Intestinal Diseases

Department of Gastrointestinal Surgery

shengjing Hospital of China Medical University
youwei kou( 寇有为 )
Vote
Have you ever heard about intestinal obstruction?

A Yes.very familiar

B Yes, a little

C No
 Catalogs

□ Anatomy and Physiology

□ Intestinal infectious disease
Intestinal tuberculosis
Typhoid Intestinal Perforation
□ Enteritis disease
Acute hemorrhagic enteritis
Crohn's disease
□ Intestinal obstruction*
□ Mesenteric vascular ischemic
disease(self-study)
Intestinal infectious disease

Intestinal tuberculosis
Intestinal tuberculosis is a chronic and specific
infection caused by the invasion of intestinal tract by
Mycobacterium tuberculosis

85% in ileocecal region

It can be divided into ulcer type and

hyperplasia type
 Intestinal tuberculosis
Clinical manifestation

General sympyoms: low fever, night

sweat, fatigue, emaciation, anorexia

Local symptoms: Ulcer type: chronic

abdominal pain and diarrhea
Hyperplasia type: incomplete intestinal
obstruction, right lower abdominal mass
 Intestinal tuberculosis

Diagnosis: routine blood test, erythrocyte

sedimentation rate(ESR), chest X-ray; barium
enema, colonoscopic biopsy.
Treatment:
Internal medicine
Surgical treatment
 Intestinal tuberculosis

Indications of surgical treatment:

1. Abscess or intestinal fistula due to perforation
2. Intestinal obstruction
3. Uncontrollable intestinal bleeding
4. Perforation with acute peritonitis
Operation method:
Intestinal resection and anastomosis
ileocecal resection or right hemicolectomy
Single choice

Intestinal tuberculosis mainly occurs at ?

A: Jejunum
B: Duodenum
C: Ileocecal region
D: Colorectal region
 Crohn’s disease

Essentials of diagnosis:
• Diarrhea
• Abdominal pain and palpable mass
• Low-grade fever, lassitude, weight loss
• Anemia
• Radiographic findings of thickened, stenotic bowel with ul
ceration and internal fistulas
 Crohn disease
Etiology
Crohn's disease is caused by a combination of environmental, im
mune and bacterial factors in genetically susceptible individuals. It
results in a chronic inflammatory disorder, in which the body's imm
une system attacks the gastrointestinal tract possibly directed at
microbial antigens. While Crohn's is an immune related disease, it
does not appear to be an autoimmune disease(in that the immune
system is not being triggered by the body itself).The exact underlyi
ng immune problem is not clear; however, it may be an immunode
ficiency state. About half of the overall risk is related to genetics wi
th more than 70 genes found to be involved.Tobacco smokers are
two times more likely to develop Crohn's disease than nonsmoker
s. It also often begins after gastroenteritis.
 The three most
common sites of
pathology intestinal
involvement in
Crohn's disease
are ileal, ileocolic
and colonic.
 pathology
• it shows a transmural pattern of inflammation. Under a micros
cope, biopsies of the affected colon may show mucosal inflam
mation, characterized by focal infiltration of neutrophils, into t
he epithelium. This typically occurs in the area overlying
lymphoid aggregates. These neutrophils, along with
mononuclear cells, may infiltrate the crypts, leading to inflam
mation (cryptitis) or abscess (crypt abscess).
• Ulceration is an outcome seen in highly active disease. There
is usually an abrupt transition between unaffected tissue and t
he ulcer—a characteristic sign known as skip lesions.
• Granulomas, aggregates of macrophage derivatives known a
s giant cells, are found in 50% of cases and are most specific
for Crohn's disease.
 Clinical findings

• Diarrhea: continuous or episodic diarrhea is noted in about 90%

of patients.
• Recurrent abdominal pain: mild colic initiated by meals, centered
in the lower abdomen, and relieved by defecation is common.
• Abdominal symptoms and constitutional effects:episodic attacks
of abdominal pain and diarrhea accompanied by lassitude, malai
se, weight loss, fever and anemia is a common syndrome
• Anorectal lesion: anal fissure, large ulcers, complex anal fistulas
or pararectal abscess
• Anemia
• Malnutrition
• Acute onset
 Crohn's disease
More common in the terminal ileum, the lesions can be limited
to one or more intestinal loops, showing a segmental
distribution.

