Small intestine short note by S.

Wichien (SNG KKU)

Anatomy (length 4-6 m) Duodenum -25 cm -1st part--intraperitonium -2nd,3,4th--retroperitonium -lig of Treitz--demacrated from jejunum Jejunum/ileum -peritoneal part -no landmark demacrated jeju/ileum -40%proximal=jejunum 60%distal=ileum Mucosa -plicae circulars (valvulae conniventes) Vasa recta -proximal longer than distal Lymphoid follicle -peyer patch -ileum =most prominent Artery -Duodenum--celiac,SMA -Distal duo,jejunum,ilium--SMA Venous -SMV Lymph drainage -Mesenteric LN>cistern chyli> thorasic duct>lt subclavian Parasym -vagus Symphathetic -splanchnic n Histology 4 layers 1.Mucosa -Villi and crypt (of Lieberkuhn) -simple columnar epithelium -3layers 1.epithelium=absorp,secrete 2.lamina propia=CNT,bl.supply,lymph 3.m.mucosae=smooth m. Cell 1.enterocyteabsorp,digestive enz 2.globet cellmucin (defend mech) 3.enteroendocrine cellcarcinoid tumor 4.paneth cellbase of crypt :GF, digest enz, antimicro peptide 5.microfold (M) cellimmune 6.intraepi lymphocyteimmune 2.submucosa -dense CNT -leukocyte,fibroroblast -vascular,lymphatic vv,nerve, GG cell (Meissner plexus) 3.muscularis propia -outer=long -inner=cir -GG cell of myenteric (Auerbach plexus) 4.serosa -mono mesothelial cell -component of viseral peritoneum Development -embryogenic gut tube -endoderm during 4th wk GA -duodenumforegut -jejunum/ileum--midgut -initial commu c yolk sac :6th wk = obliterate :vitelline duct (omphalomesenteric duct) :incomplete obliter = meckel diver Mesoderm -adhere endo--visceral peritoneum adhere ecto--parietal peritoneum -mesoderm division--perito cavity 5th wk -270counterclockwise rotation -celiac and SMA/V derived from vitelline vascular system -neuron derived from neural crest 6th wk -lumen obliterate--lumen -error in recanalize--web/stenosis 9th wk -crypt-villus architecture 12th wk -organogenesis completed DuodenumFBC, calcium Jejunumfolic IleumB12, bile

Small intestine short note by S.Wichien (SNG KKU)

Acquired diverticular -false diverticular -lack muscularis -incidence increase by age 1.duodenum/near ampulla -more common -periampullary/juxtapapillary/ peri vaterian diver -75% medial wall 2.jejunalileal diverti -80%--jejunum--large/multiple 15%--ileum--small/solitary Pathophysio -abnor of intes smooth m or dysregulate motility -asso bact overgrowth :b12 def/megaloblastic/malabsorpt Clinical -asymp unless asso c/p--inci 6-10% :intes obstruct/diverticulitis/hmg perforate/malabsorpt -periampullary duodenal diver :cholangitis/stone/pancreatitis Dx -incidental on imaging/endo/sx -enteroclysis--most sen for jeju-ileal Tx 1.Asymptom--no sx 2.C/p -jejunoileal--segmental resection -duodenal--diverticulectomy Bleeding duodenal diver -lat duodenotomy+oversewn

Meckel diverticulum Rule of 2 2% prevelence 2:1 f:m 2 foot prox IC valve 2yr 2 heterotopic muco--gastric/pancreas Meckel at inguinal/femoral hernia -Littre hernia Pathophysio -fail of vitelline duct obliterate -vitelline a remnant--mesodiver band smb obstruction 1.volvulus around band 2.mesodiver band 3.intussusception 4.stricture--chronic diverticulitis Clinical asymp unless c/p--incidence rate4-6% 1.bleeding--most common of child 2.intes obstr--most common of adult 3.diverticulitis--as appendicitis Dx -CT--not good -enteroclysis--good but not in c/p -scan--if have ectopic mucosa Tx Symp meckel diverticula -diverticulectomy -remove band Bleeding/perforate -segmental resecsection Incidental finding -controversy -against prophylactic sx of asymp -some--selective (have band/narrow base) I/C for incidental diverticulectomy 1.<18 year 2.sign of previous diverticulitis 3.mesodiverticular band 4.palapble heterotopic tissue

Small intestine short note by S.Wichien (SNG KKU)

