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surgery > Small & Large intestine 1 - د.مازن عبدالله > Flashcards

Small & Large intestine 1 - د.مازن عبدالله Flashcards

1
Q

whats the anatomy of the Small intestine ?

A
  • its the largest( it represent 75% of all bowel) part extend from the GD junction to the ileocecal junction
  • diameter at the GD is 4cm while it become narrow at the ileocecal junction about 2.5cm
  • surface area around 95%
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2
Q

how long the large intestine is ?

A

its 1.5 m

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3
Q

what definition of the consiptation in WHO ?

A
  • when the bowel movement is only 3 or less in a week
  • when there is strain in quarter or whole bowel movement
  • feel incomplete defecation
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4
Q

what the type of the consiptation ?

A

1- megcolon

2- non mega colon

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5
Q

what the type of the megacolon conspitation ?

A

1-Hirschspurge disease
(disease is a condition that affects the large intestine (colon) and causes problems with passing stool. The condition is present at birth (congenital) as a result of missing nerve cells in the muscles of the baby’s colon)

2- non-Hirschburge megrectum and megacolon

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6
Q

what the typs of the non megacolon constipation ?

A

1- slow transit
(reduced motility of the large intestine, caused by abnormalities of the enteric nerves.)

2-normal transit
(colonic motility (the way muscles contract and relax to move contents through the colon) is unaltered; stool moves through the colon at a normal rate.difficulties in stool passage, for example due to harder stools.)

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7
Q

whats the Idiopathic megarectum and megacolon ?

A

(means there is constipation of unknown etiology because the feces accumulation )

  • pt will come with history of sever constipation , abdominal pain , abdominal distention and manual evacuation because of the fecal loading
  • when we do abdominal exam feel hard fecal mass arise out of the pelvis
  • when we do rectal examination we will saw large fecloma in the lumen and the anus is patulous (loose, open)
  • we can do sigmidoscopy
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8
Q

how to diagnosis pt with megarectum and megacolon ?

A
  • pt will come with history of sever constipation , abdominal pain , abdominal distention and manual evacuation because of the fecal loading
  • when we do abdominal exam feel hard fecal mass arise out of the pelvis
  • when we do rectal examination we will saw large fecloma in the lumen and the anus is patulous (loose, open)
  • we can do sigmidoscopy
  • do imaging by “Double contrast barium enema “
    that show the megarectum

-we do “ Anorectal physiology test “
(assess the function of the muscles in your anal canal to see if they are working normally, and also checks the sensitivity of the rectum to small volumes of air and its response to distension)

so the pt will have delayed first sensation
and raised maximum tolerated volume

  • full thickness rectal biobsy
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9
Q

what the definite diagnosis of the pt with megarectum and megacolon ?

A

-“Double contrast barium enema “
that show the megarectum

-“ Anorectal physiology test “
pt will have delayed first sensation
and raised maximum tolerated volume

  • full thickness rectal biopsy
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10
Q

what the treatment of the Idiopathic megarectum and megacolon ? as Hirschsprung’s disease

A

1-emptying the rectum by washout and manual evacuation under anesthesia

2- develop regular daily bowel habit by using osmotic laxatives or use the suppositories

3- biofeedback therapy in resistance cases
(using electronic or other instruments, and with a goal of being able to manipulate the body’s systems at will)

1- resection of the dilated rectum and colon

2-colectomy (removal of all or part of the colon) with formation of ileorectal anastomosis

3-restorative proctocolectomy استئصال
(removes the entire colon and rectum while preserving the anal sphincter )

4- vertical reduction rectoplasty is a new treatment

5- stoma formation

اما استئصال الجزء المنتفخ / او نستئصل جزء ونسوي اناستموسز /او نشيل VRR الكولون كله / اوتقنيه جديده هي

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11
Q

whats the non-megacolon constipation ?

A

pt will have difficulty in the defcation , abdominal pain , and distention

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12
Q

whatre the causes of the non-megacolon constipation ?

