Small Intestine Ii

Small IntestineSmall Intestine

James Taclin C. Banez, James Taclin C. Banez, MD, MD, FPCS, FPSGS, DPBS,DPSAFPCS, FPSGS, DPBS,DPSA

Small IntestineSmall Intestineone of the most important organs for one of the most important organs for immune defenseimmune defense

largest endocrine organ of the bodylargest endocrine organ of the body

Starts from the pylorus and ends at the Starts from the pylorus and ends at the cecumcecum

3 parts:3 parts:1.1. DuodenumDuodenum (20cm) (20cm)

2.2. JejunumJejunum (100 to 110cm) (100 to 110cm)

3.3. IleumIleum (150 to 160 cm) (150 to 160 cm)

AnatomyAnatomyHas plicae circulares or valves of Has plicae circulares or valves of KerkringKerkring

A.A. Duodenum:Duodenum: Retro-peritonealRetro-peritoneal Supplied by the celiac artery & SMASupplied by the celiac artery & SMA

B.B. Jejunum:Jejunum: Occupies upper left of the abdomenOccupies upper left of the abdomen Thicker wall and wider lumen than the Thicker wall and wider lumen than the

ileumileum Mesentery has less fat and forms only Mesentery has less fat and forms only

1-2 arcades1-2 arcades

C.C. Ileum:Ileum: Occupies the lower right; has more fat Occupies the lower right; has more fat

and forms more arcadesand forms more arcades Contains Contains Payer’s patchesPayer’s patches Ileum & jejunum is supplied by the SMAIleum & jejunum is supplied by the SMA

FunctionFunctionA.A. Digestion & Absorption:Digestion & Absorption:

B.B. Endocrine Function:Endocrine Function:– Secretes numerous hormones involved in GIT Secretes numerous hormones involved in GIT

function.function.1.1. SecretinSecretin

2.2. CholecystokeninCholecystokenin

3.3. Gastric inhibitory peptideGastric inhibitory peptide

4.4. EnteroglucagonEnteroglucagon

5.5. Vasoactive intestinal peptideVasoactive intestinal peptide

6.6. MotilinMotilin

7.7. BombesinBombesin

8.8. SomatostatinSomatostatin

9.9. NeurotensinNeurotensin

FunctionFunctionC.C. Immune function:Immune function:

1.1. Major source ofMajor source of IgAIgA

2.2. Integrity of the GUT wallIntegrity of the GUT wall prevents bacterial prevents bacterial translocation into the wall of the intestine translocation into the wall of the intestine and abdominal cavity which can lead to and abdominal cavity which can lead to sepsissepsis

3.3. Gut associated lymphoid tissueGut associated lymphoid tissue – part of the – part of the immune defense system which clears the immune defense system which clears the abdominal cavity of pathogenic bacteria abdominal cavity of pathogenic bacteria found in found in Peyer’s patchesPeyer’s patches

Small Bowel Surgical LesionsSmall Bowel Surgical Lesions

1.1. Small bowel obstruction:Small bowel obstruction:a.a. MechanicalMechanical

b.b. IleusIleus

2.2. Small bowel infectionSmall bowel infection

3.3. Chronic inflammationChronic inflammation

4.4. NeoplasmNeoplasm

5.5. DiverticulaDiverticula

6.6. Ischemic enteritisIschemic enteritis

7.7. Short bowel syndromeShort bowel syndrome

SMALL BOWEL SMALL BOWEL OBSTRUCTIONOBSTRUCTION

Small Bowel ObstructionSmall Bowel Obstruction

Causes of Causes of Mechanical ObstructionMechanical Obstruction::1.1. Post-operative adhesionPost-operative adhesion (75%) (75%)

2.2. Midgut volvulousMidgut volvulous

3.3. HerniasHernias

4.4. Crohn’s diseaseCrohn’s disease

5.5. Neoplasm (primary or extrinsic compression Neoplasm (primary or extrinsic compression or invasion)or invasion)

6.6. Superior mesenteric artery syndrome Superior mesenteric artery syndrome (compression of transverse duodenum)(compression of transverse duodenum)

Midgut VolvulousMidgut Volvulous

Pathophysiology:Pathophysiology:

Accdg. to it’s anatomical relationship to the Accdg. to it’s anatomical relationship to the intestinal wall:intestinal wall:

1.1. Intraluminal Intraluminal ( foreign bodies, gallstone, and ( foreign bodies, gallstone, and meconium)meconium)

2.2. IntramuralIntramural (neoplasm, Crohn’s, hematomas) (neoplasm, Crohn’s, hematomas)

3.3. Extrinsic Extrinsic (adhesion, hernias & carcinomatosis)(adhesion, hernias & carcinomatosis)

Classify Accdg to Degree of Classify Accdg to Degree of ObstructionObstructionPartial small-bowel obstructionPartial small-bowel obstruction – – passage of gas and fluid.passage of gas and fluid.

Complete small-bowel obstruction Complete small-bowel obstruction (obstipation)(obstipation)– Closed loop obstructionClosed loop obstruction (obstructed (obstructed

proximal and distal) ex. Volvulusproximal and distal) ex. Volvulus

Strangulated bowel obstructionStrangulated bowel obstruction

Manifestation:Manifestation:1.1. colicky abdominal paincolicky abdominal pain2.2. nausea / vomitingnausea / vomiting3.3. obstipationobstipation4.4. abdominal distentionabdominal distention5.5. hyperactive bowel sound / hypoactive BShyperactive bowel sound / hypoactive BS6.6. signs of dehydration (sequestration of fluid in signs of dehydration (sequestration of fluid in

bowel wall and lumen as well as poor oral bowel wall and lumen as well as poor oral intake)intake)

7.7. lab. findings:lab. findings:a.a. hemoconcentrationhemoconcentrationb.b. fluid & electrolyte imbalancefluid & electrolyte imbalancec.c. leucocytosisleucocytosis

Manifestation:Manifestation:Features of Strangulated obstructionFeatures of Strangulated obstruction::

1.1. tachycardiatachycardia

2.2. localized abd. tendernesslocalized abd. tenderness

3.3. feverfever

4.4. marked leucocytosismarked leucocytosis

5.5. acidosisacidosis

6.6. lab result:lab result:

- - elevated serum amyase, lipase, LDH, elevated serum amyase, lipase, LDH,

phosphate and potassiumphosphate and potassium

Goals in its diagnosis:Goals in its diagnosis:1.1. distinguish between mechanical obstruction distinguish between mechanical obstruction

from ileusfrom ileus

2.2. whether it is partial or complete obstructionwhether it is partial or complete obstruction

3.3. differentiate between simple and differentiate between simple and strangulating obstructionstrangulating obstruction

4.4. determine the etiologydetermine the etiology

Diagnosis:Diagnosis:1.1. Clinical history & PEClinical history & PE

2.2. Radiological Radiological examination:examination:

a.a. FPA (supine and FPA (supine and upright)upright)Triad:Triad:

1.1. dilated small bowel (>3cm )dilated small bowel (>3cm )

2.2. air-fluid levels seen in air-fluid levels seen in uprightupright

3.3. paucity of air in the colonpaucity of air in the colon

SMALL BOWEL OBSTRUCTION SMALL BOWEL OBSTRUCTION (Air Fluid Level)(Air Fluid Level)

Air-fluid level:Air-fluid level: Gas – due to swallowed airGas – due to swallowed air Fluid – a) swallowed fluidFluid – a) swallowed fluid

b) b) gastrointestinal gastrointestinal

secretion secretion

(increase epithelial water (increase epithelial water

secretion).secretion).