Obscure GI bleeding -no source by EGD/colono -90% lesion by EGD/colono -most in small bowel Cause adult -angiodysplasia 75% -neoplasm 10% child -meckel diverticula others -crohn,infectious enteritides,NSAID vasculitis,ischemia,varices,intuss Ix -enteroscopy -Tc-labeled RBC scan -angiography Push enteroscopy -long endoscope -beyond lig treitz into prox.jejunum -seen 60 cm of prox jejunum -can cauterization bleeding site Sonde enteroscopy -long-thin fiberoptic -through bowel by peristalsis following inflation of balloon at instru tip -visualized during instru withdrawal -50-75% smb -no bx,cauterization Double ballon endoscopy Wireless capsule enteroscopy Intraoperative enteroscopy -during laparotomy,laparoscopy -endoscope(usually colonoscope) :peroral or enterostomy -transillumination bowel -may identify angiodysplasia -mark lesion c suture on serosa Chylous ascitis -TGA ascites fluid -milky,creamy -intes lymp in peritoneal cavity -intestine--chylomicron--into lymp Cause -abdo malignancy/cirrhosis -infection--TB,filaria -abdo sx :AAA repair/retroperito LN dissection IVC resection/liver transplant -trauma -cong LN abnor--1lymph hypoplasia -RTX,pancreatitis ,rt HF 3 Mechanism 1.exudate of chyle from dilate lymph on bowel wall,mesentery --obstr cisterna chili/malignancy 2.direct leak-lymphoperitoneal fistula --sx,trauma 3.exudate of chyle through wall of dilate retroperitoneal lymph vv --congen lymphangiectasia --thorasic duct obstr Sx relate -1st post op wk--vv disruption -delayed--adhesion induced obstr Ix 1.paracentesis -fluid TGA >110 -may be clear in fasting pt 2.CT -LN/mass 3.lymphangiogram/lymphoscintigraphy -sx planning Rx -Tx underlying cause -most rxn by hi-prot diet,low fat -medium chain TGA :not contribute to chylomicron -no rxn=TPN -octrotide can dec lymph flow -60% rxn to conservation -30% require sx Sx -localized -nonabsorb suture -peritoneovenous shunting=hi c/p

Small intestine short note by S.Wichien (SNG KKU)

Small bowel obstruction Lesion 1.intraluminal--FB,GS,meconium 2.intramural--tumor,crohn,hematoma 3.extrinsic--adhesion,hernia,ca Common etiology 1.prior abdo sx : intra-abdo adhesion 2.neoplasm -1 neoplasm -2 neoplasm--melanoma metas -local invasion--desmoid -carcinomatosis 3.hernias : external/internal 4.crohn dz 5.volvulus 6.intussusception 7.RTx induced stricture 8.postischemic stricture 9.foreign body 10.gall stone ileus 11.diverticulitis 12.meckel diverticulum 13.hematoma 14.congen abnormality--web,malro 15.rare = SMA synd Clinical presentation -colicky abdominal pain -n/v -obstipation -abdominal disten--distal ileum -hyperactive bowel sound Strangulated obstruction -tachycardia -localized abdominal tender -fever -marked leukocytosis -acidosis Diagnosis 1.mechanical or ileus 2.etiology 3.partial or complete 4.simple or strabgulate X-ray sensitivity : 70-80% Specificity : low Triads 1.dilated small bowel loop (>3cm) 2.air fluid level on upright position 3.paucity of air in colon CT sensitivity : 80-90% specificity : 70-90% (low sensitivity <50% in partial obstr :Poor identify transitional zone) Findings -discrete transitional zone -contrast not pass transition zone Closed loop -U shape,C shape dilated bowel loop -radial distribution of mesenteric vv converging toward a torsion point Strangulation -thickening bowel wall -pneumatosis intestinalis -portal venous gas -mesenteric haziness -poor uptake iv contrast to bowel wall Small bowel follow through (small bowel series) -in partial obstruction -barium/water soluble contrast -can therapeutic :gastrograffin--hypertonic :shift fluid to lumen--inc P.gradient Enteroclysis -200-250 ml of barium then 1-2 l of methylcellulose solution

Small intestine short note by S.Wichien (SNG KKU)

