The SMALL INTESTINES

NEIL C. MENDOZA, MD, FPCS

SmallIntestine
AnatomyandPhysiology
Jejunum
suspendedinamobilemesentery
2/5ofwholeintestinallength
maybeinvolvedinadhesions
Ileum
3/5ofwholeintestinallength

BloodSupply

Proximalduodenumceliacaxis

RemainderofthesmallintestineSuperiormesenteric
artery

PHYSIOLOGYSMALLBOWEL
Primaryfunctions:
digestionandabsorption

Allingestedfoodandfluidandsecretionsfromthe
stomach,liver,pancreasreachthesmallbowel

Totalvolume9lit/dayandallwillbeabsorbed
except12lit

INVESTIGATIONS
SMALLBOWELDISORDERS
1.Radiologyplainerectfilm
obstructionandperforation

2.Smallbowelfollowthrough
establishedinvestigationtooutlinethesmallbowel
tumors,Crohnsdisease,fistulas,polyps
3.Enteroclysis

SBFT(smallbowelfollowthrough)
Theesophagus,stomach,andduodenumareeasily
evaluatedindetail.

Thesmallbowelisthenradiographedatperiodic
intervalsandfluoroscopicallyspottedbytheRadiologist

ThistypeofSBFTcantakehourstocompleteanddetail
ofthelumencannotbeassessedastheloopsofsmall
intestineoverlapasthebariumprogresses

Enteroclysis
minimallyinvasiveradiographicprocedureofthesmall
intestine,whichrequirestheintroductionofacatheter
intotheintestine,followedbytheinjectionofbariumand
methylcellulose.

Thebariumcoatstheintestineandthemethylcellulose
distendsthelumentogiveadoublecontrastexamthat
allowsforfluoroscopicvisualizationoftheentiresmall
bowel.

Enteroclysis
maybehelpfulindiagnosingalmostalldiseasesthataffect
thesmallbowel
mayalsobehelpfulinrulingoutdiseasesinpatientswith
unexplainedabdominalcomplaints.
Indications:

Suspectedorknownsmallbowelobstruction

Neoplasms(cancers)

Inflammatoryboweldisease

Unexplainedgastrointestinalbleeding

Malabsorption

Polyps

Adhesivebands

Postsurgicalchanges

Disadvantages:
placementoftheenteroclysiscathetercanbe
uncomfortableforthepatient,evenwiththeuseof
anestheticsprayandXylocainejelly

patientwillreceivehigherdosesofradiationin
comparisontothetraditionalsmallbowelfollow
throughexamduringthisexam.

Advantages:
muchquickerthanaroutinesinglecontrastSmallBowel
FollowThroughexam
distentionofthesmallbowelmakesitpossibletodisplay
alldilatedbowelloopssimultaneouslyattheendofthe
exam
helptodetermine:foldthickness,ulceration,polyps,
constrictions,andadhesivebands

INVESTIGATIONS

SMALLBOWEL

Selectivesplanchnicangiographyreliablemethodfor
detectionofangioplastic
lesions
ThebleedingsitecanbelocatedifthepatientI
sbleedingactivelyatthetimeofinvestigation

INVESTIGATIONS
Ultrasoundoftheabdomen
candifferentiatefluidfilleddilatedsmallbowelloop
fromabdominalcysticstructures

canassessfreefluidwithinperitonealcavity

canassessasolidmassbelongingtothesmallbowelif
largeenough

INVESTIGATIONS
Isotopescintigraphy

IsotopelabelledredcellsoccultGIbleeding

Isotopelabelledwhitecellssuspectedintraabdominal
inflammation/abscessformation,inflammedbowel
(Crohnsdse)

Isotopelabelledmealintestinaltransittime

INVESTIGATIONS
Quantitativeestimationoffecalfat
remainsthemostsensitivetestofdisordersof
digestionandabsorption

Onastandarddietof100goffat,thefecalfatoutput
normallyislessthan6g/day

INVESTIGATIONS
Jejunalmucosalbiopsy
Celiacdiseasesubtotalvillousatrophy
Whipplesabnormalmucosalpathogens

INVESTIGATIONS
BACTERIALOVERGROWTH
smallbowelbecomescolonizedbybacteria
increaseintheconcentrationorganismswhichare
normallyconfinedtothelowersmallbowelandcolon
affectedintestinebecomesinflammedanddilated