Bowel distention / Bowel distention / elevated intramural elevated intramural pressure ---> ischemia pressure ---> ischemia ------> necrosis.------> necrosis.

(strangulated bowel (strangulated bowel obstruction)obstruction)

Diagnosis:Diagnosis:b.b. CT scanCT scan (90% sensitive / 90% specific) (90% sensitive / 90% specific)

– Findings of small bowel obstruction:Findings of small bowel obstruction:a.a. Discrete Discrete transition zonetransition zoneb.b. Intra-luminal contrast unable to passed beyond the Intra-luminal contrast unable to passed beyond the

transition zonetransition zonec.c. Colon containing little gas or fluidColon containing little gas or fluid

− Strangulation is suggested:Strangulation is suggested:a.a. Thickening of the bowel wallThickening of the bowel wallb.b. Pneumatosis intestinalisPneumatosis intestinalisc.c. Portal venous gasPortal venous gasd.d. Mesentery hazinessMesentery hazinesse.e. Poor uptake of intravenous contrast into the wall of the Poor uptake of intravenous contrast into the wall of the

affected bowelaffected bowel

− Limitation:Limitation: unable to detect partial intestinalunable to detect partial intestinal obstructionobstruction (<50% sensitivity) (<50% sensitivity)

Treatment:Treatment:1.1. Correct fluid & electrolyte imbalanceCorrect fluid & electrolyte imbalance::

– Isotonic fluidIsotonic fluid– Monitor resuscitation (foley catheter/CVP)Monitor resuscitation (foley catheter/CVP)

2.2. NPO / TPNNPO / TPN3.3. Broad spectrum antibioticBroad spectrum antibiotic (due to bacterial (due to bacterial

translocation)translocation)4.4. Placed NGTPlaced NGT to decompress the stomach and to decompress the stomach and

decrease nausea, distention and risk of decrease nausea, distention and risk of aspirationaspiration

5.5. Expeditious celiotomyExpeditious celiotomy (to minimize risk of (to minimize risk of strangulation).strangulation).

– Type of operation based on operative finding Type of operation based on operative finding causing intestinal obstructioncausing intestinal obstruction

Ileus / Pseudo-ObstructionIleus / Pseudo-Obstruction

Impaired intestinal motilityImpaired intestinal motility

Most common cause of delayed discharge Most common cause of delayed discharge following abdominal operationsfollowing abdominal operations

Temporary and reversibleTemporary and reversible

Ileus / Pseudo-ObstructionIleus / Pseudo-ObstructionEtiologies:Etiologies:1.1. Abdominal surgeryAbdominal surgery

2.2. Infection & inflammation (sepsis/peritonitis)Infection & inflammation (sepsis/peritonitis)

3.3. Electrolyte imbalance (Hypo K, Mg & Na)Electrolyte imbalance (Hypo K, Mg & Na)

4.4. Drugs (anticholinergic, opiates)Drugs (anticholinergic, opiates)

5.5. Visceral myopathies (degeneration/fibrosis of Visceral myopathies (degeneration/fibrosis of smooth muscle)smooth muscle)

6.6. Visceral neuropathies (degenerative disorders of Visceral neuropathies (degenerative disorders of myenteric & submucosal plexuses)myenteric & submucosal plexuses)

ILEUSILEUS

Symptoms:Symptoms:

1.1. Inability to tolerate solid & liquid by Inability to tolerate solid & liquid by mouthmouth

2.2. Nausea/vomitingNausea/vomiting

3.3. Lack of flatus & bowel movementsLack of flatus & bowel movements

4.4. Diminished or absent bowel soundDiminished or absent bowel sound

5.5. Abdominal pain and distentionAbdominal pain and distention

Diagnosis:Diagnosis:

1.1. History of recent abdominal surgeryHistory of recent abdominal surgery

2.2. Discontinue opiates Discontinue opiates

3.3. Serum electrolyte determinationSerum electrolyte determination

4.4. CT scan better than FPA in postoperative CT scan better than FPA in postoperative setting to exclude presence of abscess or setting to exclude presence of abscess or mechanical obstructionmechanical obstruction

Therapy:Therapy:

1.1. NPO, if prolong TPN is requiredNPO, if prolong TPN is required

2.2. NGT to decompress the stomachNGT to decompress the stomach

3.3. Correct fluid & electrolyte imbalanceCorrect fluid & electrolyte imbalance

4.4. Give Give ketorolacketorolac and reduce the dose of and reduce the dose of opioidsopioids

CHRONIC IDIOPATHIC CHRONIC IDIOPATHIC INFLAMMATORY INFLAMMATORY DISEASE OF THE DISEASE OF THE

BOWELBOWEL

CROHN’S DISEASECROHN’S DISEASERegional, transmural, granulomatous Regional, transmural, granulomatous enteritis. enteritis. Chronic, idiopathic inflammatory dseChronic, idiopathic inflammatory dseEthnic groups ---> East Europe Ethnic groups ---> East Europe (Ashkenazi Jewish) (Ashkenazi Jewish) Female predominance, 2x higher smokersFemale predominance, 2x higher smokersFamilial association (30x in siblings / 13 x Familial association (30x in siblings / 13 x in 1in 1stst degree relatives). degree relatives).Higher socioeconomic statusHigher socioeconomic statusBreast feedingBreast feeding is protective is protective

Etiology:Etiology:UnknownUnknown

Hypothesis:Hypothesis:1.1. Infectious:Infectious: - Chlamydia / Pseudomonas / - Chlamydia / Pseudomonas /

Mycobacterium paratuberculosis / Listeria Mycobacterium paratuberculosis / Listeria monocytogenesis / Measles / Yersinia monocytogenesis / Measles / Yersinia enterocoliticaenterocolitica

2.2. Immunologic abnormalities:Immunologic abnormalities:• Humeral & cell-mediated immune reactions against Humeral & cell-mediated immune reactions against

gut cells.gut cells.