Small bowel obstruction Tx Treatment -isotonic fluid iv -foley catheter to mornitor Uo -may be CVP or pulmo a.catheter -broad spectrum ATB -NG tube -operate before irrevers ischemia -nonviable bowel is resected Conservative Tx shoud in 1.partial obstruction -success 65-81% -not improve in 48hr--should sx 2.obstruct in early post op -colorectal sx -usually partial/rare strangulate -can extended conservative Tx 2-3 wk 3.due to chron dz 4.carcinomatosis I/C for Sx 1.peritonitis 2.strangulation 3.complete smb obstruction 4.failed conservative Tx Viable bowel -color -peristalsis -marginal arterial pulsation borderline case -Doppler probe--pulsatile flow -iv fluorescein dye in bowel wall :under ultraviolet illuminaion Sx hemodynamic stable -short length of bowel question should be resected and 1anasto -if viability of large proportion is in question,effort to preserve intes should be made,and reexplore in 24-48hr in second look operation Small bowel perforation cause -most com--endoscope--ERCP c EST -PU -infection:TB,typhoid,CMV,crohn -ischemia,drugs(Nsaids),radiation meckel/acquired diverticula lymphoma,adenoca,melanoma,FB CT -most sense for duodenal perforate -retroperitoneal air -contrast extravasate -paraduodenal collection -free perforate--free air Rx 1.Duodenal Retroperitoneal -nonoperative -in absence progression,sepsis Intraperitoneal -sx require -pyloric exclusion and gastrojejunos or tube duodenostomy 2.Jejunal/ileal -sx repair--segmental resection

Small intestine short note by S.Wichien (SNG KKU)

Ileus Common etiology -abdo sx -Infection--sepsis,abscess,peritonitis -elyte--hypok/mg/na/ca,hypermg -drug--anticholi,opiate,ca blocker,TCA -hypothyroid -ureteric colic -retroperitoneal hmg -SC inj -MI -mesenteric ischemia Chronic intes pseudo-obstruction 1cause 1.Familial type -familial visceral myopathy(T1,2,3) -familial visceral neuropathy(T1,2) 2.Sporadic type -visceral myopathy -visceral neuropathy 2cause 1.Smooth m.disorder -scleroderma,myotonic dystrophy -amyloidosis 2.Neuro--chaga ds,parkinson,SCI 3.Endocrine--DM,hypothy,hypoparathy 4.Miscellaneous--radiation enteritis 5.Phamaco--Phenothiazine,TCA 6.viral infection--CMV,EBV Pathophysiology -sx stress-induced sympathetic reflex -inflam rxn-mediator release -anesthetic/analgesic effect Return of normal motility -small bowel=24 hr -gastic=48 hr -colon=3-5 d Diagnosis -post op--persist ileus beyond to 3-5d -medication--opioid -electrolyte -x-ray -CT(s/p sx)--test of choice in abscess -diag-laparotomy or laparoscopy + full thickness bx of small bowel :dx specific underlying Therapy -limiting oral intake -correcting the underlying factor -NG tube decompression -if prolong ileus=TPN -Nsaid+reduce duration in opioids -epidural block--reduce syste opioid -mu-R antagonist--alvimopam chronic pseudo obstruction -palliation of symptom -possible avoid sx -prokinetic--poor efficacy -refractory ds :may decompressive gastrostomy or extended small bowel resection Reduce post op ileus intra-op -minimize handling bowel -lap approach ,if possible -avoid excess fluid Post op -early enteal feeding -epidural anesth -avoid excess fluid -correct elyte -consider mu-R antagonist Blind loop syndrome -no food pass to that segment -B12 def (bact overgrowtguse B12) -steatorrhea (disturb conjugate bile salt) -diarrhea -wt loss -abdo pain Schilling test -ddx from intrinsic factor def 1.oral B12urine B12 :if B12<6%B12 malabsorb 2.oral B12+iv intrinsic factorurine B12 :if B12<6%no intrinsic factor 3.oral B12+iv ATBurine B12 :if blind loopinc B12

Small intestine short note by S.Wichien (SNG KKU)

Intes fistula Internal fistula -enterocolonic fistula -colovesicular fistula External fistula -enterocutaneous fistula -rectovaginal fistula Enterocolonic fistula :<200 cc = low output >500 cc = high output :>80% iatrogenic c/p from enterostomy or intes anastomosis Spontaneous fistula -usually from progress of Crohn dz Clinical presentation Iatrogenic -p/o d5-10 -initial signs : fever,leukocytosis, prolong ileus,abdo tender, wound infection -asso intraabdo abscess -drainage of enteric material through abdo wall Dx -enteral contrast then CT :initial test :leak of contrast :if intraabdo abscess--percu.drain -if fistula not clear on CT :small bowel series or enteroclysis exam -fistulogram Therapy step1:stabilization -fluid/electrolyte -initial parenteral route -tx infection--ATB/drain abscess -protect skin step2:investigation step3:decision dtep4:definitive mx -sx procedure step5:rehabilitation Tx -nutrition,TPN -trial oral in low output fistula -somatostatin reduce volume of fistula accelerate fistula close Time of sx -conservative 2-3 mo :spontaneous closure -if fail to resolve,sx may be required -simple closure=hi recurrence -alternative=biologic sealant Outcome -10-15% mortality=sepsis,UDZ -50%close spontaneous Factor inhibit spon closure Hi-hi output fistula So-short tract F-foreign body R-radiation enteritis I-infection E-epithelialization of fistula tract N-neoplasm D-distal obstruction