A

1- Medication :
Fe, Ca supplement , opiate ,anticholainaergic ,sympathomimtic ,anti depressent , ca blockers , anti parkinson , antipschotic , anti depressent , antihypertensive , antiarrythemic , beta antagosit , anti histamin, antacid (AL) , anti diarrial

2- Organic stenosis
by colonic cancer or any mass
or inflammmtory ,ischemic , surgical stenosis

3-Endocrine disease
hypothyrodism , hyperparathyrodism, hypopituritism , hypercalcemia , DM, renal faliure , pregnency

4- Neurological as 
Spinal cord injury
spina bifida
cerebrovascular disease
Parkinson’s disease
multiple sclerosis
Autonomic neuropathy

5-Enteric neuropathies: chronic intestinal pseudo-obstruction

6-Myogenic disorders: Myotonic dystrophy, dermatomyositis, scleroderma, amyloidosis, chronic intestinal
pseudo-obstruction

Anorectal disorders: Anal fissures anal strictures

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13
Q

GIVE EXAMPLE ABOUT THE MEDICATION THAT CAUSE THE CONSTIPATION ?

A

Opiates (morphine), anticholinergic agents, Tricyclic antidepressants (amitriptyline), antispasmodics (dicyclomine, mebeverine, peppermint oil), Calcium channel blockers (verapamil, nifedipine), Antiparkinsonian drugs, anticonvulsants (carbamazepine), Sympathomimetics (ephedrine), antipsychotics (chloropromazine, clozapine, haloperidol, risperidone), diuretics (furosemide), antihypertensives (clonidine), antiarrhythmics (amiodarone), beta-adrenoceptor antagonists (atenolol), antihistamines, calcium or aluminium containing antacids, Calcium supplements, iron supplements, antidiarrheal (loperamide), 5-HT3-receptor

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14
Q

GIVE EXAMPLE ABOUT THE NEUROLOGICAL DISORDER THAT CAUSE THE CONSTIPATION ?

A

Neurological disorders:
Spinal cord injury, Parkinson’s disease, cerebrovascular disease, paraplegia, multiple sclerosis,
Autonomic neuropathy, spina bifida

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15
Q

GIVE EXAMPLE ABOUT THE ORGAIC STENOSIS THAT CAUSE THE CONSTIPATION ?

A

GIVE EXAMPLE ABOUT THE NEUROLOGICAL DISORDER THAT CAUSE THE CONSTIPATION ?

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16
Q

GIVE EXAMPLE ABOUT THE ENTERIC DISORDER THAT CAUSE THE CONSTIPATION ?

A

chronic intestinal pseudo-obstruction

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17
Q

GIVE EXAMPLE ABOUT THE MYOGENIIC DISORDER THAT CAUSE THE CONSTIPATION ?

A

chronic intestinal pseudo-obstruction

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18
Q

GIVE EXAMPLE ABOUT THE ANORECATAL DISORDER THAT CAUSE THE CONSTIPATION ?

A

Anal fissures anal strictures

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19
Q

how to investigate the non-megacolon constipation ?

A
  • history …
  • measure the whole gut transit time
    (10–73 hours) (swallow red die)
  • defecating protography
    (an examination of the lower bowel and rectum using x-rays. It shows how your rectum functions during the emptying of your bowels.)

-abdominal transit study

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20
Q

if 5 marker or few still in the bowel what that means ?

on the abdominal transit study

A

normal colonic transit

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21
Q

if the ring scattered means ?

A

hypomobility or colonic inertia (also known as slow-transit constipation)

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22
Q

if most of the ring gathered ?

A

pt have obstruction

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23
Q

what the treatment of the non megacolon consitipation ?

A

1- dietary fibers
2- laxatives
3- biofeedback

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24
Q

how to dignosis of the iodopathic slow transit constipation ?

A
  • history pt have constipation during the childhood
  • by the abdominal transit study when the pt swallow 20 radio-opaque markers on 3 days
  • on the 6th day we do X ray
  • normally 80% of the markers pass
  • after 120h (5day)or six day if retention of more than 80% is abnormal الاحتفاظ
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25
Q

what the benefit of the abdominal transit study ?

A

distinguish the slow whole transit gut from the rectal outlet delay

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26
Q

what the treatment of the iodopathic slow transit constipation ?

A
  • Dietary
  • Biofeedback
  • Surgery

+Total colectomy and ileorectal anastomosis is the preferred procedure,
+segmental resection
+stoma creation

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27
Q

what the Angiodysplasia ?

A
  • its vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. Lesions are often multiple, and frequently involve the cecum or ascending colon, although they can occur at other places
  • malformation is consist of dilated tortuous submucosal vein but in sever cases it happen in the mucosa
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28
Q

in which age group happen the Angiodysplasia ?

A

in middle and elderly no gender predominant
5-25% in age over 60
may assocaited with aortic stenosis

29
Q

what the clincal feature of the Angiodyslasia ?