Main symptoms: Diarrhea, abdominal pain, and weight

loss.

Some other symptoms: Low fever, abdominal mass in the right

lower abdomen or around the umbilicus, incomplete intestinal
obstruction.
Image examination

X-ray with barium meal:

narrow, stiff, and mucosal
folds dfsappeared at terminal
ileum, line-like sign
Colonoscoptc biopsy can
help to confirm the diagnosis
 treatment

• There is no cure for Crohn's disease and remission m

ay not be possible or prolonged if achieved. In cases
where remission is possible, relapse can be prevente
d and symptoms controlled with medication, lifestyle
and dietary changes
• Medications used to treat the symptoms of Crohn's di
sease include 5-aminosalicylic acid formulations, pre
dnisone, immunomodulators such as azathioprine, m
ethotrexate, infliximab, adalimumab, certolizumab etc
.Hydrocortisone should be used in severe attacks of
Crohn's disease
 treatment

• Crohn's cannot be cured by surgery, as the disease even

tually recurs, though it is used in the case of partial or full
blockage of the intestine. Surgery may also be required f
or complications such as obstructions, fistulas, or absces
ses, or if the disease does not respond to drugs. After th
e first surgery, Crohn's usually comes back at the site wh
ere the diseased intestine was removed and the healthy
ends were rejoined
 treatment

• The initial treatment of Crohn’s disease is nonoperative.

Physical rest, relief of emotional stress, and a confiding p
atient-doctor relationship has favorable effects. A low- re
sidue, milk-free, high-protein diet may provide adequate
nutrition
• The indication for operation is obstruction in about ½ of c
ases; perforation, internal fistula, external fistula, absces
s, perianal disease, and growth failure in children are oth
er reasons for operation
Treatment: mainly medical treatment
Indications for surgery treatment:
 Intestinal obstruction
 Formation of abdominal abscess or intestinal
fistula after chronic intestinal perforation
 Long-term continuous bleeding
 Suspicion of malignancy
 The one who has no improvement after medical
treatmen
Multiple choice

What are the indications for surgical treatment of

Crohn's disease ?

Intestinal obstruction

Intestinal perforation

Continuous bleeding

Suspicion of malignancy

No improvement after medical treatment

 Intestinal obstruction

Definition

• Intestinal obstruction, also known as bowel

obstruction, is & mechanical functional obstruction
of the intestines which keeps food or liquid from
passing through small intestine or large intestine
(colon or rectum).
 .

Causes
and
classificatio
Classification by etiology n of
intestinal
1, Mechanical intestinal obstruction: obstruction
① Intraintestinal factors: food accumulation, fecal stone.
② Extraintestinal factors: compression of adhesive tape,
bowel incarcerated at the neck of the hernia sac.
③ Lesions of Intestinal wall: tumor, intussusception,
volvulus
Causes and classification of intestinal obstruction

Classification by etiology

2.Dynamic intestinal obstruction : Dyskinesia of

intestinal wall caused by nerve suppression or toxin
stimulation, causing intestinal peristalsis loss or
intestinal spasm. eg:slow transit constipation

3.Intestinal obstruction caused by vascular

embolism or thrombosis.
 Causes and classification of intestinal obstruction
Classification by intestinal ischemia(yes/no)
• General intestinal obstruction—- no intestinal ischemia

• Strangulated intesttnal obstruction-— intestinal ischemia

Classification by degree cf ubstrvction ・ Partial obstruction

・ Complete
obstruction
Classification by location of obstruction
・ Upper obstruction:Upper jejunum
・ Lower obstruction: Lower jujunum or ileum
 PATHOPHYSIOLOGY
• 1 pathology change ：
• （ 1 ） proximal distention ， distal empty ，
• interbording is obstruction point
• （ 2 ） intestinal wall edema ， dark-red
• （ 3 ） venous is compression ， permeability of
microvascular increase,fluid exudation into bowel and
abdomen
• （ 4 ） artery blood circulation is obstructed and
necrosis of the bowel wall, gangrene and perforation
occur
 Local Effects of Obstruction

• 1, peristalsis->hyperperistalsis->abnormal peristalsis
• 2,secretion increase and absorption decrease
• 3, accumulation of fluids and electrolytes
• 4, distension of intestinal lumen
• 5, edema of the bowel wall ->anoxemia->necrosis
 Systemic Effects of Obstruction

