Professional Documents
Culture Documents
Mamuka Zakalashvili
Bowel obstruction
Hernias
Vascular disorders
Small bowel diverticula
Sigmoid colon diverticular disease
Bowel obstruction
1. Small bowel (SB) is the most common site for obstruction.
Due to the small lumen when compared to the large bowel
2. Radiographic findings
a. Bowel distention
b. Air-fluid levels with a step-ladder appearance
c. Absence of air distal to obstruction
3. Clinical findings
a. Colicky pain
Severe pain alternating with pain-free intervals
b. Abdominal distention
c. No rebound tenderness
d. Tympanitic to percussion
e. High-pitched tinkling sounds
4. Treatment is surgery
Small and Large Bowel Obstruction
ETIOLOGIC DISORDER DISCUSSION
Adhesions MCC of small bowel obstruction (60% of cases). Adhesions from previous surgery (most
common), metastasis to the small bowel (second MCC), endometriosis, radiation
Crohn disease Lumen in terminal ileum is narrow because of full-thickness inflammation of bowel
adhesions
Duodenal atresia Atresia is distal to entry of the common bile duct. Association with Down syndrome
History of maternal polyhydramnios. Vomiting of bile-stained fluid at birth. Double bubble
sign: air in stomach and air in proximal duodenum
Gallstone ileus Occurs in elderly women with chronic cholecystitis and cholelithiasis
Fistula develops between gallbladder and small bowel. Stone lodges at the ileocecal valve
causing obstruction. Radiograph shows air in the biliary tree
Hirschsprung disease Absence of ganglion cells in Meissner and Auerbach causes localized aperistalsis.
Male dominant in 80% of cases; occurs in 10% of Down syndrome patients
Usually involves the distal sigmoid and rectum; Clinical findings: chronic constipation;
absent stool on the examining finger, because there is no stool in the rectal vault.
Complication: enterocolitis of dilated bowel (danger of perforation)
Diagnose with rectal suction biopsy; Treatment: surgical resection of affected segment
ETIOLOGIC DISORDER DISCUSSION
Indirect inguinal Second most common cause of small bowel obstruction
hernia Bowel becomes trapped in the inguinal canal
Femoral hernia Highest rate of bowel incarceration
Intussusception Peak incidence ages 15; In children, the terminal ileum invaginates into the cecum
Hyperplastic lymphoid tissue in Peyer patches that project into the lumen serves as the
nidus for the intussusception; may occur with rotavirus oral vaccine
Combination of obstruction and ischemia
Clinical findings: colicky pain with bloody diarrhea; an oblong mass is palpated in the
midepigastrium (Dance sign); usually self-reduces without intervention
May require air reduction under fluoroscopy or ultrasound
In adults, a polyp or cancer is the nidus for intussusception
Meconium ileus Complication of newborn with cystic fibrosis
Meconium lacks NaCI and obstructs the bowel lumen
Volvulus Bowel twists around mesenteric root producing obstruction and strangulation
Sigmoid colon is most common site in elderly
Cecum is the most common site in young adults
Risk factors: chronic constipation (most common), pregnancy, laxative abuse
Case 1
A 3 month old male infant was born at term with no congenital anomalies. His mother has
noted marked abdominal enlargement along with infrequent bowel movements for the
past week. On physical examination his abdomen is distended but there does not appear to
be appreciable tenderness. A plain film abdominal radiograph reveals marked colonic
dilation. What pathologic finding is most likely to be present in this infant?
Indirect heria Most common. Pathogenesis in children: persistence of peritoneal connection between
inguinal canal and tunica vaginalis. Pathogenesis in adults: protrusion of new peritoneal
process into inguinal canal
Complications: incarceration or strangulated obstruction (hemorrhagic infarction)
Treatment: Surgical
Epidemiology
a. Definitionherniations of mucosa and submucosa through the muscularis
b. Incidence in the general public is 35% to 50%.
c. Incidence increases with age.
d. Sigmoid colon is the most common site for diverticula in the entire gastrointestinal
tract.
e. Diverticula are located on the mesenteric border where the vasa recta penetrates
the muscle wall (anatomic weakness site).
Pathogenesis
a. It is due to a low-fiber diet with increased constipation.
b. Area of weakness is where vasa recta penetrate the muscular propria.
Diverticulum is juxtaposed to a blood vessel.
Associations
(1) Marfan syndrome
(2) Ehlers-Danlos syndrome
(3) Adult polycystic kidney disease
Sigmoid colon diverticular disease
Clinical findings
Diverticulosis
(1) Painless bleeding (hematochezia), is characteristic.
Usually caused by erosion of juxtaposed vessel by a fecalith
(2) Bleeding stops spontaneously in 60% of cases.
(3) Sigmoid diverticulosis is the most common cause of hematochezia.
Scarring of the juxtaposed vessel in recurrent attacks of diverticulitis prevents bleeding.
Treatment
a. Nonpharmacologic
Increase fiber in diet to prevent constipation
b. Antibiotics for acute disease
c. Colonic resection in selected cases
Examplesrepeated episodes of diverticulitis; bleeding that does not stop; abscess/fistula formation;
obstruction
Case 3
A 4-year-old girl has the sudden onset of abdominal pain and
vomiting. She has a oblong mass in the right lower quadrant and
hyperactive bowel sounds. Which of the following is the most likely
diagnosis?
(A) Appendicitis
(B) Intussusception
(C) Meckel diverticulum
(D) Necrotizing enterocolitis
(E) Strangulated hernia
The most important points
SB obstruction: bowel distention; air/fluid levels; colicky pain; adhesions from previous
surgery
Hernias: Increased intra-abdominal pressure; weakness in the abdominal wall; Indirect
inguinal hernia - MC hernia
SMA and IMA junction: watershed area
Occlusion SMA (thrombus/embolus): MCC SB infarction
SB infarction: sudden onset diffuse abdominal pain, bloody diarrhea; distention, absent
bowel sounds, no rebound tenderness;
Ischemic colitis: splenic flexure pain after eating fear of eating and weight loss
Angiodysplasia: dilation of cecal submucosal venules; 2d MCC of hematochezia; more
likely to bleed if genetic/acquired vWD present;
Meckel diverticulum - Vitelline duct remnant; 2s rule; mimics acute appendicitis
SB diverticula: duodenum MC site
Sigmoid diverticular disease: herniation mucosa/submucosa through muscularis;
mesenteric border; area of weakness where vasa recta penetrate; constipation MCC;
Sigmoid diverticulitis MC complication; left-sided appendicitis; CT scan best for Dx
Sigmoid diverticulosis: MCC hematochezia and fistulas