A

1- anemia with minor syptomas

2-(10-15%) risk of bleeding as malena and hematochezia
fresh blood through the anus

30
Q

what the differential diagnosis of the Angiodysplasia ?

A
  • Diverticulosis,
  • Ulcerative colitis (UC)
  • Ischaemic colitis
  • Radiation colitis
  • Benign polyps
  • Malignant tumors

DIUR BM

31
Q

how to investigate the Angiodysplasia ?

A

1- barium enema but not helpful
so use the raioactive technetium -99m labelled red cells to locolize source of heamorrage rate>0.1 ml/min

2- colonscopy
3- pill or capsule endoscopy
3- sup or inf mesentric angiogarphy
bleeding 0.5-1 ml/min

32
Q

what the treatment of the Angiodysplasia ?

A

1- stabilize unstable circulation

2-locolize the bleeding by the radioactive technium 99m or colonscopy

if uncontrol bleeding surgery is needed
by total colectomy with ileocecal anastomsis

33
Q

what the blind loop syndrome ?

A

is a state that occurs when the normal bacterial flora of the small intestine proliferates to numbers that cause significant derangement to the normal physiological processes of digestion and absorption with stasis of intestinal content

34
Q

what the clinical feature of the blind loop syndrome ?

A
  • steatorrhea,
  • diarrhea,
  • anemia,
  • weight loss,
  • abdominal pain,
  • multiple vitamin deficiencies,
  • joint pain
  • and occasionally neurological disorders.
35
Q

what the cause of blind loop syndrome ?

A

any thing cause stasis of the abdominal content as

stricture , stenosis , fistula, blind bouch

36
Q

what the treatment blind loop syndrome ?

A

surgical extirpation of the cause of the stasis.

37
Q

what the diverticulum ?

A

bulging sac in any portion of the gastrointestinal tract

38
Q

what the cause of diverticulosis

A

1- congintal true which include all the layers beside the muscular layer

2-aquired most common false lac of the muscular coat

39
Q

what the clincial picture of the Jejuna diverticula ?

A
  • may be asympomatic
  • or cause abdominal pain
  • or cause malabsorption syndrome
  • can cause inflammation and perforation
40
Q

what the treatment Jejuna diverticula ?

A

Resection with end-to-end anastomosis

41
Q

what the Meckel’s diverticulum ?

A

most common congenital anomaly of the GI tract

its a patent intestinal end of the vitellointestinal duct.

42
Q

how Meckel’s diverticulum common ?

A

affecting approximately 2% of the population
2:1 female predominance.
one half of the those who are symptomatic are under 2 years of age

43
Q

what the location of the Meckel’s diverticulum ?

A

it is commonly 2 feet (60cm) from the ileocaecal valve,

It is 2 inches (3–5 cm) long.

44
Q

what the clincal feature of the Meckel’s diverticulum ?

A
  • Intestinal obstruction by Intussusception or band
  • Meckel’s diverticulitis
-Perforation 
by :
1-Progression of diverticulitis,
2-Ulceration 
3-Secondary to ingested foreign body like fish bone, chicken bone 
4-Traumatic

-Severe haemorrhage by peptic ulcer
and its maroon bleeding

45
Q

how to investigate the Meckel’s diverticulum ?

A
  • small bowel enema very acutate
  • radioactive techium 99m scintigraphy
  • Angiography
46
Q

what the treatment of the Meckel’s diverticulum ?

A

Meckel’s diverticulectomy

47
Q

what the prevelance of diveticulosis ?

A

is an acquired disorder.

disease in the western world is 60% over the age of 60 years.
is rare in Africans and Asians, who eat a diet that is rich in natural fibre.

48
Q

most common site for the diverticular disease ?

A

is an acquired disorder.

found in the sigmoid colon in 90% of cases, but the caecum
on occasion, the entire large bowel can be affected.

49
Q

Diverticulosis refers

A

is an acquired disorder.

refers to the presence of diverticula without inflammation

50
Q

Diverticulitis refers

A

refers to inflammation and infection associated with diverticula.

51
Q

The majority of colonic diverticula are false or true

A

are false diverticula in which the mucosa and muscularis mucosa have herniated through the colonic wall .

-They are thought to be pulsion diverticula resulting from high intraluminal pressure

52
Q

how to investigate the diverticulosis ?

A
  • history is asyptomatic
    -barium enemia
    . (There is thickening of the circular
    muscle fibres of the intestine, which develops
    concertina or saw-tooth appearance
    on barium enema .)
53
Q

saw-tooth appearance

on barium enema means

A

diverticulosis because there is thickening of the circular

muscle fibers of the intestine

54
Q

whats the diverticulitis ?