1, water and electrolyte losses

2, blood volume decrease
lose of body fluid ：
digestive fluid: 6-8 L/24h
Saliva 1200 ml gastric juice 2000ml
Pancreatic juice 1200ml bile juice 700ml
duodenal juice 50ml
intestinal juice 2000ml large bowel juice 60ml
3, cardiopulmonary dysfunction
4, shock ： toxic materials and toxemia
 Closed-loop Obstruction

1.It is dangerous form because of the propensity for

rapid progression to strangulaton of the blood supply

2. the secretory pressure in the closed loop quite rap

idly reaches a level sufficient to interfere with venous
return from the loop.
 Clinical manifestation

Abdominal pain, vomiting, abdomfnal

distention, stop defecation and flatus.
 Characteristics of abdominal pain

1. Paroxysmal colic with bowel sounds

2. Persistent severe colic often occurs in strangulated
intestinal obstruction.
3. Severe abdominal distention without abdominal pain is
often paralytic intestinal obstruction
 Characteristics of vomiting

1. Vomiting occurs early and frequently in high obstruction,

vomitus is the content of stomach and duodenum.
2. Vomiting occurs late and less frequently in low obstruction
which is fecal-like intestinal contents.
3. Brown or bloody vomiting—-intestinal blood circulation
disorder(ischemfa)
 Characteristics of abdominal distention

1 .The degree of abdominal distention is related to the

position of obstruction. The abdominal distention was not
obvious in high obstruction,but obvious in low obstruction.
2. Asymmetric abdominal distention is the manifestation of
closed loop intestinal obstruction such as volvulus

Closed loop intestinal obstruction

 Stop defecation and flatus

Most patients with complete obstruction no longer have

exhausted bowel movements. Residual gas or stool at the
distal end of intestine at high intestinal obstruction can still
be excreted.
Bloody stool or mucus -—strangulated intestinal
obstruction
Single choice

In addition to abdominal pain, the main

symptom of high intestinal obstruction is ?

A: Abdominal distention

B: Bloody stool

C: Vomiting

D: Abdominal mass
 Physical Examination

1, Inspection : state of nutrition , behavior ,skin color , and

turgor and warmth of the skin
2, Palpation : demonstrating the sites of the distress, then
localizing the anatomic areas of possible abnormality. Stra
ngulation obstruction with the symptom of peritoneal irritati
on sign.
3, Auscultation : simple one ----noisy and is heard as rush
es. During attacks of colic ,the sounds become loud ,hig
h-pitched and metallic .
4, Digital examination of the rectum
 Blood tests

Blood tests for WBC^b

liver and kidney function
levels of electrolytes(K+;Na^TCI ,Ca2+)
arterial blood gas analysis
Image examination
Abdominal X-ray at standing position
Multiple air-liquid levels
How to diagnose intestinal obstruction?

• Clinical manifestation
• Abdominal examination
• X-rays
• CT scanning of the
abdomen
 What is next?

① Classification?
Mechanical or dynamic obstruction?
Simple or strangulated?
Incomplete or complete?
②Cause (adhesion, neoplasms or others)
?
Common causes of
intestinal obstruction Adhesions (60%)
tMiscellaneous (<5%)
Crohn's disease {-5%)
Hernias (-10%)
Neoplasms (-
20%)
*How to Judge whether there is strangulation?
1. Persistent severe pain
2. The condition gets worse rapidly, shock appears early
and the improvement is not obvious after antishock treatment
3. With peritonitis, fever, increased WBC count
4. Asymmetric abdominal distention
5. Bloody gastrointestinal contents or extracting bloody
fluid by abdominal puncture
6. Isolated and enlarged loop of intestine seen by
abdominal X-ray
7. No significant improvement in symptoms and signs after
active non-surg^cal treatment
 Common causes

• Adhesions from previous abdominal surgery (most

common cause)
• Incarcerated hernia
• Crohn's disease causing adhesions or inflammatory
structures
• Neoplasms, benign or malignant
• Intussusception
• Volvulus
• Foreign bodies (e.g. fecal stone, swallowed objects)
• Constipation
• Mesenteric vascular embolism or thrombosis.
 Treatment

Surgical treatment:

Indications for surgical treatment:

Strangulated intestinal obstruction
Neoplastic intestinal obstruction
Congenital intestinal malformation
intestinal obstruction with no improvement after nonoperative
treatment
 Treatment

Surgical methods

1 .Simple operation to relieve obstruction Adhesion release surgery

Intussusception! volvulus reduction Entero to my to remove foreign
bodyffecal stool)
2.Enterotomy and anastomosis: tumor, inflammatory stenosis or
intestinal necrosis
3.Intestinal short circuit anastomosis
4. Enterostomy

obstruction
Enterostomy
 Sign of intestinal necrosis

① The intestinal wall has been dark or purple-black ;

② The intestinal wall has lost its tension and peristialsis

ability,and there is no contractile response to the stimulus;

③ The terminal mesenteric arterioles have no pulsation.

Multiple choice

What are the indications for surgical treatment of

intestinal obstruction ?

A Neoplastic intestinal obstruction

B. Strangulated intestinal obstruction

C. Paralytic intestinal obstruction

D. No improvement after nonoperative treatment

Common Types of Intestinal Obstructi
on
 Peritoneal Adhesions and Bands

Congenital : less
Acquired : more usual. Most are due to injure ,operation,
infection, foreign body, hematoma etc.

Most common intestinal obstruction

 Diagnosis

1, History of operation, injure ,infection.

2, Clinical manifestation .

3, maybe no manifestation in long time , suddenly the sympto

ms appears ,and the pain is severe.
 prophylaxis

1, Avoiding any unnecessary trauma ,strangulation of tissue a

nd contamination during operative procedures.

2, All debris should be removed and any unnecessary foreign

material, excessive suture material and mass ligation in the w
ound should be avoided.
 Volvulus

Definition:
A section of the intestine or even the entire small
intestine and its mesentery twisted 360-720 degrees.
More common in the small intestine, followed by the
sigmoid colon.

volvulus of small intestine volvulus of sigmoid colon

 VOLVULUS

• Volvulus is a twisting or rotation of bowel upon its mesen

tery , often resulting in intestinal obstruction. Circulatory i
mpairment may follow , particularly when the twist is mor
e than 180 degree .
• Etiology

anatomy ； physical; dynamic

 VOLVULUS

Clinical manifestation
Volvulus of small intestine
1 .Sudden onset, history of strenuous activity after a full me
al.
2. severe abdominal colic , often persistent pain with parox
ysmal exacerbation, mostly around the umbilicus.
3.Frequent vomiting
4.unable to lie flat due to abdominal pain
Volvulus of sigmoid colon
1 、 mostly seen in the elderly people.
2 、 habitual constipation
3 、 continuous distending pain of abdomen,significant bulg
ing of the left abdomen.
4 、 barium enema was blocked at the torsion site, and its ti
p was in the shape of bird’s beak.
 DIAGNOSIS

• 1, Sigmoid volvulus :
• 1,common in the elderly with chronic constipation.
• 2, cramping abdominal pain is a constant complaint.
• 3, nausea and vomiting are inconstant symptoms. And
tend to occur late
• 4, there is an enormous gas -filled loop of the large int
estine.
2 Small bowel volvulus :
1, common in the young person.
2, presents following labor activity after eating.

3, sudden onset of severe abdominal pain ,nausea, vom

iting and distention.
4, shock in the early stage with the necrosis of a large s
egment or entire small intestine.
5, not easy differentiated from other types of mechanical
intestinal obstruction until laparotomy.
 treatment

1, Sigmoidoscopic reduction with a large rectal tube or fiber o

ptic colonoscopic reduction.
2, The most volvulus should be approached by transabdomin
al operation , and the surgeon should choose the necessary p
rocedure.
 treatment

1,hydrostatic pressure
2, use barium enema

3, resection of the involved bowel including the leading

point with end-to-end anastomosis.
 INTUSSUSCEPTION

1, An intussusception is an invagination of part of the int

estinal tract into the lumen of the adjacent intestine.