Symptomsandsignscolickypain,meteorism,diarrhea,
anemia

INVESTIGATIONS
Causesofbacterialovergrowth:

1.Excessiveentryofbacteriaintothesmallbowel

2.Intestinalstasis

DISEASESoftheSMALL
INTESTINES

BACTERIAL
OVERGROWTH

1.Excessiveentryofbacteria
Achlorhydria

Gastrojejunostomy

Gastrectomy

Enterocolicfistulas

Cholangitis

LossofileocecalvalvefollowingRHC

BACTERIAL
OVERGROWTH
2.Intestinalstasis:

StenoticCrohnsdisease
Stenoticintestinalstasis

Smallboweldiverticulosis
Afferentloopstasis
Enteroentericanastomosis
Diabetismellitusautonomicneuropathy
Radiationenteritisstenosis
Sclerodermaimpairedintestinalmotility

BACTERIAL
OVERGROWTH

Clinicalfeatures:

Abdominalcolickypain

Asthenia,nausea,vomiting

Weightloss,excessivebowelsounds

Diarrhea

Anemia,hypoproteinemia

Paresthesia,peripheralneuropathyB12deficiency

BACTERIAL
OVERGROWTH
Treatment:

Surgicaltreatmentoftheunderlyingconditionwhenever
possible

Jejunaldiverticulosis,sclerodermatetracyclineand
metronidazolefor1014days

SHORTGUTSYNDROME

Encounteredaftermassiveresectionofthesmall
bowel

Encounteredinpts.withjejunoilealbypassfor
morbidobesity

SHORTGUTSYNDROME
Conditionsnecessitatingextensiveresectionofthesmall
bowel:

Crohnsdisease

Mesentericinfarction

Radiationenteritis

Multiplefistulas

Smallboweltumors

SHORTGUTSYNDROME
Resectionsofmorethanhalfofthesmallbowellength
seriousmalabsorbtion
Pts.withresidualsmallbowellengthof<2mdiminished
workcapacity
Pts.withresidualsmallbowellengthofless1mrequire
homeparenteralnutritiononanindefinitebasis
Ilealresectionsarelesswelltoleratedthanjejunal
resections

SHORTGUTSYNDROME
Treatment:

MassivesmallbowelresectionTPNregimenthatmust
provide40Kcal/Kg.bodyweight

Pts.withabout1m.ofsmallbowelTPNdiscontinued
withtimecozsmallbowelwillhypertrophy

Oralnutritionisbasedonanelementaldiet

antiperistalticagentsshouldbegiven,vitamins,B12
parenteral

ShortBowelSyndrome
SurgicalApproach

intestinallengtheningprocedures

<60cm.,intestinaltransplantation

PROTEINLOSING
ENTEROPATHY

Lossofplasmaproteinslowplasmaproteins

secondaryhyperaldosteronismwithwaterandsalt
retentionedema

Causes:
mucosaldiseaseWhipples

ulceratinglesionsvilloustumors

lymphaticobstructionlymphoma

Treattheunderlyingdisease

SMALLBOWEL
TUMORS

10%ofallGItumors(benignormalignant)

Benignsmallboweltumors:

Adenomatouspolyps

HamartomatouspolypsPeutzJaegerssyn.

Leiomyomas,lipomas,fibromas

Hemangiomas,neurofibromas

BENIGNSMALLBOWELTUMORS
Clinicalpresentations:
Bowelobstructionduetointussusception
Chronicbloodlosschronicanemiafecalocultblood
Melenaacuteanemia

DIAGNOSIS:
bariumfollowthrough
abdominalCT
endoscopicvideocapsulefornonobstructinglesions

TREATMENTbowelresectionwithendtoend
anastomosis

MALIGNANTSMALLBOWELTUMORS
ADENOCARCINOMAS

MALIGNANTCARCINOID

LYMPHOMA

METASTASESFROMDISTANTTUMOR

MALIGNANTSMALLBOWELTUMORS
Clinicalpresentations:

LowerGIbleedingocultormelena
Diarrhea
Perforationperitonitis
Bowelobstruction

DIAGNOSIS:
contrastfollowthrough

CTforelectivecases

plainabdoXrayinacutecases

TREATMENTsegmentalbowelresection

MALIGNANTSMALLBOWELTUMORS
SMALLBOWELADENOCARCINOMA

Commonlywelldifferentiatedmucussecreting
tumors
Usuallylocatedintheproximalintestine
Spreadtolymphnodes,liver,peritonealserosa

