Stomach, duodenum, Small intestine

Alicja Rymaszewska Clinical Ward of General and Oncological Surgery for

Children and Adolescents

y gastroesophageal reflux – normal especially in newborns

antireflux mechanisms are immature) y gastroesophageal reflux disease

Antireflux mechanisms y Anatomical

y 1 ) lower sphincter esophagus (1-3 cm), spontaneous relaxation

y 2 ) section intra-abdominal esophagus section- an increase of intra-abdominal pressure

y 3 ) Gubroff ’s valve ( folds of the mucosa border esophagus and the stomach)

y 4 ) Angle of His sharp/ obtuse y 5) esophageal hiatus - the right arm of the sphincter of the

diaphragm – sphincter pressure y 6 ) ligament diaphragmatic - esophageal hiatus hernia ;

hiatal hernia

y Functional: - Coordinated esophageal peristalsis - Differential pressure chest- abdomen - saliva - Emptying of the stomach

Symptoms y In the digestive system :

y - Regurgitation , vomiting y - Delayed physical development y - Inflammation of the esophagus ( bleeding - anemia , anxiety when

feeding , dysphagia ) y In the respiratory system :

y - Chronic cough - y airway inflammation; y - Shortness of breath y - Apnea y - SIDS ( Sudden Infant Death Syndrome ) = sudden infant death

syndrome - reflex n . X.- tightening of the airways neurobehavioural : y - Sandifer syndrome ( tilt of the head and neck forward) y - Tearfulness , irritability y - Sleep disorders

Diagnosis

y pH-metria 24 h y X ray with contrast y Endoscopy

Congenital defects coexisting with GERD yEsophagus atresia yDuodenum atresia yCongenital diaphragm hernia yAbdominal wall defects yMaltrotations

Treatment y Conservative - mostly infants :

y - Positional - 45-60st y - Frequent feeding with smaller volumes y - Thickening of food y - Pharmacological (drugs neutralizing , prokinetics,

drugs that reduce the secretion of HCl - H2 blockers,PPIs)

Infants - wait for 1 years of age !

y Operational - indications : y urgent :

y - Complications of gastroesophageal reflux disease ( erosions , ulcers , scars, metaplasia - Barrett's esophagus )

y - Recurrent pulmonary inflammation , apnea

y Scheduled : y - Failure of conservative treatment y - The coexistence of hernia ( paraesophageal and tackles )

Operacje:

Objective: To restore as much as possible antireflux barrier

Fundoplication : redouble fundus to form a cuff around the esophagus

Fundoplication rear : - Nissen ( 360 *) - Toupet (270*) Fundoplication front

deepening Hisa angle : - Thal in modification Boix

Ocho Gastropexia - not in children:

- Front : PSV - Rear : Hill

The aim of surgery • Lengthening the abdominal esophagus • Recreate the angle of His • Strengthening the barriers gastro- oesophageal /

by fundoplication of the stomach around the inlet • Narrowing of the diaphragm hiatus

Types y Primary peptic ulcer disease :

y - otherwise healthy children systemic y -most often duodenum ulcer y -often family history

y Secondary ulcers : y - In children treated for other reasons y - Often life-threatening conditions / shock , trauma ,

sepsis / = stress ulcer

y Cushing ulcer - traumatic(cranio- cerebral injuries ) y Curling's ulcer - burning

Primary ulcer Secondary ulcer y Etiologic agent of Helicobacter pylori y Location: the most common ulcer XII - with

concomitant inflammation in the membrane gastritis

y Symptoms: - newborn and infant rapid progress with gastrointestinal bleeding gastrointestinal perforation - The child of preschool age and older abdominal pain , loss of apetite, anemia due to bleeding

y Conservative treatment : - Alkalizing agents , H2 blockers - Tetracycline or amoxicillin and metronidazole effective in 80 % of children resolution of symptoms after approx. 8 weeks of treatment

y Rarely, surgical treatment .

y Etiological factor : y after extensive trauma , burns , surgery y Location: the most common ulcer without

mucositis y Symptoms: stomach bleeding , perforation

treatment: - Prevention by prophylactic H2 blockers administration in children treated for other reasons

y - Treatment : endoscopic or operational in the event of perforation or massive bleeding that persists despite conservative treatment ( cold compresses on the abdomen , ingots with cold saline into the stomach )

Conservative treatment y Endoscopy : - rubber band ligation -

Injections ( adrenaline ) y operations :

y - closing of perforation y Closing of bleeding vessels within sores - y In exceptional circumstances, partial resection of the

stomach

Narrowing of the antrum of the stomach, caused by

overgrowth of the muscle layer in neonates and infants, which hinders the passage of gastric contents from the stomach to duodenum the twelfth months

y One of the most comon surgical issue in newborns and infantf

y 1-4 / 1000 y 4-8 times more often boys y 3-6 week y Family history

Hipothesis No clear etiopathogenesis ! Hypothesis formation : - Development disorders or decreased amounts of

ganglion cells - Ganglion cell immaturity - Irritant effect truncated milk in the stomach ----