A

inflammation of one or more diverticula

55
Q

whats the incidance of diverticulitis ?

A

incidence 10 to 25% of people with diverticulosis

56
Q

whats the complication of diverticulitis ?

A

1- Intestinal obstruction because of fiberosis
or adherent loop in small intestine

2- Recurrent inflammation
3- Perforation lead to peritonitis and abcess formation
4-Haemorrhage in 17% of cases
5- Fistula formation
(vesicocolic, vaginocolic, enterocolic, colocutaneous) occurs in 5% of cases, with vesicocolic being the most common.

57
Q

what the chance of hemarrage and fistula in diverticulitis ?

A

hemorage is more 17% while fistula 5% most common with the bladder

58
Q

what the clincal feature of the diverticulitis ?

A

-may be uncomplicated diverticulitis as such as distension, flatulence and a sensation of heaviness

  • or may be complicated as
    left iliac fossa pain with or without peritonitis.

Fever, malaise and leucocytosis

pass loose stools or may be constipated;

pneumaturia (flatus feces in the urine as urinary symptoms may herald the formation of a vesicocolic fistula

abdominal examination show that
-lower abdominal tenderness on the left

-sigmoid is paplpe (common site )and tender

on rectal exam revel a tender mass

59
Q

how to dignosis the divriticulitis ?

A
  • depond on the syptomas and signs
    -radiograpgy
    -ct to see the bowel thickening , abcess and extraluminal disease
    -barium enemas and sigmoidoscopy
    in stable acute pt

-water soluble enemas
for large bowel obstruction
- colonoscopy
- cystoscopy

60
Q

what the mangemant for non complicated diverticulitis ?

A

-diet containing roughage النخاله
as bread, flour, fruit and vegetables

  • Bulk formers such as bran, Celevac, Isogel and Fybogel
  • Antispasmodics for painful diverticular disease

pt will recover without surgery,
50 to 70% will have no further episodes.
Risk of complications increases with recurrent disease.

61
Q

what the mangemant for complicated diverticulitis ?

A

Acute diverticulitis
-treated by bed rest and intravenous antibiotics (usually cefuroxime and metronidazole).

-surgery is to control sepsis in the peritoneum and circulation

62
Q

Indications for operation in case of diverticulitis ?

A
  • peritonitis and failure to resolve on conservative treatment
  • young patients with more than two attacks of inflammation
63
Q

what the type of surgery in the diverticulitis ?

A

1- The ideal operation one-stage resection. This involves removal of the affected segment and restoration of continuity by end-to-end anastomosis.

2- If there is obstruction, inflammatory oedema and
adhesions or the bowel is loaded with faeces,
Hartmann’s operation is the procedure of choice

3-perforation, peritonitis soon becomes general
and may be purulent, with a mortality rate of about 15%.
Gross faecal peritonitis carries a mortality rate of > 50%
a primary resection and Hartmann’s procedure
b primary resection and anastomosis after on-table lavage in selected cases;
c exteriorisation of the affected bowel

4-Fistulae can be cured only by resection of the diseased bowel and closure of the fistula.

5- Haemorrhage from diverticulitis must be distinguished from angiodysplasia. On-table lavage and colonoscopy may be necessary to localise the bleeding site. If the source cannot be located, then subtotal colectomy and ileostomy is the safest

64
Q

what the type of ideal surgery for the divericultis ?

A

a one-stage resection. This involves removal of the affected segment and restoration of continuity by end-to-end anastomosis.

65
Q

what if there is obstruction, inflammatory oedema and

adhesions or the bowel is loaded with faeces ?

A

Hartmann’s operation is the procedure of choice

66
Q

In acute perforation, peritonitis ?

A

may be purulent, with a mortality rate of about 15%.
Gross faecal peritonitis carries a mortality rate of > 50%

a primary resection and Hartmann’s procedure 
b primary resection and anastomosis after on-table lavage in selected cases;
c exteriorisation (The act of removing something from a body. )of the affected bowel
67
Q

if fistula ?

A

cured only by resection of the diseased bowel and closure of the fistula

68
Q

if Haemorrhage?

A

must be distinguished from angiodysplasia
.
On-table lavage( washout the fecal load in the obstructed colon) and colonoscopy may be necessary to localise the bleeding site. If the source cannot be located, then subtotal colectomy and ileostomy is the safest

surgery (28 decks)

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