Pts.withresectabletumors25%5yearsurvival
rate

CARCINOIDTUMORS
Derivedfromenterochromaffincells
Commonplaces:appendix,ileum,rectum

Clinicalfeatures:flushing,diarrhea,
bronchoconstrictioncausedbyserotoninandother
vasoactivesubstancessecretedbythetumor

CARCINOIDTUMORS
Diagnosis:

elevatedlevelsof5HIAA5hydroxyindolacetic
acidthebreakdownproductofserotonininthe
urine

TREATMENT:
resectionoftheprimarytumorandmetastastatictumor

Lymphoma

presentswithfatigue,weightlossandabdominal
pain

Treatment:PrimarilySurgical

adjuvanttherapyrecommendedwithpositive
margins

GastroIntestinalStromalTumors(GIST)
mostcommonsarcomaoftheGItract
Clinicalpresentationisvariable
Tumorsareoftenasymptomatic
Patientsmayhavecommon,nonspecificsymptoms,
resultinginunderdiagnosisormisdiagnosis
AllGISThavethepotentialtobecomemalignant
Riskisbasedonsizeandmitoticindexat
presentation

GISTCLINICALPRESENTATION
Oftenasymptomatic,especiallywhensmall
Maybesymptomaticiflarge
signs/symptomsrelatedtolocationandsizeoftumor
VagueGIpainordiscomfort
GIhemorrhage
Anemia
Anorexia,weightloss,nausea,fatigue
Acuteintraperitonealbleedingorperforation

GIST- SITES OF GROWTH

Other(rectum,esophagus,
mesentery,retroperitoneum

Colon
10% 15%

50%
Stomach

25%
Small
intestine

GIST
2majorhistologicpatterns,whichoverlapwithmany
nonGISTsarcomasandothermalignancies
Spindlecell
Epithelioid
Inthepast,GISTwereusuallyclassifiedas:
Leiomyoma
Leiomyoblastoma
Leiomyosarcoma
Manypatientspreviouslydiagnosedwithoneofthese
tumorsactuallyhadaGIST

GISTDIAGNOSIS
Initialworkupshouldincludeimaging:
CTofabdomenandpelviswithoral/IVcontrast
Consider18FDGPET
Endoscopicultrasound
Liverfunctiontests
Completebloodcounts
Surgicalassessment
Resectablevsnonresectable
Primarytumoronlyvsmetastatic

ENDOSCOPY&EUS

ULCERATEDGASTRICGIST

FDGPET
FDGPET(Fluorodeoxyglucosepositronemission
tomography)
Providesthestatusofglucosemetabolismin
tumors
GISTarehighlymetabolicallyactive

Easydetectionhighlysensitivebutnotspecificfor
metabolicallyactiveGIST

Stagingworkup
Evaluatetheextentofthedisease
Assessformetastaticdisease

CTMassivestromalgastrictumor

GISTFDGPETImaging
Hepatic,abdominalandpelvicmetastases

GISTTREATMENT
Surgeryremainstheprincipaltreatmentforresectable
primaryGIST
Standardsarcomachemotherapyisineffective
Limitedresponserate~5%
Mediantimetoprogression34months
Noimpactonsurvival
Comorbidityduetotumorlocalizationlimitseffectiveness
ofradiationtherapy

SURGICALCONSIDERATIONS
Completegrossresectionwiththeintactpseudocapsuleis
thegoalofresection
Carefultumorhandlingiscritical
Rupturingofthepseudocapsulecancausetumor
bleedingand/ordissemination
Unlikeadenocarcinomas,GISTtendtodisplace,not
invade,surroundingorgans
Negativemicroscopicmarginsaredesirable
Lymphadenectomyisunnecessary,asGISTrarely
metastasizetotheregionallymphnodes

RECURRENCEAFTERSURGERY
Recurrenceiscommon
majorityofhighriskpatientshaverecurrenceofGIST
followingsurgery
Mediantimetorecurrenceis7monthsto2years
Only10%ofpatientsremaindiseasefreeafterextended
followup
Recurrentdiseaseshouldbetreatedasmetastatic
disease

