The SMALL INTESTINES

NEIL C. MENDOZA, MD, FPCS

Small Intestine
Anatomy and Physiology
Jejunum
suspended in a mobile mesentery
2/5 of whole intestinal length
may be involved in adhesions
Ileum
3/5 of whole intestinal length

Blood Supply

Proximal duodenum - celiac axis

Remainder of the small intestine - Superior mesenteric

artery

PHYSIOLOGY SMALL BOWEL

Primary functions:
digestion and absorption

All ingested food and fluid and secretions from the

stomach, liver, pancreas reach the small bowel
Total volume- 9 lit /day and all will be absorbed
except 1-2 lit

INVESTIGATIONS
SMALL BOWEL DISORDERS

1. Radiology- plain erect film

obstruction and perforation
2. Small bowel follow-through
established investigation to outline the small bowel
tumors, Crohns disease, fistulas, polyps

3. Enteroclysis

SBFT (small bowel follow through)

The esophagus, stomach, and duodenum are easily
evaluated in detail.
The small bowel is then radiographed at periodic
intervals and fluoroscopically spotted by the Radiologist
This type of SBFT can take hours to complete and detail
of the lumen cannot be assessed as the loops of small
intestine overlap as the barium progresses

Enteroclysis
minimally invasive radiographic procedure of the small
intestine, which requires the introduction of a catheter
into the intestine, followed by the injection of barium and
methylcellulose.
The barium coats the intestine and the methylcellulose
distends the lumen to give a double contrast exam that
allows for fluoroscopic visualization of the entire small
bowel.

Enteroclysis
may be helpful in diagnosing almost all diseases that affect
the small bowel

may also be helpful in ruling out diseases in patients with

unexplained abdominal complaints.
Indications:
Suspected or known small bowel obstruction
Neoplasms (cancers)
Inflammatory bowel disease
Unexplained gastrointestinal bleeding
Malabsorption
Polyps
Adhesive bands
Post surgical changes

Disadvantages :
placement of the enteroclysis catheter can be
uncomfortable for the patient, even with the use of
anesthetic spray and Xylocaine jelly
patient will receive higher doses of radiation in
comparison to the traditional small bowel follow
through exam during this exam.

Advantages :
much quicker than a routine single contrast Small Bowel
Follow Through exam
distention of the small bowel makes it possible to display
all dilated bowel loops simultaneously at the end of the
exam

help to determine: fold thickness, ulceration, polyps,

constrictions, and adhesive bands

INVESTIGATIONS
SMALL BOWEL

Selective splanchnic angiography- reliable method for

detection of angioplastic
lesions
The bleeding site can be located if the patient I
sbleeding actively at the time of investigation

INVESTIGATIONS
Ultrasound of the abdomen
can differentiate fluid-filled dilated small bowel loop
from abdominal cystic structures
can assess free fluid within peritoneal cavity
can assess a solid mass belonging to the small bowel if
large enough

INVESTIGATIONS
Isotope scintigraphy
Isotope-labelled red cells- occult GI bleeding

Isotope-labelled white cells- suspected intraabdominal

inflammation/abscess formation, inflammed bowel
(Crohns dse)
Isotope labelled meal- intestinal transit time

INVESTIGATIONS
Quantitative estimation of fecal fat- remains the most sensitive test of disorders of
digestion and absorption

On a standard diet of 100 g of fat, the fecal fat output

normally is less than 6g/day

INVESTIGATIONS
Jejunal mucosal biopsy
Celiac disease- subtotal villous atrophy
Whipples- abnormal mucosal pathogens

INVESTIGATIONS
BACTERIAL OVERGROWTH
small bowel becomes colonized by bacteria
increase in the concentration organisms which are
normally confined to the lower small bowel and colon
affected intestine becomes inflammed and dilated
Symptoms and signs- colicky pain, meteorism, diarrhea,
anemia

INVESTIGATIONS
Causes of bacterial overgrowth:
1. Excessive entry of bacteria into the small bowel
2. Intestinal stasis

DISEASES of the SMALL

INTESTINES

BACTERIAL OVERGROWTH
1. Excessive entry of bacteria
Achlorhydria

Gastro-jejunostomy
Gastrectomy
Enterocolic fistulas
Cholangitis

Loss of ileocecal valve following RHC

BACTERIAL OVERGROWTH
2. Intestinal stasis:
Stenotic Crohns disease
Stenotic intestinal stasis
Small bowel diverticulosis
Afferent loop stasis
Entero- enteric anastomosis
Diabetis mellitus- autonomic neuropathy
Radiation enteritis- stenosis
Scleroderma- impaired intestinal motility

