Lower GI surgeryDr.Ishara Maduka

ContentsAnatomyIntestinal obstructionAppendicitisInflammatory bowel diseaseColorectal carcinomaStomas

Anatomy revision

Intestinal obstruction - TypesTypes according to pathologyMechanical obstructionAdynamic obstruction

Types according to site of obstructionSmall intestinal obstructionLarge intestinal obstruction

Mechanical obstructionObstruction due to external or internal factor leading to narrowed lumen with normal peristalsis.

Mechanical obstruction - causes

Lesions Extrinsic to Intestinal WallAdhesions (usually postoperative) Hernia External (e.g., inguinal, femoral, umbilical, or ventral hernias) Internal (e.g., congenital defects such as paraduodenal, foramen of Winslow, and diaphragmatic hernias or postoperative secondary to mesenteric defects) Neoplastic Carcinomatosis, extraintestinal neoplasm Intra-abdominal abscess/ diverticulitisVolvulus (sigmoid, cecal)

Lesions Intrinsic to Intestinal WallCongenital Malrotation Duplications/cysts Traumatic HematomaIschemic stricture Infections Tuberculosis Actinomycosis Diverticulitis

Neoplastic Primary neoplasms Metastatic neoplasms Inflammatory Crohn's disease Miscellaneous Intussusception Endometriosis Radiation enteropathy/stricture

Intraluminal/ Obturator LesionsGallstone Enterolith Bezoar Foreign body

Whats adynamic obstructionAdynamic obstruction means failure of progression of bowel contents in absence of mechanical obstruction but due to absent or ill coordinated bowel contractions.

Normal peristaltic wave

Causes of Adynamic IleusFollowing celiotomysmall bowel- 24h, stomach- 48h, colon- 3-5dInflammation e.g. appendicitis, pancreatitisRetroperitoneal disorders e.g. ureter, spine, bloodThoracic conditions e.g. pneumonia, # ribsSystemic disorders e.g. sepsis, hyponatremia, hypokalemia, hypomagnesemiaDrugs e.g opiates, Ca-channel blockers, psychotropics

Symptoms and signs of bowel obstructionColicky central abdominal painVomiting - early in high obstructionAbdominal distension - extent depends on level of obstructionAbsolute constipation - late feature of small bowel obstructionDehydration associated with tachycardia, hypotension and oliguriaFeatures of peritonism indicate strangulation or perforation

InvestigationsSupine abdominal X rayOther Ix depending on DD

Supine x ray in Intestinal obstruction

TreatmentAdequate resuscitation prior to surgery is importantSurgery in under resuscitated patient is associated with increased mortalityIf obstruction presumed to be due to adhesions and there are no features of peritonismConservative management for up to 48 hours is often safeRequires regular clinical review

If features of peritonism or systemic toxicity presentNeed to consider early operationExact procedure will depend on underlying cause

AppendicitisInflammation of the appendix is called appendicitis.Patients present with pain in the right iliac fossa.

Differentials for pain in RIFAppendicitisUrinary tract infectionNon-specific abdominal painPelvic inflammatory diseaseRenal colicEctopic pregnancyConstipation

Risk

Clinical featuresCentral abdominal pain moving to right iliac fossaNausea, vomiting, anorexiaLow-grade pyrexiaLocalised tenderness in right iliac fossaFeatures of peritonism rebound tenderness, percussion tenderness

InvestigationsAppendicitis is a clinical diagnosisUSS, FBC, UFR can help to exclude differential diagnoses

TreatmentTreatment is surgical for confirmed acute appendicitis.

Inflammatory bowel diseaseIBD

IBDChronic inflammatory condition involving the bowels which have a protracted, relapsing course.2 pathologiesUlcerative colitis Crohns disease

Clinical featuresDiarrhoea

PR bleeding

Weight loss

Fever during attacks

Colorectal carcinoma

Epidemiologyone of the most common cancers in the worldUS:4th most common cancer (after lung, prostate, and breast cancers)2nd most common cause of cancer death (after lung cancer)2001:130,000 new cases of CRC 56,500deaths caused by CRC

Adenoma carcinoma sequence

Risk factorsAgeAdenomas, PolypsSedentary lifestyle, Diet, ObesityFamily History of CRCInflammatory Bowel Disease (IBD)Hereditary Syndromes (familial adenomatous polyposis (FAP))

Dietary factors implicated in colorectal carcinogenesis

consumption of red meat

animal and saturated fat

refined carbohydrates

alcoholincreased risk

Contd..dietary fiber

vegetables

fruits

antioxidant vitamins

calcium

folate (B Vitamin)decreased risk

Symptoms and signsGeneral symptomsweight loss

loss of appetite

night sweats

feverSpecific symptomsrectal bleeding

change in bowel habits

obstruction

abdominal pain & mass

iron-deficiency anemia

TreatmentSurgical resection the only curative treatment

Likelihood of cure is greater when disease isdetected at early stage

Early detection and screening is of pivotalimportance

Screening for CRC

fecal occult blood test (FOBT)chemical test for blood in a stool sample. annual screening by FOBT reduces colorectal cancer deaths by 33%

Flexible sigmoidoscopy can detect about 65%75% of polyps and 40%65% of colorectal cancers. rectum and sigmoid colon are visually inspected

SurgeryHemicolectomy or colectomy depending on the location of the tumour.A stoma may have to be created either temporarily or permanently.

Stomas

Whats a stomaA stoma is a surgically created communication between a hollow viscus and the skinIncludes a colostomy, ileostomy, urostomy, caecostomy, jejunostomy and gastrostomyFunctionally they can be end or loop stoma

PositioningAway from umbilicus, scars, costal margin and anterior superior iliac spineEnsure compatible with the clothing worn by the patientIdeally should be marked preoperatively by stoma nurse

ComplicationsNecrosisDetachmentRecessionStenosisProlapseUlcerationParastomal herniationFistula formation

Retraction

Prolapse

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