GISTTREATMENTOPTIONS
IntermediateandhighriskGISThaveahighrateof
recurrence
Recurrentdiseaseshouldbetreatedasmetastatic
disease
Traditionalchemotherapyandradiationtherapyare
ineffectiveforGIST
Patientfollowupisnecessary
Neoadjuvanttherapymayenhanceresectability
Adjuvanttherapymayreducerecurrence

JEJUNALSTROMALTUMORw/MUCOSAL
ULCERATION

SMALLBOWELDIVERTICULOSIS
Duodenaldiverticula90%areasymptomatic

70%periampullaryregioncholangitis,pancreatitis,CBD
stones
Jejunaldiverticularare,maycauseobstruction,

bleeding,perforation,bacterialovergrowthwithinthe
diverticulum
Meckelsdiverticulumwithin40cm.oftheileocecalvalve
maycausebleeding,obstruction,acuteinflammation
TREATMENT
ResectionwithEnterorrhapy

MechanicalObstructionoftheSmall
Intestine
impairmentinnormalflowofluminalcontents

intrinsicorextrinsic

earlydiagnosiskeytomanagement

SMALLBOWELOBSTRUCTION

Responsiblefor12to16%ofadmissionstothe
surgicalserviceinpatientswithacuteabdominal
pain.

Mechanicalblockagewithfailureofpassageof
bowelcontents

Etiology:SBO

Extraluminal

Adhesions>60%,especiallyafterpelvicsurgery

Neoplastic20%.Majorityaremetastaticthathave
peritonealimplants

Hernias10%.Mostcommonareventral,inguinalor
internal

Abscesses

CausesofIntestinalObstruction
Young
Adult

Adult

GroinHernia

Adhesions

Adhesions
(70%)

Midgut
Volvulus

Intussusception

Groin
Hernia

Meconium
ileus

Meckels
Diverticulum

Neonate
Atresia

Infant

GroinHernia
(10%)
Cancer
(5%)

Causes
Symptoms
Signs
Plainfilms

SBO
Colonic
Adhesionsand
Cancer
GroinHernias Inflammation
crampsand crampsand
vomiting
vomitingless
regular
frequent
interval
mildmoderate moderate
marked
distension
distension
dilatedloops dilatedair
withairfluid filledcolon
levels,paucity w/w/oSB
distally
distension

CAUSES:SBO
Intramural

Neoplasms
Adenocarcinomas:50%,distalduodenumorproximal
jejunumcausehemorrhageorulceration
Lymphomas:20%,nonHodgkins.Ileum>jejunum>
duodenum.Occasionallyobstruct

Carcinoid:>50%indistalileum.Mostasymptomatic

Leiomyosarcoma:>5cmindiameter.Obstruction,
bleeding,perforationiscommon.

CAUSES:SBO

Inflammatory
Crohns5%.Acuteinflammationandedemaor
chronicstrictures.
Infectious
Congenital
Malrotation,duplication,congenitalbands

Others:Traumatic,Intussusception,radiation

CAUSES:SBO

Intraluminal
Gallstones,enteroliths,Bezoars,foreignbodies

Presentation&Pathophysiology

Classicalpresentation:

colickyabdominalpain,nausea,vomiting,abdominal
distentionandobstipation

Vomitingmorecommoninproximalobstruction

Feculentvomitingindicatesdistalorlateobstruction

Presentation&Pathophysiology

Diarrhea

Inbothpartialorcompleteobstruction,diarrheamaybe
presentearlyinthecoursebecauseofincreasedmotility
andcontractileactivityofbowelinordertopropel
luminalcontentsbeyondpointofobstruction

Increasedordecreasedbowelsounds:Increasedearly,
mayseeperistalticwaves;later

Decreasedornone,oncebowelisexhausted

Hypotensionandshock:
Boweldilateswithaccumulationofwaterandelectrolytes
inthelumenandwithinthewallofthebowel(third
spacing)leadingtodehydrationandhypovolemia

Compromisedventilation:
Increasedabdominalpressure,decreasedvenousreturn,
elevationofdiaphragm

Fever:
Strangulatedbowel;Closedloopobstructionhas
increasedintraluminalpressureswithdecreasein
mucosalbloodflow.