Small intestine short note by S.Wichien (SNG KKU)

Mesenteric ischemia 4 mechanisms 1.a.emboli -most common of acute MI -heart:lt atrium/ventricle/valve -50% SMA -distal to origin middle colic a 2.a.thrombosis -preexisting atherosclerotic lesion -near origin 3.vasospasm (nonocclusive mesen ischemia:NOMI) -in critical ill pt c vasopressor agent 4.v.thrombosis -5-10% of acute MI -95%--SMV -1 or 2cause (coagulation dz) Pathophysiology Acute -mucosal sloughing--3hr -full thickness infarct--6 hr Chronic -development of collateral vv -symptom--involved >=2 chronic v.thrombosis -involve portal/spleenic v.=portal HT Clinical Acute -severe abdo pain -out proportion to exam--hallmark -colicky pain--mid abdomen -n/v -diarrhea -bowel infarction=peritonitis,bl stool Chronic -insidious onset -postpandrial abdominal pain -wt loss -food fear chronic mesen v thrombosis -asymptomatic--collateral v -usually incidental findings -bleeding--esophageal varice Angiography acute MI -most reliable for dx -sens 74-100%, spec 100% -but invasive,time consume,costly NOMI -diffuse narrowing of mesen vv -absence of obstruction chronic arterial MI -gold std for dx CT NOMI -nonspecific,pt at risk -should angiography Acute mesen venous thrombosis -test of choice (sense 90%) Chronic arterial MI -atherosclerotic calcified plaque -near origin of prox mesenteric vv -prominent collateral

Small intestine short note by S.Wichien (SNG KKU)

Mesenteric ischemia Tx -if peritonitis are detected,should EL Emboli/thrombus acute MI -std tx=surgical revascularization -embo/thrombolectomy,mesen bypass -in no peritonitis,thrombolytic drugs is alternative option Thrombolysis -streptokinase,urokinase,rtPA -success in small/peripheral/partial obstruction -less likely success in>12 hr of onset -pt who develop peritonitis during thrombolysis should EL -limit for acute MI caused by SMA thrombosis is limit by experience NOMI -vasodilator=papaverine hydrochloride Acute mesen venous thrombosis -anticoagulant -heparin -initial as soon as dx,even intraop -evaluate hereditary and acquired thrombophilia -absence thrombotic ds,pt should on warfarin 6-12 mo Chronic arterial MI -sx revascularization :aortomesenteric bypass grafting and mesenteric endarterectomy -alternative :percu transluminal mesenteric angioplasty alone or c stent Chronic v. mesen thrombosis -chronic anticoag -prevent recurrent bleeding of varice :propanolol :endoscopic tx :sx portosystemic shunt in can't control by conservative Radiation enteritis Pathophysio -free radical--break DNA--apoptosis -most terminal ileum Acute inj -villous blunting -infiltrate leuco/plasmas cell in crypt -mucosal slough/ulcer/hmg -related to dose--at least 4500 cGy -stop XRT--improve Clinical -n/v,diarrhea,cramp abdo.pain -subside after discontinued Tx -self limited -supportive--anti-emetic,iv -avoid sx if no IC -perforation/hi gr obstruction/hmg :limited resection :1anas healthy lesion Chronic inj -occlusive vasculitis -chronic ischemia/fibrosis -stricture/abscess/fistula Clinical -within 2yr of XRT -partial smb obstruct -crampy abdo.pain -wt loss Dx Enteroclysis--most accurate test CT--r/o recurrent Preventive -<5000 cGy -multibeam XRT--dec max RT expose -tilt table--move bowel from RT area

Small intestine short note by S.Wichien (SNG KKU)

