Q17. Enumerate the causes of short bowel syndrome and discuss its management.
Write a note on intestinal failure.
Discuss in brief : surgical options to manage short bowel syndrome.
Ans. Short bowel syndrome is also called Type 3 intestinal failure.
Intestinal failure – Inability to mantain protein – energy, fluid-electrolyte and micronutrient balance due to obstruction, dysmotility, surgical resection, congenital defect or disease associated absorption defect
Hope hospital classification
Type Timing of use of TPN Causes
1. Short term (< 14 days) Often perioperative ileus, pancreatitis, pseudo- obstruction, radiation enteritis, IBD
2. > 28 days TPN need Anastomotic leaks, enteroatmospheric fistulas, diseases requiring extensive enterectomy (volvulus, mesenteric ischemia)
3. (Short Bowel
Syndrome) > 6 months TPN need Massive bowel resection due to various causes is irreversible
Important causes of SBS
Adult Children
Mesenteric ischemia (m.c.) Crohn’s disease
Trauma abdomen Volvulus Motility disorders Desmoids
Gastroschises (m.c.) Volvulus
Necrotizing enterocolitis Intestinal atresia
Microvillus inclusion disease
Short Bowel Syndrome is defined as small intestinal length less than 200 cm or less than 30% of its prior normal length in that patient. This is an arbitrary value and the actual limit depends on the remnant bowel type as follows:
Type of SBS Length that leads to SBS
1. Jejunostomy <100–150 cm
2. Jejunocolic anastomosis <60 cm
3. Jejunoileocolonic <35 cm
Pathophysiology
Loss of ileocecal valve Bacterial overgrowth
Loss of ileum Bile salt and vitamin B12 deficiency Loss of jejunum Decreased nutrient absorption
Loss of colon Decreased short chain fatty acid absorption Decreased carbohydrate fermentation
Adaptation to SBS y Hyperphagia
y Increase in the absorptive surface area of intestine (structural adaptation) y Alteration in gastrointestinal transit and motility (functional adaptation) The adaptation can continue for up to 24 months.
Management measures Medical options
y Fluid, electrolyte and acid-base balance
y Parenteral support with enteral nutrition as tolerated
y Oral rehydration and antimotility agents (loperamide, codeine, cholestyramine) y Octreotide is not to be used if the loss is < 3 litres as it decreases protein synthesis in the
intestine and may potentially inhibit the adaptation process
– Glucagon like peptide-2 analogues (Teduglutide) – enhances proliferative indices of adaptation by increasing crypt cell proliferation and villous height and increased expression of glucose transporters.
Effect intestinal wet weight absorption by increase of around 1 liter/day and about 20% reduction in TPN requirement.
Surgical options
y Autologous gastrointestinal reconstruction (AuGIR): Aims to optimize the absorptive surface and function of remnant bowel by nontransplant procedures as follows:
– SRSB – Segmental reversal of small bowel – 10 to 12 cm jejunum is reversed and reanastomosed
– Colonic interposition
y Intestinal lengthening procedures
– STEP (Kim) – serial transverse enteroplasty
– LILT (Bianchi) – longitudinal intestinal lengthening and tailoring y Both the procedures cause around 40% reduction in TPN requirement
y When all these procedures are unsuccessful, final step is to check for indications of intestinal transplant and enrol the patient.
Indications for small bowel transplant are as follows:
y SBS with overt or impending liver failure caused by TPN induced liver disease y SBS with multiple central line thrombosis
y > 2 episodes of central line infection or hospitalization or single evidence of fungal infection
y Frequent severe dehydration despite IV fluid supplementation and TPN.
Q18. Write the causes of Enterocutaneous fistula.
Write a note on management of a patient with enteroatmospheric fistula.
Discuss GI – cutaneous fistulas.
Enumerate the factors that interfere with spontaneous closure of the enterocutaneous fistulas.
Ans.
y Fistula word is latin meaning pipe/flute
y It is defined as an abnormal communication between two epithelialized surfaces y M.C. cause – Iatrogenic
y Types
Based on communication Internal
External (enterocutaneous)
Based on output High output (> 500 ml/day)
Moderate output
Low output (< 200 ml/day)
y Webster and Carrey classification of causes of small intestinal fistuals – TYPE A: Congenital (malformations)
– TYPE B: Trauma related or damage control surgery related
– TYPE C: Infective etiology (actinomycosis, tuberculosis, cytomegalovirus, etc.) – TYPE D: Irradiation enteritis, inflammatory cause (Crohn’s, ulcerative colitis,
diverticulitis), Tumor (small bowel, large bowel malignancies)
– TYPE E: Perforation with abscess. Includes iatrogenic injuries or traumatic injuries when associated with abscess.