3.3. Genetic factors:Genetic factors:• Chromosome 16Chromosome 16 (IBD1 --> NOD2) (IBD1 --> NOD2)

Pathology:Pathology:Affect any portion of GIT:Affect any portion of GIT:

– Small bowel alone (30%)Small bowel alone (30%)– Ileocolitis (55%)Ileocolitis (55%)– Colon alone (15%)Colon alone (15%)

HallmarkHallmark – focal, – focal, transmural inflammation of transmural inflammation of the intestinethe intestine

Earliest signEarliest sign --> --> aphthous aphthous ulcersulcers surrounded by halo surrounded by halo erythema over a non-erythema over a non-caseating granuloma.caseating granuloma.

CHRON’S DISEASECHRON’S DISEASE

Pathology:Pathology:As the aphthous ulcer enlarge As the aphthous ulcer enlarge and coalesce transversely and coalesce transversely forming forming cobblestone cobblestone appearance.appearance.Advanced dseAdvanced dse ---> transmural ---> transmural inflammation. This results to inflammation. This results to COMPLICATIONSCOMPLICATIONS

1.1. adhesions to adjacent bowel,adhesions to adjacent bowel,2.2. stricture formation (fibrosis), stricture formation (fibrosis), 3.3. intra-abdominal abscesses, intra-abdominal abscesses, 4.4. fistula or free perforation fistula or free perforation

(peritonitis)(peritonitis)

Skip lesions and w/ fatSkip lesions and w/ fat wrappingwrapping (encroachment of (encroachment of mesenteric fat onto the serosal mesenteric fat onto the serosal surface) --> surface) --> pathognomonic pathognomonic for Crohn’s.for Crohn’s.

ADVANCED CHRON’S DSEADVANCED CHRON’S DSE

CHRON’S DSE. ANAL CHRON’S DSE. ANAL FISTULAFISTULA

Clinical Manifestation:Clinical Manifestation:Most common symptom:Most common symptom:

1.1. Abdominal painAbdominal pain2.2. DiarrheaDiarrhea3.3. Weight lossWeight loss

Other symptoms depends on type of complications:Other symptoms depends on type of complications:1.1. obstruction (fibrosis)obstruction (fibrosis)2.2. perforation (peritonitis, fistula, intraabdominal abscess)perforation (peritonitis, fistula, intraabdominal abscess)3.3. toxic megacolon (marked colonic dilatation, adb. tenderness, fever toxic megacolon (marked colonic dilatation, adb. tenderness, fever

& leukocytosis)& leukocytosis)4.4. cancer (6x greater/more advanced---> poor prognosis)cancer (6x greater/more advanced---> poor prognosis)5.5. perianal dse (fissure, fistula, stricture or abscess)perianal dse (fissure, fistula, stricture or abscess)

Extra-intestinal manifestation:Extra-intestinal manifestation:– erythema nodosum & peripheral arthritis are correlated w/ severity erythema nodosum & peripheral arthritis are correlated w/ severity

of intestinal inflammation.of intestinal inflammation.


1.1. Endoscopy Endoscopy (esophagogastroduodenoscopy (EGD) (esophagogastroduodenoscopy (EGD) /colonoscopy) w/ biopsy./colonoscopy) w/ biopsy.

2.2. Barium enema / intestinal series Barium enema / intestinal series

3.3. EnteroclysisEnteroclysis (small bowel) more (small bowel) more accurateaccurate

4.4. CT scan – to reveal intra-abd. abscessesCT scan – to reveal intra-abd. abscesses

Treatment:Treatment:I.I. Medical:Medical:

– Intravenous fluidsIntravenous fluids– NGT to rest GIT (elemental diet/TPN)NGT to rest GIT (elemental diet/TPN)– Medications:Medications:

1.1. to relieve diarrheato relieve diarrhea2.2. relieve painrelieve pain3.3. control infection (antibiotic)control infection (antibiotic)4.4. Anti-inflammatory ( aminosalicylates, corticosteroid, Anti-inflammatory ( aminosalicylates, corticosteroid,

immunomodulators – azathioprime 6-immunomodulators – azathioprime 6-mercaptopurine and cyclosporine)mercaptopurine and cyclosporine)

II.II. Surgical:Surgical:– Indicated if: Indicated if:

with complicationswith complications

– Types:Types:Segmental resection w/ primary anastomosis:Segmental resection w/ primary anastomosis:

– Microscopic evidence of the dse at the resection Microscopic evidence of the dse at the resection margin does not compromise a safe anastomosis, margin does not compromise a safe anastomosis, hence, a frozen section is unnecessary.hence, a frozen section is unnecessary.

StricturoplastyStricturoplasty

Bypass procedures (gastrojejunostomy)Bypass procedures (gastrojejunostomy)

Tuberculous Enteritis:Tuberculous Enteritis:In developing and under develop countriesIn developing and under develop countriesResurgence in develop countries due to:Resurgence in develop countries due to:

1.1. AIDS epidemicAIDS epidemic2.2. Influx of Asian migrantsInflux of Asian migrants3.3. Use of immunosuppressive agentsUse of immunosuppressive agents

Forms:Forms:1.1. Primary infectionPrimary infection (caused by M. tuberculosis (caused by M. tuberculosis

bovine from ingested milk)bovine from ingested milk)2.2. Secondary infectionSecondary infection (swallowing bacilli from (swallowing bacilli from

active pulmonary TB)active pulmonary TB)

Tuberculous Tuberculous EnteritisEnteritis

Tuberculous Enteritis:Tuberculous Enteritis:

Patterns:Patterns:1.1. Hypertrophic – causes stenosis or obstructionHypertrophic – causes stenosis or obstruction2.2. Ulcerative – diarrhea and bleedingUlcerative – diarrhea and bleeding3.3. Ulcero-hypertrophicUlcero-hypertrophic

Treatment:Treatment:– Chemotherapy (given 2 wks prior to surgery up Chemotherapy (given 2 wks prior to surgery up

to 1 yr).to 1 yr).RifampicinRifampicinIsoniazidIsoniazidEthambutolEthambutol

– Surgery (perforation, obstruction, hemorrhage).Surgery (perforation, obstruction, hemorrhage).

