Small Intestine Part 1 Flashcards
Embryology
The duodenum arises from the
Junction of the foregut and midgut
Embryology
The jejunum and upper part of the ileum develop from
Proximal limb of the midgut loop
Embryology
The distal ileum develops from the
Caudal limb of the midgut loop
Microscopic anatomy
Mucosa
Epithelium
Muscularis mucosa
Lamina propia
Microscopic anatomy
Submucosa
Blood vessels
Lymphatics
Myenteric meissners plexus
Microscopic anatomy
Produce an alkaline secretion to protect against acidic gastric chyme
Duodenal brunners gland
Microscopic anatomy
Lymph node aggregates called___________ are most prevalent in the ileum
Peyers patches
Layers of the small intestine
Muscularis
Inner - circular
Outer - longitudinal layers
Between - myenteric auerbach’s plexus
Layers of the small intestine
Single layer of mesoepithelial cells lining the exterior of the SI
Serosa
Layers of the small intestine
Mucosa
Epithelium
Lamina propria
Muscularis mucosa
Layers of the small intestine
Sub mucosa
Meissners plexus
Layers of the small intestine
Muscularis propria
Circular muscle
Auerbach’s plexus
Longitudinal muscle
Layers of the small intestine
The strongest layer of the small intestine
This should be included when performing intestinal anastomoses
Submucosa
Specific cells
Arise from pluripotential cells in the crypts of Liberkuhn and migrate to the tips of villi
Enterocytes
About 95% of the epithelial cells are enterocytes and it is specialized for
Digestion and absorption of dietary nutrients
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
Specific cells
Located above the peyers patches
Specialized for antigen presentation
Microfold M cells
Specific cells
Specialized for mucous secretion
Goblet cells
Specific cells
Specialized to produce and secrete hormones
Entero endocrine cells
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
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
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
Describe jejunum
Larger diameter Thicker wall More prominent plicae circulares Few arcade 1-2 Long vasa recta
Describe ileum
Many aracades
Short vasa recta
Fatty messentery
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