Common age related causes of colovesical fistula y Crohn’s (20 to 40 yrs age group)
y Colorectal malignancy (40 to 60 yrs age group)
y Diverticulitis (50 to 80 yrs age group, overall m.c. cause)
Management outline of enterocutaneous fistulas is as follows:
No. Phase Days from
Diagnoses Interventions
A Stabilization 1–2 days y Fluid, electrolyte, acid—base balance y Nutrition enteral or parenteral and immune
enhancing formulas with care to avoid refeeding syndrome
y Control of infection
y Clearance of dead space/collections y Skin care measures (sump suction, NVAC
device) and avoidance of bed sores and DVT in bedridden patients
y Control or output (proton pump inhibitors, octreotide, infliximab)
B Investigation 7–10 days y Fistulogram
y CECT for intraabdominal collection/dead spaces
y Colonoscopy/UGI endoscopy as indicated C Decision Upto 4–6 weeks y Wait and watch approach
y Proceed to definitive surgery if there is presence of any of the following (Mn: FRIENDS—factors affecting spontaneous fistula closure)
− Foreign body (suture, mesh, debris)
− Radiation as etiology
− Inflammation/infection
− Epithelialization with tract length < 2.5 cm long with > 1 cm2 defect in bowel
− wallNeoplasm
− Distal obstruction
− Steroids therapy
− High output (> 500 ml/day) y Planning of operative approach y Optimal time for operation D Definitive
surgery After 2 months or interim intervention in inevitable circumstances
y Resection and anastomosis with or without feeding tubes (gastrostomy/jejunostomy) y Diversion stoma followed by restoration of
intestinal continuity at a later date E Healing and
Rehabilitation Ongoing phase after
A-D y Continue nutritional support
y Physical and mental rehabilitation y Complete oral/enteral diet
Q19. Write a note on Meckel’s diverticulum.
What is Meckel’s diverticulum? Write its clinical features. Discuss the management of an incidentally discovered Meckel’s diverticulum during Surgery.
Ans. Introduction
y Most common congenital anomaly of the small intestine
y Occur in 2% of the population y Equal incidence in men and women
y It is located on the antimesenteric border of the ileum 45 to 60 cm proximal to the ileocecal valve.
Etiology
Results from incomplete closure of the omphalomesenteric or vitelline, duct.
This failure can result in any of the following manifestations:
y Omphalomesenteric ligament (fibrous band) y Omphalomesenteric fistula
y Omphalomesenteric cyst y Meckel’s diverticulum.
Heterotopic tissue within the Meckel diverticulum y Gastric mucosa (M.C.)
y Pancreatic mucosa is encountered in about 5% of diverticula y Colonic mucosa.
Clinical Manifestations
y Incidental finding during autopsy or surgery
y Most common clinical presentation in children is gastrointestinal bleeding
y Most common clinical presentation in adults is intestinal obstruction which can be due to – Volvulus around fibrous band which connects meckel’s to umbilicus
– Intussusception with meckel’s as a lead point
– Incarceration of the diverticulum in an inguinal hernia (Littre’s hernia)
y Diverticulitis—more common in adult patients and is clinically indistinguishable from appendicitis
y Benign tumors—Leiomyomas, angiomas, and lipomas
y Malignant tumors—Adenocarcinomas, which generally originate from the gastric mucosa, sarcoma and carcinoid tumor.
Diagnoses
y Scintigraphy with sodium 99 mTc-pertechnetate
More accurate in children than in adults where, the sensitivity and specificity can be improved by the use of pentagastrin and glucagon or histamine 2 (H2) receptor antagonists (e.g. cimetidine)
y In adult patients, when nuclear medicine findings are normal, barium studies should be performed
y In patients with acute hemorrhage, angiography is sometimes useful.
Treatment
y Symptomatic Meckel’s diverticulum—Open or laparoscopic diverticulectomy or segmental ileal resection which is required for treatment of patients with bleeding because the bleeding site is usually in the ileum adjacent to the diverticulum caused by ulceration due to the acid secretion by the heterotopic gastric mucosa
y Asymptomatic diverticula—Should be resected in all patients upto age of 80 years if patient can tolerate the extra time required in the procedure because a 6.4% rate of
development of complications from the Meckel’s diverticulum is calculated to occur over a lifetime whereas the morbidity of the procedure is only around 2%.
Q20. What is Intussusception? Discuss its causes and management.
Ans. Intusussception is telescoping of one portion of the intestine into the other.