Typhoid enteritis:Typhoid enteritis:Caused by Salmonella typhiCaused by Salmonella typhi

Diagnosis:Diagnosis:– Culture from blood or fecesCulture from blood or feces– Agglutinins against O and H antigenAgglutinins against O and H antigen

Treatment:Treatment:– Medical:Medical:

Chloramphenicol / trimethropin-sulfamethoxazole / Chloramphenicol / trimethropin-sulfamethoxazole / amoxycillin / quinolonesamoxycillin / quinolones

– Surgical:Surgical:perforations / hemorrhageperforations / hemorrhage

Segmental resection (w/ primary anastomosis or Segmental resection (w/ primary anastomosis or ileostomy)ileostomy)

DIVERTICULAR DIVERTICULAR DISEASE OF THE DISEASE OF THE SMALL BOWELSMALL BOWEL

Meckels DiverticulumMeckels DiverticulumMost prevalent congenital anomaly of GITMost prevalent congenital anomaly of GIT

True diverticulaTrue diverticula

60% contains heterotopic mucosa:60% contains heterotopic mucosa:1.1. Gastric mucosaGastric mucosa (60%) (60%)

2.2. Pancreatic aciniPancreatic acini

3.3. Brunner’s glandBrunner’s gland

4.4. Pancreatic isletsPancreatic islets

5.5. Colonic mucosaColonic mucosa

6.6. EndometriosisEndometriosis

7.7. Hepatobiliary tissuesHepatobiliary tissues

Meckels DiverticulumMeckels Diverticulum

Rules of Twos:Rules of Twos:1.1. 2% prevalence2% prevalence2.2. 2:1 female 2:1 female

predominancepredominance3.3. Location 2 feet Location 2 feet

proximal to the proximal to the ileocecal valve in ileocecal valve in adults.adults.

4.4. Half of those are Half of those are asymptomatic are asymptomatic are younger than 2 years younger than 2 years of age.of age.

Meckels DiverticulumMeckels DiverticulumComplications:Complications:

1.1. Bleeding (most commonBleeding (most common)) – due to ileal – due to ileal mucosal ulceration.mucosal ulceration.

2.2. Obstruction:Obstruction:a.a. Volvulus of the intestineVolvulus of the intestineb.b. Entrapment of intestine by the mesodiverticular Entrapment of intestine by the mesodiverticular

bandbandc.c. IntussuceptionIntussuceptiond.d. Stricture due to diverticulitisStricture due to diverticulitise.e. As Littre’s hernia – found in inguinal or femoral As Littre’s hernia – found in inguinal or femoral

hernia sac.hernia sac.

Meckels DiverticulumMeckels DiverticulumClinical manifestation:Clinical manifestation:

1.1. AsymptomaticAsymptomatic

2.2. 4% symptomatic due to complication4% symptomatic due to complication

50% are younger than 10y/o50% are younger than 10y/oSymptomatic (Bleeding > obstruction > diverticulitis)Symptomatic (Bleeding > obstruction > diverticulitis)

a.a. bleeding is 50% in children and pt younger 18y/obleeding is 50% in children and pt younger 18y/o

bleeding is rare in pt older than 30y/obleeding is rare in pt older than 30y/o

b.b. intestinal obstruction most common in adultintestinal obstruction most common in adult

c.c. diverticulitisdiverticulitis is indistinguishable to appendicitis is indistinguishable to appendicitis

Neoplasm seen: ---Neoplasm seen: ---> Carcinoid> Carcinoid


Diagnosis:Diagnosis:For asymptomatic usually discovered as an For asymptomatic usually discovered as an incidental findings in radiographic imaging, incidental findings in radiographic imaging, endoscopy, or intraoperatively.endoscopy, or intraoperatively.

1.1. EnteroclysisEnteroclysis has 75% accuracy but not has 75% accuracy but not applicable during acute cases.applicable during acute cases.

2.2. Radionuclide scansRadionuclide scans (99m Tc-pertechnate) (99m Tc-pertechnate) for ectopic gastric mucosa or in active for ectopic gastric mucosa or in active bleedingbleeding

3.3. AngiographyAngiography to localize site of bleeder to localize site of bleeder


Management:Management:1.1. Diverticulectomy:Diverticulectomy:

diverticulitisdiverticulitis

obstruction (w/ removal of associated band)obstruction (w/ removal of associated band)

2.2. Segmental resection for:Segmental resection for:BleedingBleeding

If with tumorIf with tumor

Acquired Small Bowel Acquired Small Bowel DiverticulaDiverticulaEpidemiology:Epidemiology:

False diverticulaFalse diverticulaIncreases w/ age; Increases w/ age; seldom seen < 40y/o seldom seen < 40y/o (50-70y/o)(50-70y/o)

1.1. Duodenum:Duodenum: 1.1. Most common; usually Most common; usually

adjacent to ampullaadjacent to ampulla2.2. Called Called periampullary, periampullary,

juxtapapillary, or peri-juxtapapillary, or peri-Vaterian diverticulaVaterian diverticula

3.3. 75% arise in the medial 75% arise in the medial wallwall

Acquired Small Bowel Acquired Small Bowel DiverticulaDiverticula

Jejunoileal:Jejunoileal:80% - jejunum 80% - jejunum (tends to be large (tends to be large and multiple)and multiple)15% - ileum (tends 15% - ileum (tends to be small and to be small and solitary)solitary)5% - both ileum and 5% - both ileum and jejunumjejunum

Acquired Small Bowel DiverticulaAcquired Small Bowel Diverticula

Pathophysiology:Pathophysiology:Abnormalities of intestinal smooth muscleAbnormalities of intestinal smooth muscle or dysregulated motility leading to herniation.or dysregulated motility leading to herniation.Associated w/:Associated w/:

1.1. Bacterial overgrowthBacterial overgrowth – vit B12 deficiency, – vit B12 deficiency, megaloblastic anemia, malabsorption & megaloblastic anemia, malabsorption & steatorrheasteatorrhea

2.2. Periampullary duodenal diverticulaPeriampullary duodenal diverticula::1.1. Obstructive jaundiceObstructive jaundice2.2. PancreatitisPancreatitis

3.3. Intestinal obstructionIntestinal obstruction due to compression of due to compression of adjacent boweladjacent bowel



Best diagnosed w/ Best diagnosed w/ enteroclysisenteroclysis

Treatment:Treatment:

1.1. Asymptomatic ---> left aloneAsymptomatic ---> left alone

2.2. Bacterial overgrowth --> antibioticsBacterial overgrowth --> antibiotics

3.3. Bleeding and obstruction ---> segmental Bleeding and obstruction ---> segmental resection for jejunoileal diverticula.resection for jejunoileal diverticula.


