Small & Large intestine 1 - د.مازن عبدالله Flashcards
whats the anatomy of the Small intestine ?
- 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%
how long the large intestine is ?
its 1.5 m
what definition of the consiptation in WHO ?
- 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
what the type of the consiptation ?
1- megcolon
2- non mega colon
what the type of the megacolon conspitation ?
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
what the typs of the non megacolon constipation ?
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.)
whats the Idiopathic megarectum and megacolon ?
(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
how to diagnosis pt with megarectum and megacolon ?
- 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
what the definite diagnosis of the pt with megarectum and megacolon ?
-“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
what the treatment of the Idiopathic megarectum and megacolon ? as Hirschsprung’s disease
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
whats the non-megacolon constipation ?
pt will have difficulty in the defcation , abdominal pain , and distention
whatre the causes of the non-megacolon constipation ?
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
GIVE EXAMPLE ABOUT THE MEDICATION THAT CAUSE THE CONSTIPATION ?
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
GIVE EXAMPLE ABOUT THE NEUROLOGICAL DISORDER THAT CAUSE THE CONSTIPATION ?
Neurological disorders:
Spinal cord injury, Parkinson’s disease, cerebrovascular disease, paraplegia, multiple sclerosis,
Autonomic neuropathy, spina bifida
GIVE EXAMPLE ABOUT THE ORGAIC STENOSIS THAT CAUSE THE CONSTIPATION ?
GIVE EXAMPLE ABOUT THE NEUROLOGICAL DISORDER THAT CAUSE THE CONSTIPATION ?
GIVE EXAMPLE ABOUT THE ENTERIC DISORDER THAT CAUSE THE CONSTIPATION ?
chronic intestinal pseudo-obstruction
GIVE EXAMPLE ABOUT THE MYOGENIIC DISORDER THAT CAUSE THE CONSTIPATION ?
chronic intestinal pseudo-obstruction
GIVE EXAMPLE ABOUT THE ANORECATAL DISORDER THAT CAUSE THE CONSTIPATION ?
Anal fissures anal strictures
how to investigate the non-megacolon constipation ?
- 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
if 5 marker or few still in the bowel what that means ?
on the abdominal transit study
normal colonic transit
if the ring scattered means ?
hypomobility or colonic inertia (also known as slow-transit constipation)
if most of the ring gathered ?
pt have obstruction
what the treatment of the non megacolon consitipation ?
1- dietary fibers
2- laxatives
3- biofeedback
how to dignosis of the iodopathic slow transit constipation ?
- 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
what the benefit of the abdominal transit study ?
distinguish the slow whole transit gut from the rectal outlet delay
what the treatment of the iodopathic slow transit constipation ?
- Dietary
- Biofeedback
- Surgery
+Total colectomy and ileorectal anastomosis is the preferred procedure,
+segmental resection
+stoma creation
what the Angiodysplasia ?
- 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
in which age group happen the Angiodysplasia ?
in middle and elderly no gender predominant
5-25% in age over 60
may assocaited with aortic stenosis
what the clincal feature of the Angiodyslasia ?
1- anemia with minor syptomas
2-(10-15%) risk of bleeding as malena and hematochezia
fresh blood through the anus
what the differential diagnosis of the Angiodysplasia ?
- Diverticulosis,
- Ulcerative colitis (UC)
- Ischaemic colitis
- Radiation colitis
- Benign polyps
- Malignant tumors
DIUR BM
how to investigate the Angiodysplasia ?
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
what the treatment of the Angiodysplasia ?
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
what the blind loop syndrome ?
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
what the clinical feature of the blind loop syndrome ?
- steatorrhea,
- diarrhea,
- anemia,
- weight loss,
- abdominal pain,
- multiple vitamin deficiencies,
- joint pain
- and occasionally neurological disorders.
what the cause of blind loop syndrome ?
any thing cause stasis of the abdominal content as
stricture , stenosis , fistula, blind bouch
what the treatment blind loop syndrome ?
surgical extirpation of the cause of the stasis.
what the diverticulum ?
bulging sac in any portion of the gastrointestinal tract
what the cause of diverticulosis
1- congintal true which include all the layers beside the muscular layer
2-aquired most common false lac of the muscular coat
what the clincial picture of the Jejuna diverticula ?
- may be asympomatic
- or cause abdominal pain
- or cause malabsorption syndrome
- can cause inflammation and perforation
what the treatment Jejuna diverticula ?
Resection with end-to-end anastomosis
what the Meckel’s diverticulum ?
most common congenital anomaly of the GI tract
its a patent intestinal end of the vitellointestinal duct.
how Meckel’s diverticulum common ?
affecting approximately 2% of the population
2:1 female predominance.
one half of the those who are symptomatic are under 2 years of age
what the location of the Meckel’s diverticulum ?
it is commonly 2 feet (60cm) from the ileocaecal valve,
It is 2 inches (3–5 cm) long.
what the clincal feature of the Meckel’s diverticulum ?
- 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
how to investigate the Meckel’s diverticulum ?
- small bowel enema very acutate
- radioactive techium 99m scintigraphy
- Angiography
what the treatment of the Meckel’s diverticulum ?
Meckel’s diverticulectomy
what the prevelance of diveticulosis ?
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.
most common site for the diverticular disease ?
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.
Diverticulosis refers
is an acquired disorder.
refers to the presence of diverticula without inflammation
Diverticulitis refers
refers to inflammation and infection associated with diverticula.
The majority of colonic diverticula are false or true
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
how to investigate the diverticulosis ?
- 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 .)
saw-tooth appearance
on barium enema means
diverticulosis because there is thickening of the circular
muscle fibers of the intestine
whats the diverticulitis ?
inflammation of one or more diverticula
whats the incidance of diverticulitis ?
incidence 10 to 25% of people with diverticulosis
whats the complication of diverticulitis ?
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.
what the chance of hemarrage and fistula in diverticulitis ?
hemorage is more 17% while fistula 5% most common with the bladder
what the clincal feature of the diverticulitis ?
-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
how to dignosis the divriticulitis ?
- 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
what the mangemant for non complicated diverticulitis ?
-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.
what the mangemant for complicated diverticulitis ?
Acute diverticulitis
-treated by bed rest and intravenous antibiotics (usually cefuroxime and metronidazole).
-surgery is to control sepsis in the peritoneum and circulation
Indications for operation in case of diverticulitis ?
- peritonitis and failure to resolve on conservative treatment
- young patients with more than two attacks of inflammation
what the type of surgery in the diverticulitis ?
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
what the type of ideal surgery for the divericultis ?
a one-stage resection. This involves removal of the affected segment and restoration of continuity by end-to-end anastomosis.
what if there is obstruction, inflammatory oedema and
adhesions or the bowel is loaded with faeces ?
Hartmann’s operation is the procedure of choice
In acute perforation, peritonitis ?
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
if fistula ?
cured only by resection of the diseased bowel and closure of the fistula
if Haemorrhage?
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