Causes
y Idiopathic (m.c.)
y Peyer patch hypertrophy (viral gastroenteritis, URI, administration of rotavirus vaccine) (3 months to 3 years)
y Meckel’s diverticulum (1 year onward) y Malignancy of bowel or mesentery
y Intestinal polyps (Peutz Jegher’s syndrome), Intestinal duplication y Inflamed appendix
y Submucosal lipoma
y Submucosal hemorrhage associated with Henoch-Schönlein purpura y Foreign body
y Ectopic pancreatic or gastric tissue
y Postoperative small bowel intussusception in the absence of a lead point.
Fig. 6: Intussusception
Clinical Presentation
y Severe cramping abdominal pain, vomiting, passage of bloody mucous (red currant jelly stool)
y Examination reveals a sausage shaped mass in the abdomen which may sometimes resolve spontaneously and is therefore an example of ‘vanishing lump’
y Emptiness in the right iliac fossa in cases is called Sign of Dance
y The child often draws the legs up during the pain episodes and is usually quiet during the intervening periods.
Diagnoses
y Abdominal ultrasound - target sign on a transverse view and pseudokidney sign when
Treatment
Nonoperative Management
y Hydrostatic reduction by enema using contrast/air/barium
y Contraindications - Presence of peritonitis or hemodynamic instability
y Successful reduction is accomplished in more than 80% of cases and confirmed by resolution of the mass along with reflux of air into the terminal ileum
y Recurrence rate - 11% usually managed by another hydrostatic reduction. A third recurrence is an indication for operative management.
Surgical Management y Indications
– Presence of peritonitis – Failed hydrostatic reduction – Third recurrence
– Complete small bowel obstruction
y The surgical reduction is done in a retrograde fashion
y Bowel resection is required in cases in which the intussusception cannot be reduced, the viability of the bowel is uncertain, and/or a lead point is identified
y An ileocolectomy with primary reanastomosis is usually performed. An appendectomy is also performed simultaneously
y It can also be done using laparoscopy.
Q21. Give a list of causes of neonatal intestinal obstruction and discuss management in brief.
Write a note on necrotizing enterocolitis.
Write a note on meconium Ileus.
Discuss the causes and management of a newborn presenting with intestinal obstruction.
Ans.
Proximal Distal
y Duodenal atresia y Malrotation y Midgut volvulus y Annular pancreas y Pseduodenal portal vein
y Jejunal atresia > ileal atresia y Meconium ileus
y Hirschsprung’s disease y Meconium plug syndrome y Necrotizing enterocolitis y Colonic atresia
Duodenal atresia y Types
– Mucosal stenosis
– Mucosal web with normal muscular layers (Windsock deformity) – Two ends joined by fibrous cord
– Two ends separate
y Characteristic radiological appearance—Double bubble sign y Association with down syndrome
y Management
Diamond shaped duodenoduodenostomy with/out tapering duodenoplasty done by giving incision transverse in the bowel proximal to atresia and longitudinal in distal bowel and anastomozing them.
Jejunoileal atresia y Types
– Mucosal web – Fibrous cord
– A – V- shaped small mesenteric defect B – apple peel/Christmas tree large defect
– String of beads/string of sausage appearance due to multiple small atretic segments in between normal segments
y Type 3 B and 4 have a retrograde blood supply y Characteristic radiologic sign – Triple bubble sign
y Management – Multiple anastomosis over stent or resection anastomosis with or without a tapering enteroplasty.
Malrotation
y Normal gut rotation is 270°C counterclockwise.
y Normal Ladd bands – Go from cecum and an ascending colon to retoperitoneum and lateral abdominal wall
y Normal SMV and SMA relation—SMV is on the right side of SMA y Midgut volvulus—rotates clockwise
y Surgery—Do counterclockwise rotation to correct the problem y Most common rotation abnormality is Non rotation
y Most common malrotation—incomplete rotation
y Other rotation abnormalities—partial rotation and reverse rotation
y In malrotation, SMV comes to left of SMA because of ‘whirlpool sign of malrotation appreciated on CECT with CT angiogram – SMV with mesentery rotated around the axis of SMA’
y Other signs – corkscrew duodenum
y Duodenojejunal flexure appearing in upper GI barium study before the pedicle of L2 vertebrae
y Ladd Procedure – Main steps include:
– Widen the base of mesentery – Relieve volvulus
– Appendectomy.
Necrotizing enterocolitis
y Most common GI surgical emergency in neonates y Most common site involved is ileal mucosa
y Very important cause of short bowel syndrome in children
y Prematurity is the most important risk factor for developing necrotizing enterocolitis y Patients with ARDS are also at increased risk
y Pneumatosis intestinalis that develops here contains hydrogen y BELL’S Staging system is used to stage necrotizing enterocolitis y Management
– Conservative management is successful in 90% cases.
