPN

Treatment of CIPO

Palliative of symptoms Fluids Surgery should be avoided

Treatment of CIPO Has been associated with palliation of symptoms, however because of cardiac toxicity and reported death, restricted

Cisapride (propulsid)

Chrons disease Chronic, idiopathic trans mural inflammatory disease with a propensity to affect the

Distal ileum

Chrons disease Most common in

Female 3rd decade and 6th decade

Features of chrons

``` Genetic and environmental factors First degree relatives Monozygotic twins Higher socioeconomic status Smokers ``` Breast feeding protective against developing chrons

Pathophysiology of Chrons disease Causative agents

``` Chlamydia Listeria monocytogenes Pseudomonas species Reovirus Mycobacterium para tuberculosis ```

Pathophysiology of Chrons disease Genetic host susceptibility

Non pathogenic commensal enteric flora.

Pathophysiology of Chrons disease Pathologic hallmark

Focal trans mural inflammation of the intestine

Other pathologic lesions of chrons disease Earliest lesions characterized

Aphthous ulcer Arise over lymphoid aggregates

Other pathologic lesions of chrons disease Highly characteristic of chrons disease

Granulomas Noncaseating Found in any layer of the bowel wall and mesenteric lymph node

Other pathologic lesions of chrons disease Form as disease progresses, aphthae coalesce into larger ulcers.

STELLATE-SHAPED ULCERS

Chrons disease Form when multiple ulcers fuse in a direction parallel to the longitudinal axis of the intestine.

LINEAR OR SERPIGINOUS ULCERS

Chrons disease Form with transverse coalescence of ulcers

COBBLESTONE MUCOSA

Chrons disease * Occurs with advanced disease. * Serosal involvement results in adhesion of the inflamed bowel to other loops of bowel or other adjacent organs.

Transmural inflammation

Chrons disease •Inflammation in Crohn's disease can affect discontinuous portions of intestine: so-called skip lesions that are separated by intervening normal appearing intestine.

SKIP LESIONS

Chrons disease morphology symptoms

Christmas

Crowns disease * A feature of Crohn's disease that is grossly evident and helpful in identifying affected segments of intestine during surgery. * Encroachment of mesenteric fat onto the serosal surface of the bowel * This finding is virtually pathognomonic of Crohn's disease.

Fat wrapping

•Layers of the bowel wall affected: Ulcerative and chrons

UC: Limited to mucosa and submucosa | •CD: May involve the full thickness of the bowel wall

•Longitudinal extent of inflammation Ulcerative colitis and chrons

UC: Inflammation is continuous and affects the rectum | •CD: May be discontinuous and spares the rectum

It is also important to remember that, although ulcerative colitis is a disease of the colon, it can be associated with inflammatory changes in the distal ileum

Backwash ileitis

The most common symptoms of Crohn's disease are

abdominal pain, diarrhea, and weight loss

•Patients with Crohn's disease can be classified by their PREDOMINANT clinical manifestation:

a) fibrostenotic disease (b) fistulizing disease (c) aggressive inflammatory disease.

•Constitutional symptoms, particularly _______________________________, may also be prominent and are occasionally the sole presenting features of Crohn's disease.

weight loss and fever, or growth retardation in children

Crohn's disease •The disease affects the small bowel in 80% of cases and majority have

ileocecal disease.

Crohn's disease •Uncommon sites of involvement include the

esophagus, stomach, and duodenum.

•An estimated one fourth of all patients with Crohn's disease will have an _______________ of their disease.

EXTRAINTESTINAL MANIFESTATION

Diagnosis of Crohn's disease

No single symptom, sign, or diagnostic test establishes the diagnosis of Crohn's disease.

Dx Crohn's disease •Main diagnostic tool Can reveal focal ulcerations adjacent to areas of normal appearing mucosa along with polypoid mucosal changes that give a "cobblestone appearance." •Skip areas of involvement are typical. •Pseudopolyps, as seen in ulcerative colitis, are also often present.

COLONOSCOPY with intubation of terminal ileum

Dx of Crohn's disease •May reveal strictures or networks of ulcers and fissures.

•2)CONTRAST EXAMINATIONS of the small bowel and colon:

Dx of Crohn's disease * May reveal intra-abdominal abscesses * Useful in acute presentations to rule out the presence of other intra-abdominal disorders.