Short bowel syndrome <200 cm of residual small bowel Fxn definition -insuff in absorption -result in diarrhea,dehydrate,malnutri Cause adult -acute mesenteric ischemia -malignancy -crohn disease -small bowel resection 75%=single operation 25%=multiple operation pediatric -intes atresia -volvulus -NEC Pathophysiology smb resection -<50%--tolerated >50%--clinical malabsorpt TPN dependence -lack fxn colon--<100cm -intact colon--<60cm Other factor 1.intact colon or not 2.intact IC valve or not 3.healthy or dz residual of smb 4.resect jejunum or ileum (ilium=absorb bile s.,B12) Intes adaptation -1-2 yr s/p sx -hypergastrinemia Short bowel Tx 1.Medical -repletion fluid,elyte -most--initial require TPN -ileus resolve--gradual enteral nutri -hi dose H2antagonist or PPI -antimotility agent :loperamide,diphenoxylate -octreotide--reduce GI secretion -1-2 yr post op--adapt period :TPN and enteral nutri are titrated to independence from TPN -TPN s/e=catheter sepsis,venous thrombosis,liver/kidney failure, osteoporosis 2.Nontransplant sx therapy Goal -inc nutrient and fluid absorption -slowing intes transit/inc intes length Operation -segmental reversal of small bowel -interposition of segment colon -construction small intes valve -electrical pacing of small bowel Intes lengthening procedure Longitu intes lengthening and tailoring -LILT -separate dual vasculature -longitudinal division of bowel -end to end anastomosis -in peds,dilated residual small bowel Serial transverse enteroplasty proce -STEP -lengthening of dilated bowel -by serial intes stapling 3.Intestinal transplant I/C--c/p of intes failure/TPN -impending/overt liver failure -thrombosis of major central v -frequent catheter sepsis -frequent severe dehydration

Small intestine short note by S.Wichien (SNG KKU)

Neoplasm Benign 1.leiomyomajejunum 2.adenomaduodenum -most common -<1cmendoscopic Tx ->2cmSx 3.hemangioma -Osler Weber Randu synd 4.hamatoma -Peutz jegher synd Malignant (rare = 1.2-2.4% of GI malig) 1.adenocarcinoma 35-50% :most in duodenum :marker-CEA 2.carcinoid tumor 20-40% 3.lymphoma 10-15% :most in ileum 4.GIST 15% :most in stomach :2nd=small bowel 5.metasstasis -colorectal, melanoma, panc, lung Carcinoid tumor -marker:5HIAA (5-hydroxyindole acetic acid) -syndrome asso iver metas -mediator:serotonin,bradykinin,subs-P -metabolism during pass through liver carcinoid syndrome -diarrhea -flushing -hypotension -tachycardia -fibrosis of endocardium/valve rt heart Adenoma -Tubular--least aggressive -Villous--most aggressive -Tubulovillous FAP -nearly 100% duodenal adenoma -100x duodenal ca Risk of CA -red meat -smoke -crohn dz -celiac sprue -Hereditary nonpolyposis colorectal ca (HNPCC) -fam adenomatous polyposis (FAP) -peutz jegher synd :100 fold than normal Pathophysiology Small bowel ca=rare due to 1.dilutional of carcinogen in chyme 2.rapid transit 3.low conc of bact --> low conc carcinoge product of bact 4.secretory IgA 5.epi cellular apoptosis mechanism Clinical presentation -1st--most--asymptom until large -2nd--hemorrhage -partial small bowel obstruction :luminal obstruction or :intussusception -palpable abdo mass -jx--2nd to--liver metas/periampull -stool occult bl/hepatomegaly/ascites Imaging Enteroclysis -sens >90% -test of choice in distal smb tumor Upper GI c small bowel follow through -sens 30-44% CT -low sens for mucosal/inamural lesion -useful in staging RBC scan EGD -duodenum Capsule enteroscopy Endoscopic u/s -layer of intes wall

Small intestine short note by S.Wichien (SNG KKU)

Treatment symptomatic benign lesion should be resected or removed endoscopically Duodenal tumor <1cm--endoscopic polypectomy >2cm--difficult to endosco,should sx Sx option -transduodenal polypectomy -segmental duodenal resection -pancreaticoduodenectomy :in near ampulla of vater Carcinoid -resection of all visible dz -segmental intes resection and regional lymphadenectomy <1cm--no LN >3cm--75-90% LN -30% of case=multiple lesion, :should exam entire small intestine -metas ds :debulking--dec carcinoid synd -CMT=doxo,5FU,streptozocin -octreotide=tx carcinoid synd Lymphoma -localized=segmental intes resection -if diffuse dz,CMT=1tx GIST -segmental intes resection -if know dx before,wide lymphadenec can be avoid,rarely node metas -imatinib (gleevec) :tyrosine kinase inhibit Metas ca -symtomatic=palliative resection or bypass except in advance case -systemic tx may offer if effective for 1ca

Adenoma in FAP -aggressive tx -if possible--removed endoscopic -if sx require--PD :multiple/sessile lesion :periampullar region -surveillance :f/u in 6 mo and q 1yr if no recur Jejunal/ileum ca -wide-local excision -regional lymphadenectomy -local advance,metas :palliative resection or bypass -CMT no proven efficacy in adjuvant or palliative tx of small b.adenoca