– Resuscitation
– Look for ominous signs and indications for surgery and if present immediate surgery is life saving.
Indications for surgery
y Fixed palpable and visible bowel loops with abdominal distension y Nonresponder to medical therapy
y Resistant thrombocytopenia y Signs of perforation peritonitis y Progressive acidoses
y Erythema and edema of bowel wall.
However, it should be remembered that surgery does not prevent disease progression. It is the management of general condition that saves the life here.
m.c. site of stricture after necrotizing enterocolitis – splenic flexure.
Meconium Ileus
y Triad of generalized abdominal distension, bilious vomiting and non passage of meconium for 12 to 24 hours after birth.
y Usually a sign of presence of cystic fibroses (can be confirmed with pilocarpine iontopheresis test). Other obstructing condition associated with cystic fibroses is jejunoileal atresia
y Abdominal X-ray features – snowstorm appearance
y Complicated meconium ileus – meconium ileus with perforation
Management—hydrostatic gastrograffin contrast enema and 5 ml 10% N acetylcysteine orally 6 hrly.
If the patient does not resolve by this conservative means, treatment is enterotomy f/b 4%
N acetylcysteine with warm saline or enterotomy and pushing the contents into colon f/b closure of enterotomy.
Meconium plug syndrome
It is not associated with meconium ileus. It is a large intestinal obstruction associated with y Hirschsprung disease
y Maternal diabetes y Hypothyroidism
Q22. Enumerate the causes of mesenteric ischemia.
What are the types of mesenteric ischemia? Discuss its management in brief.
Write a note on intestinal angina.
Discuss acute mesenteric ischemia.
Ans. Mesenteric ischemia can be acute or chronic
Acute mesenteric ischemia Causes
Occlusive Increased wall tension Non occlusive Inadequate outflow Embolic (m.c.) Closed loop obstruction Cardiogenic shock Mesenteric venous
thrombosis Thrombus Pseudoobstruction Hemorrhagic shock Mesenteric nodal
disease
Volvulus Septic shock Pancreatic neoplasms
Strangulated hernia Critically ill patients
Aortic dissection Pancreatitis
Aortic insufficiency Burns
Mesenteric tear
Acute superior mesenteric ischemia y Both sexes are affected equally
y Embolic cause (myocardial infarction, cardiac thrombus, atrial fibrillation) > thrombotic cause (cerebral infarction, PVD, coronary artery disease, disseminated cancer).
y Mesenteric venous thrombosis causes include thrombophilia, OC pills, liver cirrhoses and inflammatory bowel disease.
Clinical features
y Symptoms are out of proportion of physical signs
y Any patient with sudden onset pain abdomen > 2 hours with no other definite cause should be evaluated for AMI
y All causes of acute abdomen are included in its differential diagnoses.
Investigations
y Increased TLC, metabolic acidoses, hyperamylasemia, elevated lactate levels are seen.
y Sensitive and specific marker is alfa-glutathione-s- transferase
y X-ray abdomen—dilated loops, pneumatosis intestinalis and pneumatosis portalis may be seen
y Investigation of choice for arterial occlusion is CT angiography.
y Others—mesenteric angiography – diagnostic and therapeutic and gold standard y MR angiography
y Duplex scanning of mesenteric vessels y Diagnostic laparoscopy.
Management
Resuscitation of patient with oxygen, IV fluids, electrolyte correction, pain relief and antibiotics.
y Primary anastomosis of bowel should not be done if revascularisation is carried out y Intraoperative determination of cause of mesenteric ischemia
Mortality: NOMI> SMAT > SMAE > SMVT Chronic mesenteric ischemia
y Most common cause—atherosclerosis
y Other causes—vasculitis, takayasu disease, SMVT
y It is more lethal than acute mesenteric ischemia because if SMAT complicates a case of chronic mesenteric ischemia, it has a very high mortality rate.
Clinical features y Old age, females
y Mesenteric angina (postprandial colicky epigastric pain) y Weight loss
Site: Celiac > IMA > SMA Investigations: same as above
Management
y Revascularisation is indicated in symptomatic disease y Short, nonostial, focal disease—endovascular angioplasty
y 2 or more than 2 vessels with critical stenosis—open SMA revascularisation with antegrade or retrograde bypass (retrograde means through infra renal aorta or iliac vessel)
Results
y Mesenteric angioplasty and stenting has high success rate with low morbidity and mortality
y Open bypass on the other hand has decreased rate of restenosis and decreased incidence of symptomatic recurrences.
Q23. Write a note on superior mesenteric artery syndrome.