Treatment:Treatment:DiverticulectomyDiverticulectomy if located if located in the duodenum in the duodenum

1.1. For medial duodenal diverticula ---> do lateral For medial duodenal diverticula ---> do lateral duodenotomy and oversewing of the bleederduodenotomy and oversewing of the bleeder

2.2. May invaginate the diverticula into the May invaginate the diverticula into the duodenal lumen then excisedduodenal lumen then excised

3.3. If related to the ampulla ---> extended If related to the ampulla ---> extended sphincterotoplastysphincterotoplasty

4.4. If perforated ----> excised and closed w/ If perforated ----> excised and closed w/ omental patch; if inflammed ---> placed omental patch; if inflammed ---> placed gastrojejunostomy gastrojejunostomy

MESENTERIC MESENTERIC ISCHEMIAISCHEMIA

Mesenteric IschemiaMesenteric IschemiaClinical Syndrome:Clinical Syndrome:1.1. Acute mesenteric ischemiaAcute mesenteric ischemia

PathophysiologyPathophysiology1.1. Arterial embolusArterial embolus: (most common-50%; heart; : (most common-50%; heart;

usually lodge distal to origin of the middle colicusually lodge distal to origin of the middle colic2.2. Arterial thrombosisArterial thrombosis: occlusion occurs at : occlusion occurs at

proximal near it’s origin.proximal near it’s origin.3.3. VasospasmVasospasm (nonocclusive mesenteric ischemia (nonocclusive mesenteric ischemia

– NOMI): usually in critically-ill pt. receiving – NOMI): usually in critically-ill pt. receiving vasopressors.vasopressors.

4.4. Venous thrombosisVenous thrombosis: (5-15%) and 95% SMV: (5-15%) and 95% SMVa.a. Primary – no etiologic factor identifiedPrimary – no etiologic factor identifiedb.b. Secondary – heritable or acquired coagulation disorderSecondary – heritable or acquired coagulation disorder

Mesenteric IschemiaMesenteric IschemiaClinical Syndrome:Clinical Syndrome:2.2. Chronic Mesenteric Ischemia:Chronic Mesenteric Ischemia:

Develops insidiously allows for collateral Develops insidiously allows for collateral circulation to developcirculation to developRarely leads to infarction.Rarely leads to infarction.Usually due to Usually due to arteriosclerosisarteriosclerosisUsually two mesenteric arteries are involvedUsually two mesenteric arteries are involved

Mesenteric IschemiaMesenteric IschemiaManifestation:Manifestation:

A.A. Acute mesenteric ischemia:Acute mesenteric ischemia:Severe abdominal pain out of proportion to the Severe abdominal pain out of proportion to the degree of abd. tenderness (hallmark)degree of abd. tenderness (hallmark)− Colicky at the mid-abdomen.Colicky at the mid-abdomen.

Nausea / vomiting, diarrhea Nausea / vomiting, diarrhea

abd. distention,peritonitis, passage bloody stoolabd. distention,peritonitis, passage bloody stool

B.B. Chronic mesenteric ischemia:Chronic mesenteric ischemia:Postprandial abd. pain “food-fear”, (most common) Postprandial abd. pain “food-fear”, (most common)

Mesenteric IschemiaMesenteric Ischemia

No laboratory test sensitive for No laboratory test sensitive for the detection of acute mesenteric the detection of acute mesenteric ischemia prior to the onset of ischemia prior to the onset of intestinal infarction.intestinal infarction.

The presence of it’s hallmark The presence of it’s hallmark sign, is an indication for sign, is an indication for immediate celiotomy.immediate celiotomy.


AngiographyAngiography – – most reliable; 74 – most reliable; 74 – 100% sensitivity 100% sensitivity and 100% and 100% specificity; specificity;

– It is It is gold standard gold standard for the diagnosis of for the diagnosis of arterial mesenteric arterial mesenteric ischemia. ischemia.


CT scanningCT scanning is used to: is used to:1.1. Disorder other abd. Disorder other abd.

condition causing abd. paincondition causing abd. pain

2.2. Evidence of occlusion or Evidence of occlusion or stenosis of mesenteric stenosis of mesenteric vasculature.vasculature.

3.3. Evidence of ischemia in Evidence of ischemia in the intestine & mesenterythe intestine & mesentery

4.4. Test of choice for acute Test of choice for acute mesenteric venous mesenteric venous thrombosisthrombosis

Mesenteric IschemiaMesenteric IschemiaTreatment:Treatment:

w/ signs of peritonitis w/ signs of peritonitis --> celiotomy check --> celiotomy check for viability of the for viability of the bowel:bowel: Necrotic ----> Necrotic ---->

segmental segmental resectionresection

Questionable Questionable viability ----> viability ----> second look second look laparotomielaparotomiess

Mesenteric IschemiaMesenteric IschemiaSurgical revascularizationSurgical revascularization (embolectomy / thrombectomy / (embolectomy / thrombectomy / mesenteric bypass).mesenteric bypass). Not done if: Not done if:

1.1. segment is necroticsegment is necrotic

2.2. is too unstable patientis too unstable patient Done pt diagnosed w/ emboli or thrombus-Done pt diagnosed w/ emboli or thrombus-

induced acute mesenteric ischemia w/o signs of induced acute mesenteric ischemia w/o signs of peritonitis.peritonitis.

May give thrombolysis May give thrombolysis (streptokinase, (streptokinase, urokinaseurokinase, , recombinant tissue plasminogen recombinant tissue plasminogen activator).activator). Useful only in partially occluded Useful only in partially occluded vessels and has given w/in 12 hrs. after onset of vessels and has given w/in 12 hrs. after onset of symptoms.symptoms.

NEOPLASM OF THE NEOPLASM OF THE SMALL BOWELSMALL BOWEL

NeoplasmNeoplasmRare:Rare:

1.1. Rapid transit timeRapid transit time

2.2. Local immune system of the small bowel mucosa Local immune system of the small bowel mucosa (IgA)(IgA)

3.3. Alkaline pHAlkaline pH

4.4. Relatively low concentration of bacteria; low Relatively low concentration of bacteria; low concentration of carcinogenic products of bacterial concentration of carcinogenic products of bacterial metabolism.metabolism.