Hypergastrynemia hyperacidity - The role of growth factors in the local - Disturbances in the local synthesis of NO - reduced

muscle relaxation - Erythromycin - folic acid deficiency during pregnancy

Symptoms Progressive : Regurgitation after feeding , vomiting initially , then

increased , projectile , ingesta , without the admixture of bile

Persistent good appetite Weak growth b.w. Stools in the form of pellets -

alleged constipation - dehydration

y Putting the stomach - visible through the thin abdominal walls peristaltic waves in the upper abdomen

y Symptom olives - palpable rounded , moving creature knobby epigastric

Diagosis y Ultrasound!!!!!!!! y Blood tests hypochloremic hypocaliemic metabolic alkalosis

zasadowica H - alkalosis – kindeys are saving H and giving hypocaliemia Cl - hypochloremia y RTG: of abdomen – bloated stomach, slight gas in

intestines - passage of the gastrointestinal tract – string sign”=

tit sign, shoulder sign - difficulties in passing to duodenum

Treatment y Firstly – stomach probe - no feeding - water and electrolyte balance y Surgery: pyloromyotomy longitudinalis m. Ramstedta-Webera (dividing the muscle of

thepylorus to open up the gastric outlet). This surgery can be done through a single incision (usually 3–4 cm long) or laparoscopically(through several tiny incisions), depending on the surgeon's experience and preference

y Start to feed a baby with gradually bigger amounts even 6 hours after the surgery

Duplication of gastrointestinal tract y Malformation involving the existence of an additional

segment of the gastrointestinal tract y 2 forms:

y cystic y Cylindrical - proper bowel next to and peripherally in the

mesentery

y It occurs from the mouth to the anus y The three main features: closely linked to the digestive

tract - common wall y The source of vasculature are the arteries of the

gastrointestinal tract y The three-layer wall construction

J. cienkie Żołądek

Characteristic features y Closely linking the digestive tract y Vascularization of arterias od digestive tract y The three-layer construction of the wall ( Mucosa ,

muscle and serum ) y The mucosa is not always the mucosa of the section at

which there is ( in the chest can be respiratory ephitelium)

y Always on the edge of mesenteric !

Occurence y Rare - 1 : 35.000 y Chest - 24% y Belly - 70 % : the most small intestine - ileum ,

jejunum, and esophagus, ileocecal region rarely large intestine , rectum and stomach (usually greater curvature and pyloric region ) least likely to duodenum

y Both cavity , neck - 6% y Typically, the shape of cysts y Other drawbacks are often comorbid

symptoms y Tumor ( compression ) y disordered breathing , y difficulty swallowing , y vomiting y abdominal pain, flatulence y Obstruction of the gastrointestinal tract – vomiting y bleeding . - ulceration y Difficulty in passing stool y perforation y In the stomach - carcinoid – symptoms of carcinoid

syndrome(serotonin ) y asymptomatic

Diagnosis y Usg y Rtg y TK y Scyntygraph

STOMACH DUPLICATION cystic or cylindrical Mostly no connection thick wall The most common prepyloric area Cylindrical form along the greater curvature of the

stomach Symptoms: obstruction , ulceration , carcinoid

DUPLIcATION of DUODENUM - The upper part of duodenum , a considerable distance

before common bile duct -removed entirely , weaving together the duodenum and stomach by Billroth I method

- Just above the common bile duct - resection , gastric stump and duodenum closure and anastomosis of the prepyloric stomach part of the first loop of jejunum by Billroth II

- Integral cystic dupplications on the left side of the concave portion of the descending adjacent to the pancreatic head resection aren’t subject to total resection

- Integral to the right of the convex parts- cylindrical cystic and cystic – like above, Cylindrical , broad anastomosis with duodenum with the removal of the wall

- Strong stimulation of the celiac plexus pectoris

Duplication of the jejunum and ileum - the most common - Frequently cylindrical - jejunum - Cystic frequently in the ileum - Cylindrical Integral usually have a connection with

inlet- not cause distension - Often, chronic or acute bleeding anemia trobieli- ----

Statement during the operation redouble its cylindrical requires resection with adjacent normal intestine due to a common wall and vascularity

- Cystic dupplication - centrally in mesentery , they have no connection with the mouth of intestine sometimes cause twist , intussusception - Ileo cecum angle

COLON duplication - Most frequently ascending colon and sigmoid -

Form of cystic and cylindrical - cylindrical form resection / connection intestinal

lumen - Duplication of cecum is resected with cecum

assembling the ileum of the ascending colon rectum rarely

Rectum Duplication - Often accompanied by other defects of this area --

Duplication is to the right rear of the rectum , is connected to the inlet

- Rarely separate anus- celostomy lower - Loosely access by a combined perineal resection -

Common wall - connection

Treatment Operations (! ) :

Excision of the whole membrane excision mucosa + marsupialization partial resection and anastomosis

Cystic duppliction

Tubular dupplication