Ans.
(Imp: Always Remember: The angle between abdominal aorta and superior mesenteric artery is normally acute (40 to 60 degrees), when it becomes more acute (5 to 25 degrees), it causes compression of the third part of duodenum which results in SMA syndrome.
On the other hand, the compression of left renal vein between abdominal aorta and Superior mesenteric artery is known as nutcracker syndrome.
y Superior mesenteric artery syndrome is also known as Wilkie syndrome, Cast syndrome, mesenteric root syndrome or arteriomesenteric duodenal ileus.
y It is the compression of the third part of the duodenum between Aorta and SMA.
y Established dimensions to label SMA syndrome – Aorta – SMA angle < or = 25°(Normal – 40 to 60°)
– Aortomesenteric distance < 9 mm (Normal – 10 to 20 mm) Etiopathogenesis
y Any factor that decreases the retroperitoneal fat pad and lymphatic tissue decreases the protection of third part of duodenum from SMA and predisposes to SMA syndrome y It can be chronic relapsing congenital variant or acute/induced variant
y Predisposing factors – Recent rapid weight loss
– Prolonged supine immobilization – Tall asthenic women
– Scolioses
– Placement of body cast – After left nephrectomy surgery.
Clinical presentation
y Chronic congenital variant patients have a lifelong history of intermittent exacerbations of symptoms such as nausea, vomiting, weight loss, epigastric pain especially after eating y Acute variant can present with above symptoms with a sudden and unremitting nature y Patients can also present in shock, Upper GI bleeding, Perforation peritonitis, dehydration
and fluid and electrolyte abnormalities due to persistent vomiting.
Diagnoses
y CECT with CT angiography with lateral films
y Upper GI Barium study or hypotonic duodenography can also be used.
Treatment
y Acute variant – usually responds to conservative measures which include the following:
– NPO and Nasogastric decompression
– Resuscitation and correction of the fluid and electrolyte abnormalities – Monitoring of temperature, pulse, blood pressure and urine output – Metoclopramide or other prokinetic agent has also been tried.
– Jejunostomy feeds or parenteral hyperalimentation.
The goal of the conservative measures is restoration of weight which will take care of the symptoms.
y Chronic relapsing cases and cases which do not improve on the conservative management require surgery.
y Duodenojejunostomy (Open/Laparoscopic, anatomic/Roux-en-Y) is the operative procedure of choice.
Q24. What is morbid obesity? Discuss its management in brief.
Give the classes of obesity for Indian population. Discuss the etiopathogenesis and management of morbid obesity in current scenario.
Ans.
BMI classes Asia Others
Underweight – <18.5
Normal <23 18.5–24.9
Overweight 23–24.9 25–29.9
Mild obesity (1) 25–32.4 30–34.9
Severe obesity (2) 32.5–37.4 35–39.9
Morbid obesity (3) >37.5 40–49.9
Superobese – > 50 kg/m2
Definition
BMI > 40 kg/m2 or twice the ideal body weight for that age and height.
Pathophysiology y Familial predisposition
y Increased levels of ghrelin cause increased food intake
y Metabolic syndrome—Type 2 diabetes, impaired glucose tolerance, hypertension, dyslipidemia
Medical therapy
y 10% weight loss at the rate of 0.5 to 2 lb/ week y Maintenance of weight loss for 6 months
y Plan is to give very low calorie diet with decreased fat intake and decreased carbohydrate intake
y Drugs approved – Sibutramine (SNRI—serotonin and norepinephrine reuptake inhibitor) and Orlistat (pancreatic lipase inhibitor)
Indications for surgery y BMI > 40 kg/m2
y BMI >35 kg/m2 with co-morbidity
y With failed medical therapy, motivated attitude and psychiatric stability y Knowledgable about operation
y No medical problems precluding survival.
Absolute contraindication - Prader Willi syndrome Preoperative evaluation
y Documented medically supervised diet
y First generation cephalosporin for 24 hrs preoperation y Ultrasound for gallstones
y UGI endoscopy for GERD
y Orthopedic, psychiatric, nutritionist, physician and endocrinologists consult
y To prevent DVT – sequential compression device boots, ambulation within 4 to 6 hrs and LMWH for 2 weeks
y ABGA.
Operations Restrictive
y Vertical banded gastroplasty
y Adjustable gastric banding (Fielding and Allen) y Sleeve gastrectomy
– Has superior weight loss and better appetite control than RYGB.
– Advantages—technical simplicity, no malabsorption or internal hernias, no need for serial readjustments
– Disadvantage—leak, bleeding Mildly malabsorptive
y Roux-en-y gastric bypass