2, 80% of intussusception occur in children under 2 year

s. In adults ,in contrast to children, the cause is usually r
elated to intestinal tumors.
3, main symptom: pain; bloody stool; abdominal mass
Intussusception

Clinical manifestation

Typical symptoms are abdominal

pain, bloody stool, and abdominal mass.
1. Abdominal pain: manifested as sudden
paroxysmal abdominal pain.
2. Mucus bloody stool: jam-like stool .
3. Abdominal mass
 Intussusceotion

Treatment

1. Air (or oxygen, barium) enema reduction

Suitable for: Early patients (within 48 hours)
Pressure: 60-80mmHg

2. Surgical treatment

《 Intestinal Diseases 》 -48/54 页 - 中■雨课堂

111 Rain Classroom
 Short bowel syndrome

Essentials of diagnosis
• Extensive small bowel resection
• Diarrhea
• Steatorrhea
• malnutrition
 Clinical course

• During the immediate postoperative period, more than 2

L of daily fluid and electrolyte losses from diarrhea are c
haracteristic. The diarrhea is less severe after a few we
ek, and eventually a reasonably normal existence is pos
sible in most cases. The progression from strict depend
ence on intravenous feeding to nutritional maintenance
by oral intake is possible because of intestinal adaptatio
n, a compensatory increase of absorptive capacity in the
intestinal remnant.
• The intensity of these responses is proportionate to the
amount of intestine removed, the segment remaining(gr
eater after proximal than after distal small bowel resecti
on), and the presence of a luminal stream
 Treatment

General measures: treatment of severe small bowel syndrome d

ivided into three stages
• Stage 1(intravenous feeding): During this period, which lasts
1-3 months, patients should receive nothing by mouth

• Stage 2(intravenous and oral feeding) oral intake until diarrhe

a less than 2.5L/d, intravenous nutrition should continue. An o
ral rehydration solution used for diarrhea are applicable. Milk
may aggravate diarrhea. Making breakfast the largest meal of
the day is advantagable

• Stage 3(complete oral intake): After about 6 months, complet

e dependence on oral intake may expected in patients with 1-
2 meters of remaining small bowel, but full adaptation may re
quire up to 2 years.
 polyps and polyposis

• Definition ：
• polyps ： the protrude lesion into bowel lumen from the
mucosa surface of the bowel
• polyposis ： polyps with specific clinical manifestation a
nd quantity more than 100
• pathology ： adenomatous polyps
inflammatory polyps
hamartomatic polyps
metaplastic polyps
mucosa hypertrophy neoplasm
•
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 Peutz-Jeghers syndrom
• characteristic ：
• mostly young patient
• family history
• harmatomatic ， malignant change
• all the alimentary tract ， mostly the small intestine.
Mouth, lips, hand, foot and pupendum pigmentation
complicated with intususception and bleeding

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Clinical manifestation
• Recurrent abdominal pain
• Intestinal bleeding
• Intestinal obstruction
• Intestinal intussusception
• Malignant change
Treatment
• Endoscopy electric coagulation or ligature
• Operation for local resection or segment resection

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MCC 批号 GIS1709773 有效期 2018-09-19 ，过期资料，视同作废
MCC 批号 GIS1709773 有效期 2018-09-19 ，过期资料，视同作废
MCC 批号 GIS1709773 有效期 2018-09-19 ，过期资料，视同作废
MCC 批号 GIS1709773 有效期 2018-09-19 ，过期资料，视同作废
Familial adenomatous polyposis
• characteristic ： APC gene mutation
• mostly young ， propensity malignant change, large bo
wel, less frequent invade into small intestine. operation
Polyposis complicated with multiple osteoma and
soft tissue tumor called as Gardner syndrom
• characteristic ： 30~40 years old ， hereditary
malignant change, operation

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Quiz of clinical case
 Single choice

The elderly male patients suffered from abdominal pain, frequent

vomiting and stopped defecating for 6 hours after morning
running. Two years ago, subtotal gastrectomy was performed for
perforation of duodenal ulcer. Physical examination: tenderness of
upper abdomen.
1 . What examination should the patient do first?

A colonoscopy

B. gastroscopy

C. Upper gastrointestinal radiography

D Abdominal X-ray
Single choice

2. What is the most likely diagnosis?

A. Gastric ulcer

B. Adhesive intestinal obstruction

C cholecystitis

D Intussusception
Single choice

3. Hb 132g / L, WBC 11 x 109 / L What is the preferred treatment

for now?
A. low-pressure enema and laxatives to promote defecation
B. Emergency operation
C. Apply antiemetic, analgesic and antispasmodic treatment
D. Gastrointestinal decompression, fluid infusion and antibiotic
treatment
THE END