Bacterialtranslocation:E.coli,Strepfaecalis,and
Klebsiella

Guaiacpositive:malignancy,intussusceptionor
infarction

ElectrolyteImbalance

Proximalobstructionmayhavehypokalemia,
hypochloremiaandalkalosis

Distalobstructionlessdramaticelectrolyte
abnormalities

Hemoconcentrationasevidenceofdehydration

Radiology

Plainfilm:
diagnosticin5060%ofcases
smallboweldistention,multipleairfluidlevels,and
decreasedcolonicgasandstool
Widelyavailableandlowcost

Bariumswallowand/orenema:
Notusefulinhighgradeobstruction,contrastdiluted
byfluidinbowelleadstopoormucosaldetail.

Prolongedtransittime

Enteroclysis
Sequentialinfusionpromotesantegradeflowbeyondpointof
obstruction
Positivepredictivevalue100%;levelofobstructionin
89%;causeofobstructionin86%.
CT:Highgradeobstruction81%sensitivity,63%withall
grades
abletoshowcauseofobstructionin9395%ofcases
Reliableinshowingsignsofclosedloop,ischemiaand
infarction

Treatment

Nonoperative:
6085%resolution
NGtubedecompression,fluidresuscitation,bowelrest
Serialexamsandelectrolytemanagement
IFC
Broadspectrumantibiotics

Operative

Completeobstructionusuallydoesnotresolve.

Incidenceofstrangulationincreasessignificantly
after1224hours
manifestedbyfever,tachycardia,focaltenderness,
leukocytosis

Operativetreatmentdependsonetiologyi.e.lysisof
adhesions,smallbowelresection,etc.

PathophysiologyofPostoperativeSmallBowel
Obstruction

Adhesions

Internalherniation

Inflammation

PreventionandTreatmentofSmallBowel
Obstruction

NGtube

gastrograffinchallenge

thedecisiontooperate

PLAINABDOMINALXRAY

CTSCAN

POSTOPERATIVEILEUS
PostoperativeIleus

Definedastheprolongedinhibitionofcoordinated
movementsofthegastrointestinaltract

Possibleindicators:Nauseaandvomiting,
abdominaldistension,painandtheabsenceofflatus
andstool

PathophysiologyofIleus

Extensiveinflammatoryresponsewithintheintestinal
muscularisafterbowelsurgery(Sido,etal)

Directrelationshipbetweentheinflammatoryreaction
andthemacrophagesoftheintestinalmuscularisthat
participateandfunctionalsmoothmuscleimpairment
(Behrendt,etal)

foundaninductionofcyclooxygenase2mRNAand
proteininresidentmacrophagesthatdecreasedjejunal
circularmusclecontractilitythroughprostaglandins
(Schwartz,etal)

PreventionandTreatmentofIleus

Ceruletide,erythromycin,metoclopramide,somatostatin
haveallbeenstudiedastreatmentforpostoperativeileus
withnoconclusiveresults

demonstratedarelationshipbetweenpatient
expectationsaftersurgeryandoutcome(Disbrow,etal.)

showedbenefitsofgumchewingonpostoperativebowel
motilitybelievedtoberelatedtoshamfeeding(Asao,et
al.)

Multiplestudieshavedemonstratedthatpatientswill
oftentoleratefeedingwithin24hoursaftersurgery

PostoperativeSmallBowelObstruction

Temporaryreturnofbowelfunctionfollowedby
distensionandobstipationwithin4weeksoflaparotomy
(Stewart,etal)

principalindicators:abdominalpain,vomiting,
distension,andobstipationwithradiographic
confirmationpostoperativesmallbowelobstruction
(Frykberg&Phillips)

definedascrampyabdominalpain,vomitingand
radiographicfindingsconsistentwithintestinal
obstructionafteraninitialreturnofbowelfunction
within30daysaftersurgery(Ellozy,etal.)