•3)CT SCANNING:

Dx of Crohn's disease •Is done for disease of the proximal alimentary tract.

4)ESOPHAGOGASTRODUODENOSCOPY (EGD)

Dx of Crohn's disease * Has been increasingly used because Crohn's disease often affects the small bowel, which is difficult to image. * Capsule endoscopy is a technology that uses a swallowed video capsule to take photographs of the inside of the esophagus, stomach, and small intestine.

5)CAPSULE ENDOSCOPY

* 5)CAPSULE ENDOSCOPY * Large capsule-larger than the largest pill-is swallowed by the patient. * The capsule contains one or two video chips (cameras), a light bulb, a battery, and a radio transmitter. * As the capsule travels through the esophagus, stomach, and small intestine, it takes photographs rapidly. * The photographs are transmitted by the radio transmitter to a small receiver that is worn on the waist of the patient who is undergoing the capsule endoscopy. * At the end of the procedure, approximately 24 hours later, the photographs are downloaded from the receiver into a computer, and the images are reviewed by a physician. * The capsule is passed by the patient into the toilet and flushed away.

Nice to know

- is associated with a diagnosis of Crohn's disease

ASCA+/pANCA

+ is correlated with ulcerative colitis.

ASCA–/pANCA

•Because of the insidious, and often, nonspecific presentation, the diagnosis of Crohn's disease typically is made only after symptoms have been present for .

several years

•The initial manifestation of Crohn's disease can consist of

right lower quadrant pain mimicking acute appendicitis.

* In some patients, the initial manifestation of Crohn's disease is an acute abdomen related to small bowel obstruction, intra-abdominal abscess, or free intestinal perforation. * In other patients, perianal abscesses and fistulas requiring surgical therapy may be the first manifestation of Crohn's disease.

Nice to know

Management of Crohn's disease

* NO curative therapies are available for Crohn's disease. * GOAL of treatment is to palliate symptoms rather than to achieve cure. * Medical therapy is used to induce and maintain disease remission. * Surgery is reserved for specific indications.

Crohn's disease 1)ANTIBIOTICS:for treatment of:

Infectious complications associated with Crohn's disease * Perianal disease * Enterocutaneous fistulas * Active colonic disease

Crohn's disease • •Have shown to be superior to placebo in inducing disease remission. •Its efficacy in the maintenance of remission is less clear.

Oral 5-aminosalicylic acid (5-ASA) drugs (e.g., mesalamine):

Crohn's disease * Parent compound of 5-ASA * Widely used in UC but has been shown to be less effective than 5-ASA in CD.

Sulfasalazine

Crohn's disease •For patients with mildly to moderately severe disease that does not respond to aminosalicylates.

Oral glucocorticoids:

Crohn's disease * For patients with severe active disease. * Are effective in inducing remission, but are ineffective in preventing relapse * Their adverse side-effect profile makes long-term use hazardous. Therefore, they should be tapered once remission is achieved.

IV glucocorticoids:

Crohn's disease Some patients are unable to undergo glucocorticoid tapering without suffering recurrence of symptoms. Such patients are said to have

STEROID DEPENDENCE.

Crohn's disease For STEROID-DEPENDENT patients, along with those who do not respond to steroids at all (STEROID RESISTANT) patients, use of ______________ should be considered

immune modulators

Crohn's disease * Effective in inducing remission, in maintaining remission, and in allowing for glucocorticoid tapering in glucocorticoid-dependent patients. * Response to the medications is usually observed in 3 to 6 months. * they can decrease the risk of relapse after intestinal resection for Crohn's

4)IMMUNOMODULATORS: •THIOPURINE ANTIMETABOLITES: •Azathioprine and its active metabolite, 6-mercaptopurine

* 4)IMMUNOMODULATORS:(Cont.) * THIOPURINE ANTIMETABOLITES: * SE:

can induce bone marrow suppression and promote infectious complications.

•For patients who do not respond to the thiopurines, _____________ is an alternative that usually is given IM before switching to oral form after achieving symptomatic control.

methotrexate

•There is little role for cyclosporine in Crohn's disease; its efficacy/toxicity profile in this disease is poor.