5.5. Presence of mucosal enzymes (hydrolases) that Presence of mucosal enzymes (hydrolases) that destroy certain carcinogensdestroy certain carcinogens

6.6. Efficient epithelial cellular apoptotic Efficient epithelial cellular apoptotic mechanismsmechanisms that serve to eliminate clones that serve to eliminate clones harboring genetic mutationharboring genetic mutation

NeoplasmNeoplasm

50 – 60 y/o50 – 60 y/oRisk factors:Risk factors:

1.1. Red meatRed meat2.2. Ingestion of smoked or cured foodsIngestion of smoked or cured foods3.3. Crohn’s dseCrohn’s dse4.4. Celiac sprueCeliac sprue5.5. Hereditary nonpolyposis colorectal cancerHereditary nonpolyposis colorectal cancer

(HNPCC)(HNPCC)6.6. Familial adenomatous polyposisFamilial adenomatous polyposis (FAD) – 100% (FAD) – 100%

to develop to develop duodenal CAduodenal CA7.7. Peutz-Jeghers syndromePeutz-Jeghers syndrome

NeoplasmNeoplasmSymptoms:Symptoms:

– Most are asymptomaticMost are asymptomatic – Symptoms:Symptoms:1.1. Vague abdominal painVague abdominal pain (epigastric discomfort, N/V, (epigastric discomfort, N/V,

abd. pain, diarrhea).abd. pain, diarrhea).2.2. BleedingBleeding (hematochezia or hematemesis) (hematochezia or hematemesis)3.3. ObstructionObstruction (intussuception, circumferencial growth, (intussuception, circumferencial growth,

kinking of the bowel, intramural growth).kinking of the bowel, intramural growth). Most common mode of presentation isMost common mode of presentation is ---> --->

crampy abd. pain, distention, nausea / crampy abd. pain, distention, nausea / vomitingvomiting

HemorrhageHemorrhage usually indolent 2 usually indolent 2ndnd common common mode of presentationmode of presentation

NeoplasmNeoplasm

Diagnosis:Diagnosis:– For most are asymptomatic it is rarely For most are asymptomatic it is rarely

diagnosed preoperativelydiagnosed preoperatively– Serological examinationSerological examination

Serum 5-hydroxyindole acetic acid (HIAA)Serum 5-hydroxyindole acetic acid (HIAA) for for carcinoid.carcinoid.

CEACEA associated w/ small intestinal associated w/ small intestinal adenocarcinoma but only if w/ liver metastasis.adenocarcinoma but only if w/ liver metastasis.

NeoplasmNeoplasm

Diagnosis:Diagnosis:– Radiological examination:Radiological examination:

1.1. EnteroclysisEnteroclysis (test of choice – 90% sensitivity) (test of choice – 90% sensitivity)

2.2. UGIS w/ intestinal follow throughUGIS w/ intestinal follow through

3.3. CT scanCT scan

4.4. Angiography / RBC scan --> bleeding lesionsAngiography / RBC scan --> bleeding lesions

– Endoscopy:Endoscopy:EGD (esophagus, gastric, and duodenum)EGD (esophagus, gastric, and duodenum)

ColonoscopyColonoscopy

I.I. Benign tumors:Benign tumors:A.A. Adenomas:Adenomas: (most common benign neoplasm): (most common benign neoplasm):

1.1. True adenomas:True adenomas:Associated w/ bleeding and obstructionAssociated w/ bleeding and obstruction

Usually seen in the Usually seen in the ileumileum

Majority are asymptomaticMajority are asymptomatic

2.2. Villous adenoma:Villous adenoma:Most common in the Most common in the duodenumduodenum

““soap bubble” appearance on contrast radiographysoap bubble” appearance on contrast radiography

No report of secretory diarrheaNo report of secretory diarrhea

3.3. Brunner’s gland adenomaBrunner’s gland adenomaA.A. In the In the duodenumduodenum

B.B. No malignant potentialNo malignant potential

C.C. Mimic PUDMimic PUD

Benign tumors:Benign tumors:B.B. Leiomyoma:Leiomyoma:

Most common symptomatic Most common symptomatic benign lesionbenign lesion

Associated w/ Associated w/ bleedingbleeding

Diagnosed by Diagnosed by angiography angiography and commonly located in the and commonly located in the jejunumjejunum

2 growth pattern:2 growth pattern:1.1. Intramurally ----> obstructionIntramurally ----> obstruction

2.2. Both intramural and extramural Both intramural and extramural (Dumbbell shaped)(Dumbbell shaped)

Benign tumors:Benign tumors:

C.C. Lipoma:Lipoma:Most common in the Most common in the ileumileum

Causes obstruction Causes obstruction (lead point of an (lead point of an intussusception)intussusception)

Bleeding due to ulcer Bleeding due to ulcer formationformation

No malignant No malignant degenerationdegeneration

Benign tumors:Benign tumors:D.D. Peutz-Jeghers Peutz-Jeghers

Syndrome:Syndrome:– Inherited syndrome of:Inherited syndrome of:

1.1. Mucocutaneous Mucocutaneous melatonic pigmentationmelatonic pigmentation (face, buccal mucosa, (face, buccal mucosa, palm, sole, peri-anal area)palm, sole, peri-anal area)

2.2. Gastrointestinal polypGastrointestinal polyp (enteric (enteric jejunum and jejunum and ileumileum are most frequent are most frequent part of GIT followed by part of GIT followed by colon, rectum and colon, rectum and stomach).stomach).

Benign tumors:Benign tumors:

D.D. Peutz-Jeghers Peutz-Jeghers Syndrome:Syndrome:

– Symptoms:Symptoms:1.1. colicky abd. pain (due to colicky abd. pain (due to

intermittent intussuception)intermittent intussuception)

2.2. HemorrhageHemorrhage

– Treatment:Treatment:Segmental resection of the Segmental resection of the bowel causing obstruction or bowel causing obstruction or bleeding.bleeding.

Cure impossible due to Cure impossible due to widespread intestinal widespread intestinal involvementinvolvement

II.II. Malignant neoplasm:Malignant neoplasm:

Histologic types:Histologic types:Tumor typeTumor type Cell of originCell of origin FrequencyFrequency Predominant Predominant

SiteSite

adenocarcinomaadenocarcinoma Epithelial cellEpithelial cell 35 – 50%35 – 50% DuodenumDuodenum

carcinoidcarcinoid Enterochromaffin Enterochromaffin cellcell

20 – 40%20 – 40% IleumIleum

lymphomalymphoma lymphocytelymphocyte 10 – 15%10 – 15% IleumIleum

GIST GIST (gastrointestinal (gastrointestinal stromal tumors)stromal tumors)

? Interstitial cell ? Interstitial cell of Cajalof Cajal

10 – 15%10 – 15% --

Malignant neoplasm:Malignant neoplasm:

1.1. Adenocarcinoma:Adenocarcinoma:Most common CA of Most common CA of small bowelsmall bowel

Most common in Most common in duodenum and duodenum and proximal jejunumproximal jejunum

Half involve the Half involve the ampulla of Vater.ampulla of Vater.