SpecialformsofObstruction
Stricture
CrohnsDisease
NSAIDs
Radiationtherapy
MesentericIschemia
ifchronicandprogressive,resectionisthebest
surgicalapproach

Specialformsofobstruction
Internalhernias
abnormalitiesrelatedtoprioroperations
congenitaldefects
surgicalrepairofthedefectwithresectionofnon
viablebowel

Specialformsofobstruction
Gallstoneileus
12%ofcasesofintestinalobstructionaffecting
patients60yearsandabove
stones>2.5cm.,entersGITbyulcerationand
fistulization
cholecystoduodenalfistulamostcommonsiteofentry
presentswithintestinalobstructionandaerobilia
causesdistalilealobstruction

Gallstoneileus

Gallstoneileus

InfectiousDiseases
1.TBEnteritis
Primaryinfection
SecondaryInfection
Indicationforsurgeryobstruction
2.Typhoidenteritis
Diagnosisbloodculture
Medicalmanagement
Indicationsforsurgerybleeding,perforation

SBO:FABRICBEZOARS

ENTEROCUTANEOUSFISTULA

Abnormalcommunicationslinkingtwoepithelialized
surfaces.

Enterocutaneousfistula(ECF)isanabnormal
communicationbetweenhollowvisceraandskin.

Seriousanddreadedcomplicationofgastrointestinal(GI)
diseasesandtheirtreatments,suchassurgery

SmallBowelFistula

ETIOLOGY

Spontaneous15%to25%

Radiation

IBD

diverticulardisease

ischemicbowel

appendicitis

perforatedduodenalulcers

malignancies

ETIOLOGY
Postoperative75%to85%:

Anastomoticbreakdown

unrecognizedbowelinjuriesduringdissectionor
abdominalclosure.

Operationsforcancer,IBD,andlysisofadhesionsare
mostatrisk.

CLASSIFICATION

I.Output:

Low:200ml/24hour

Moderate:200to500ml/24hour

High:500ml/24hour(poorerprognosis)

II.AnatomiclocationintheGItract:
Unfavorable:stomach,lateralduodenum,ligamentofTreitz,and
ileum
Favorable:Esophagus,duodenalstump,pancreatobiliary,jejunum.

Anatomicfeaturesunfavorableforspontaneous
closure:

Foreignbody

Radiation

Inflammation/infection:adjacentabscessordiseased
bowel

Epithelializationofthefistulatract

Neoplasm

Distalobstruction

Also:fistulatract<2cmlengthandenteraldefects>1cm

DIAGNOSIS
Clinicalpresentation:

Fever

elevatedwhitebloodcellcount

increasingabdominaltenderness

prolongedileus

DIAGNOSIS
Clinicalpresentation:

signsofwoundinfection

sepsis

Betweenthefifthand10thpostoperativedays.

Drainageofentericcontent(fromthesurgicalwound)either
spontaneouslyoruponreopeningofthewound.

Radiologicstudies:

Plainradiography

GIcontraststudies

Fistulograms

Ultrasonography

CTscan

Mainroleistoaidintheanatomiclocalizationofthe
fistula.

MANAGEMENT
Dividedintothreephases:
1.Diagnosisandrecognition
2.Stabilizationandinvestigation

controlcomplicationswithin24to48hrsofrecognitionoffistula

maingoalisreductionoffistulaoutput.

3.Definitivecare
usuallyoccursifthefistulafailstorespondtomedicaltreatment
after4to6weeks.

MANAGEMENT

NPO

NGtube

H2antagonistorPPI

skinprotection

drainageofabscess

correctionoffluid,electrolyte,andnutritionalimbalances

MANAGEMENT

Malnutritionispresentin5590%ofpatientswithECFandisresponsibleformuchof
themorbidityandmortalityinthesepatients.
Malnutritionshouldbeconsideredifthereisabodyweightlossofatleast10%and
ifthereishypoproteinemia
mortalityin42%inpatientswithaserumalbumin<2.5g/dL
useofTPNisassociatedwithspontaneousclosure

Broadspectrumantibiotics

Somatostatin:inhibitsgastric,pancreatic,biliary,andenteric
secretions

Octreotide(somatostatinssyntheticanalogue)

ShortBowelSyndrome
Limitedilealresectionincreasesbilesaltloadto
colonresultinginmucosalinjuryanddiarrhea

>100cm.ilealresectionresultsinlossottotalbile
saltpoolleadingtosteatorrhea

DefinitiveCare:
usuallyoccursifthefistulafailstorespondtomedical
treatmentafter4to6weeks.
Operativeinterventions:
oversewingofthefistula
resectionofthediseasedsegmentwithprimary
anastomosis
exteriorization
serosalpatchwitheitherjejunumoradefunctionalized
Roux.

ThankYou