Nice to know

* Chimeric monoclonal anti–tumor necrosis factor α-antibody * Has shown to have efficacy in inducing remission and in promoting closure of enterocutaneous fistulas. * It generally is used for patients resistant to standard therapy to help taper steroid dosage.

Infliximab

•Infliximab generally is well tolerated but should not be used in patients with ongoing septic processes, such as

undrained intra-abdominal abscesses.

Crohn's disease * For patients with PERIANAL DISEASE: * __________________________ is the primary step. * Two to 4 weeks of therapy is needed before improvements are seen, and often long-term therapy is required to prevent relapse.

METRONIDAZOLE or CIPROFLOXACIN

In cases of relapse: ____________ can be considered.

AZATHIOPRINE

•In patients with fistulas: _________ and AZATHIOPRINE are drugs of choice.

INFLIXIMAB

Surgical treatment of Crohn's disease

* Fifty to 70% of patients with Crohn's disease will ultimately require at least one surgical intervention for their disease. * Surgery generally is reserved for patients whose disease is unresponsive to aggressive medical therapy or who develop complications of their disease. * FAILURE of medical management may be the indication for surgery if symptoms persist despite aggressive therapy for several months or if symptoms recur whenever aggressive therapy is tapered.

Crohn's disease One of the most common indications for surgical intervention

Intestinal obstruction

Crohn's disease ______________ frequently are encountered during operations performed for intestinal obstruction.

Abscesses and fistulas

Crohn's disease unless associated with symptoms or metabolic derangements do not require surgical intervention.

Fistulas

* INTRAOPERATIVE DISCOVERY OF INFLAMMATION LIMITED TO TERMINAL ILEUM ("TERMINAL ILEITIS") during operations performed for presumed appendicitis. * An uncommon but not rare scenario in patients with Crohn's disease. * This scenario can result from: * An acute presentation of Crohn's disease or * From acute ileitis caused by bacteria such as

Yersinia or Campylobacter.

* The usual procedure of choice for grossly evident disease. * Microscopic evidence of Crohn's disease at the resection margins does not compromise a safe anastomosis, and frozen-section analysis of resection margins is unnecessary. * Recurrence rates were similar whether margins were histologically free of or involved with Crohn's disease.

SEGMENTAL RESECTION AND PRIMARY ANASTOMOSIS:

: •Alternative to segmental resection for obstructing lesions is stricturoplasty * This technique allows for preservation of intestinal surface area * Well-suited for patients with extensive disease and fibrotic strictures who may have undergone previous resection and are at risk for developing short bowel syndrome. * In this technique, the bowel is opened LONGITUDINALLY to expose the lumen. Any intraluminal ulcerations should be biopsied to rule out the presence of neoplasia.

STRICTUROPLASTY

Crohn's disease •For strictures less than 12 cm in length)

HEINECKE-MICULICZ PYLOROPLASTY type of repair:

Crohn's disease •For longer strictures as much as 25 cm in length

FINNEY PYLOROPLASTY type of repair:

Crohn's disease •For longer strictures, with mean lengths of 50 cm.

ISOPERISTALTIC ENTEROENTEROSTOMY (side to side)

Crohn's disease * Are sometimes required in the presence of intramesenteric abscesses or if the diseased bowel is coalesced in the form of a dense inflammatory mass, making its mobilization unsafe. * Bypass procedures (gastrojejunostomy) also are used in the presence of duodenal strictures, for which stricturoplasty and segmental resection can be technically difficult.

INTESTINAL BYPASS PROCEDURES:

Outcomes of chrons disease

•Overall complication rates following surgery for Crohn's disease: range from 15 to 30%. * SURGICAL COMPLICATIONS include: * Wound infections * Postoperative intra-abdominal abscesses * Anastomotic leaks OUTCOMES of CROHN'S DISEASE

* CLINICAL RECURRENCE: * Defined as the return of symptoms confirmed as being due to Crohn's disease, affects 60% of patients by 5 years and 94% by 15 years after intestinal resection. •REOPERATION becomes necessary in approximately one third of patients by 5 years after the initial operation, with a median time to reoperation of 7 to 10 years.

Nice to know

Embryology Primitive GUT appears

4th week of gestation

Small Intestine Part 1 Flashcards

(193 cards)