2.2. Carcinoid:Carcinoid:From From Enterochromaffin cellsEnterochromaffin cells or or Kultchitsky cellsKultchitsky cells

Arise from foregut, midgut & hindgutArise from foregut, midgut & hindgut

Appendix (46%) > Ileum (28%) > Appendix (46%) > Ileum (28%) > Rectum (17%)Rectum (17%)

Malignant neoplasm:Malignant neoplasm:2.2. Carcinoid:Carcinoid:

Aggressive behavior than the appendiceal Aggressive behavior than the appendiceal carcinoid. carcinoid.

appendix – 3% metastasize; Ileum – 35% metastasizeappendix – 3% metastasize; Ileum – 35% metastasize Appendix – solitary; Ileum – 30% multipleAppendix – solitary; Ileum – 30% multiple

25-50% w/ carcinoid tumor with liver 25-50% w/ carcinoid tumor with liver metastasis develops metastasis develops carcinoid syndromecarcinoid syndrome..

Secretes Secretes serotonin, bradykinin and substance Pserotonin, bradykinin and substance P1.1. DiarrheaDiarrhea

2.2. FlushingFlushing

3.3. HypotensionHypotension

4.4. tachycardia tachycardia

5.5. fibrosis of endocardium and valves of the right fibrosis of endocardium and valves of the right heartheart..


3.3. Lymphomas:Lymphomas: Most common Most common

intestinal neoplasm intestinal neoplasm in children under in children under 10y/o.10y/o.

In adult = 10-15% of In adult = 10-15% of small bowel malignant small bowel malignant tumorstumors

Most common Most common presentationpresentation

1.1. intestinal obstructionintestinal obstruction

2.2. Perforation (10%)Perforation (10%)


3.3. Lymphomas:Lymphomas: Criteria of primary lymphomas of the small Criteria of primary lymphomas of the small

bowel:bowel:1.1. Absence of peripheral lymphadenopathyAbsence of peripheral lymphadenopathy

2.2. Normal chest x-ray w/o evidence of Normal chest x-ray w/o evidence of mediastinal LN enlargement.mediastinal LN enlargement.

3.3. Normal WBC count and differentialNormal WBC count and differential

4.4. At operation, the bowel lesion must At operation, the bowel lesion must predominate and the only nodes are predominate and the only nodes are associated w/ the bowel lesionassociated w/ the bowel lesion

5.5. Absence of disease in the liver and spleenAbsence of disease in the liver and spleen


I.I. For Benign lesions:For Benign lesions:– All symptomatic benign tumors should be All symptomatic benign tumors should be

surgically resected or removed surgically resected or removed endoscopically (EGD / colonoscopy).endoscopically (EGD / colonoscopy).

– Duodenal tumors:Duodenal tumors: 1 cm. ----> endoscopic polypectomy1 cm. ----> endoscopic polypectomy 2cm. ----> surgically resected (Whipples – 2cm. ----> surgically resected (Whipples –

located near the ampulla of Vater).located near the ampulla of Vater). Duodenal adenomasDuodenal adenomas w/ FAP shd undergo w/ FAP shd undergo

Whipples for it is usually multiple and sessile Whipples for it is usually multiple and sessile and has and has 100% degenerate to CA.100% degenerate to CA.

Treatment:Treatment:II.II. Malignant lesions:Malignant lesions:

1.1. Adenocarcinoma:Adenocarcinoma: Wide local resection w/ it’s mesentery to Wide local resection w/ it’s mesentery to

achieve regional lymphadenectomyachieve regional lymphadenectomy Chemotherapy has no proven efficacy in the Chemotherapy has no proven efficacy in the

adjuvant or palliative treatment of small-adjuvant or palliative treatment of small-intestinal adenoCA.intestinal adenoCA.

2.2. Small intestinal lymphoma:Small intestinal lymphoma: For localized: segmental resection w/ adjacent For localized: segmental resection w/ adjacent

mesenterymesentery If w/ diffused involvement: -->chemotherapy If w/ diffused involvement: -->chemotherapy

rather than surgery, is primary therapyrather than surgery, is primary therapy


3.3. Carcinoid:Carcinoid:• Segmental intestinal resection & regional Segmental intestinal resection & regional

lymphadenectomy.lymphadenectomy.− < < 1cm rarely has LN metastases1cm rarely has LN metastases

− > 3cm 75 to 90% LN metastases> 3cm 75 to 90% LN metastases

• 30% are multiple, hence entire small 30% are multiple, hence entire small bowel shd be examined prior to surgerybowel shd be examined prior to surgery..

Treatment:Treatment:3.3. Carcinoid:Carcinoid:

• If w/ metastatic lesions---> debulking, If w/ metastatic lesions---> debulking, associated w/ long-term survival & associated w/ long-term survival & amelioration of symptoms of carcinoid amelioration of symptoms of carcinoid syndromesyndrome

• Chemotherapy: ---> 30 -50% responseChemotherapy: ---> 30 -50% response1.1. DoxorubicinDoxorubicin2.2. 5-fluorouracil5-fluorouracil3.3. StreptozocinStreptozocin

• OctreotideOctreotide: - most effective for : - most effective for management of symptoms of carcinoid management of symptoms of carcinoid syndromesyndrome


4.4. Metastatic cancers:Metastatic cancers: MelanomaMelanoma associated w/ associated w/

propensity for metastasis to propensity for metastasis to the small bowel.the small bowel.

Palliative resection / bypass Palliative resection / bypass procedureprocedure

Systemic therapy depends Systemic therapy depends on the responds of the on the responds of the primary site.primary site.

SHORT BOWEL SHORT BOWEL SYNDROMESYNDROME

Short Bowel SyndromeShort Bowel Syndrome

Presence of Presence of less than 200cmless than 200cm of residual of residual small bowel in adult pts.small bowel in adult pts.

Functional definition: - insufficient Functional definition: - insufficient intestinal absorptive capacity results in intestinal absorptive capacity results in the clinical manifestations of:the clinical manifestations of:

1.1. DiarrheaDiarrhea

2.2. DehydrationDehydration

3.3. malnutritionmalnutrition


Etiologies (adult):Etiologies (adult):

1.1. Acute mesenteric ischemiaAcute mesenteric ischemia

2.2. MalignancyMalignancy

3.3. Crohn’s diseaseCrohn’s disease

Etiologies (pediatric):Etiologies (pediatric):

1.1. Intestinal atresiasIntestinal atresias

2.2. VolvulusVolvulus

3.3. Necrotizing enterocolitisNecrotizing enterocolitis


Medical therapy:Medical therapy:– Mx of primary condition causing Mx of primary condition causing

intestinal resectionintestinal resection– Correct fluid & electrolyte imbalance Correct fluid & electrolyte imbalance

due to severe diarrheadue to severe diarrhea– TPN, enteral nutrition is gradually TPN, enteral nutrition is gradually

introduced, once ileus is resolvedintroduced, once ileus is resolved


Medical therapy:Medical therapy:– H2 receptor antagonist --> to reduce H2 receptor antagonist --> to reduce

gastric acid secretiongastric acid secretion– Antimotility agents (loperamide HCL or Antimotility agents (loperamide HCL or

diphenoxylate) diphenoxylate) – Octreotide – to reduce volume of Octreotide – to reduce volume of

gastrointestinal secretiongastrointestinal secretion– TPN complication:TPN complication:

1.1. Catheter sepsisCatheter sepsis

2.2. Venous thrombosisVenous thrombosis

3.3. Liver and kidney failureLiver and kidney failure

4.4. osteoporosisosteoporosis

Short Bowel SyndromeShort Bowel SyndromeSurgical TherapySurgical Therapy::

– Non-transplant:Non-transplant: Goal is to increase nutrient and fluid absorption Goal is to increase nutrient and fluid absorption

by either slowing intestinal transit or increasing by either slowing intestinal transit or increasing intestinal lengthintestinal length

Slow intestinal transit:Slow intestinal transit:1.1. Segmental reversal of the small bowel Segmental reversal of the small bowel

2.2. Interposition of a segment of colonInterposition of a segment of colon

3.3. Construction of small intestinal valvesConstruction of small intestinal valves

4.4. Electrical pacing of the small bowelElectrical pacing of the small bowel– Limited case reportLimited case report– Frequently associated w/ intestinal obstructionFrequently associated w/ intestinal obstruction

GOD BLESSGOD BLESSSALAMAT POSALAMAT PO

THANK YOUTHANK YOU


c.c. EnteroclysisEnteroclysis 200 to 250 ml of barium followed by 1 to 2 L of 200 to 250 ml of barium followed by 1 to 2 L of

methylcellulose in water is instilled into the methylcellulose in water is instilled into the proximal jejunum via a long naso-enteric tubeproximal jejunum via a long naso-enteric tube

Short Bowel SyndromeShort Bowel SyndromeFactors predictive of achieving Factors predictive of achieving

independence from TPN:independence from TPN:1.1. Presence or absence of an intact colon Presence or absence of an intact colon

(capacity to absorb fluid & electrolytes and (capacity to absorb fluid & electrolytes and absorb short-chain FA).absorb short-chain FA).

2.2. Intact ileocecal valveIntact ileocecal valve3.3. A healthy, rather disease, residual small A healthy, rather disease, residual small

intestine is associated w/ decreased severity intestine is associated w/ decreased severity of malabsorptionof malabsorption

4.4. Resection of jejunum is better tolerated than Resection of jejunum is better tolerated than the ileum, due to bile salt and vit B12 the ileum, due to bile salt and vit B12 absorption capacity of the ileum.absorption capacity of the ileum.


Surgical Therapy:Surgical Therapy:– Non-transplant:Non-transplant:

Intestinal lengthening operation:Intestinal lengthening operation:1.1. Longitudinal Intestinal lengthening and tailoring (LILT)Longitudinal Intestinal lengthening and tailoring (LILT)

2.2. Serial transverse enteroplasty procedure (STEP)Serial transverse enteroplasty procedure (STEP)

– Intestinal transplantIntestinal transplant

Prognosis (CHRON’S DSE)Prognosis (CHRON’S DSE) High recurrence rate (most common High recurrence rate (most common

proximal to the site of previous proximal to the site of previous resection).resection).

70% recur w/in 1 yr and 85% w/in 3 yrs.70% recur w/in 1 yr and 85% w/in 3 yrs. Most common complication:Most common complication:

1.1. Wound infectionWound infection

2.2. Postoperative intra-abdominal abscessPostoperative intra-abdominal abscess

3.3. Anastomotic leaksAnastomotic leaks

• 60-300 x more frequent to develop CA60-300 x more frequent to develop CA

Mesenteric IschemiaMesenteric Ischemia NOMI NOMI – std tx. Is infusion of vasodilator – std tx. Is infusion of vasodilator

(papavarine hydrochloride)(papavarine hydrochloride) into the SMA. If into the SMA. If w/ signs of peritonitis --> immediate celiotomy w/ signs of peritonitis --> immediate celiotomy and resect necrotic segment.and resect necrotic segment.

Acute mesenteric venous thrombosisAcute mesenteric venous thrombosis Std tx. anticoagulant (heparin / warfarin).Std tx. anticoagulant (heparin / warfarin). Signs of peritonitis --> explore and resects if Signs of peritonitis --> explore and resects if

neededneeded For chronic arterial mesenteric ischemia:For chronic arterial mesenteric ischemia:

Surgical revascularization Surgical revascularization 1.1. Aortomesenteric bypass graftingAortomesenteric bypass grafting2.2. Mesenteric endarterectomyMesenteric endarterectomy3.3. Percutaneous transluminal mesenteric Percutaneous transluminal mesenteric

angioplasty alone or w/ stent.angioplasty alone or w/ stent.

Malignant neoplasm:Malignant neoplasm:4.4. GISTs: (gastrointestinal stromal tumors)GISTs: (gastrointestinal stromal tumors)

Most common Most common mesenchymal tumorsmesenchymal tumors arising in the arising in the small bowelsmall bowel

70% arises from the 70% arises from the stomachstomach followed by the followed by the small small bowelbowel

15% of small bowel malignancies15% of small bowel malignancies Formerly classified as: Formerly classified as:

1.1. LeiomyomasLeiomyomas2.2. LeiomyosarcomasLeiomyosarcomas3.3. Smooth muscle tumors of small bowelSmooth muscle tumors of small bowel

Associated w/ Associated w/ overt hemorrhageovert hemorrhage Has its expression of the receptor Has its expression of the receptor tyrosine kinasetyrosine kinase

KIT (CD117).KIT (CD117). There is pathological KIT signal There is pathological KIT signal transductiontransduction

Treatment:Treatment:4.4. Small-intestine GISTs:Small-intestine GISTs:

– Segmental resectionSegmental resection– If was preoperatively diagnosed, lymphadenectomy If was preoperatively diagnosed, lymphadenectomy

shd not be done, for rarely associated w/ LN shd not be done, for rarely associated w/ LN metastases.metastases.

– Resistant to conventional chemotherapyResistant to conventional chemotherapy– IMATINIB (Gleevec):IMATINIB (Gleevec):

− Formerly known as ST1571Formerly known as ST1571− 80% of pt w/ unresectable lesions showed clinical 80% of pt w/ unresectable lesions showed clinical

benefitsbenefits− 50 – 60% showed evidence of reduction in tumor 50 – 60% showed evidence of reduction in tumor

volumevolume− Role as neoadjuvant and adjuvant tx under investigationRole as neoadjuvant and adjuvant tx under investigation

Small Intestine Ii

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