BACTERIAL OVERGROWTH
Clinical features:
Abdominal colicky pain

Asthenia, nausea, vomiting

Weight loss, excessive bowel sounds
Diarrhea
Anemia, hypoproteinemia
Paresthesia, peripheral neuropathy- B12 deficiency

BACTERIAL OVERGROWTH
Treatment :
Surgical treatment of the underlying condition whenever
possible
Jejunal diverticulosis, scleroderma- tetracycline and
metronidazole for 10-14 days

SHORT-GUT SYNDROME

Encountered after massive resection of the small

bowel
Encountered in pts. with jejuno-ileal by-pass for
morbid obesity

SHORT-GUT SYNDROME
Conditions necessitating extensive resection of the small
bowel:

Crohns disease
Mesenteric infarction
Radiation enteritis
Multiple fistulas

Small bowel tumors

SHORT-GUT SYNDROME
Resections of more than half of the small bowel lengthserious malabsorbtion
Pts.with residual small bowel length of < 2m- diminished
work capacity
Pts. with residual small bowel length of less 1m require
home parenteral nutrition on an indefinite basis
Ileal resections are less well tolerated than jejunal
resections

SHORT-GUT SYNDROME
Treatment:
Massive small bowel resection- TPN regimen that must
provide 40 Kcal/Kg. body weight
Pts. with about 1m. of small bowel- TPN discontinued
with time coz small bowel will hypertrophy

Oral nutrition is based on an elemental diet

antiperistaltic agents should be given, vitamins, B12
parenteral

Short Bowel Syndrome

Surgical Approach

intestinal lengthening procedures

<60 cm., intestinal transplantation

PROTEIN-LOSING ENTEROPATHY
Loss of plasma proteins- low plasma proteins
secondary hyperaldosteronism with water and salt
retention- edema
Causes:
- mucosal disease- Whipples

- ulcerating lesions- villous tumors

- lymphatic obstruction- lymphoma
Treat the underlying disease

SMALL BOWEL TUMORS

10% of all GI tumors (benign or malignant)
Benign small bowel tumors:

Adenomatous polyps
Hamartomatous polyps- Peutz-Jaegers syn.
Leiomyomas, lipomas, fibromas
Hemangiomas, neurofibromas

BENIGN SMALL BOWEL TUMORS

Clinical presentations:
Bowel obstruction due to intussusception
Chronic blood loss- chronic anemia- fecal ocult blood
Melena- acute anemia
DIAGNOSIS:
- barium follow-through
- abdominal CT
- endoscopic videocapsule for nonobstructing lesions
TREATMENT- bowel resection with end to end
anastomosis

MALIGNANT SMALL BOWEL TUMORS

ADENOCARCINOMAS
MALIGNANT CARCINOID
LYMPHOMA
METASTASES FROM DISTANT TUMOR

MALIGNANT SMALL BOWEL TUMORS

Clinical presentations:
Lower GI bleeding- ocult or melena
Diarrhea
Perforation- peritonitis
Bowel obstruction
DIAGNOSIS:
- contrast follow-through
- CT for elective cases
- plain abdo X ray in acute cases
TREATMENT- segmental bowel resection

MALIGNANT SMALL BOWEL TUMORS

SMALL BOWEL ADENOCARCINOMA
Commonly- well-differentiated mucus- secreting
tumors
Usually located in the proximal intestine
Spread to lymph nodes, liver, peritoneal serosa

Pts. with resectable tumors- 25%- 5 year- survival

rate

CARCINOID TUMORS
Derived from enterochromaffin cells

Common places: appendix, ileum, rectum

Clinical features: flushing, diarrhea,
bronchoconstriction caused by serotonin and other
vasoactive substances secreted by the tumor

CARCINOID TUMORS
Diagnosis:
- elevated levels of 5 HIAA- 5 hydroxyindolacetic
acid- the breakdown product of serotonin in the
urine

TREATMENT:
resection of the primary tumor and metastastatic tumor

Lymphoma
presents with fatigue, weight loss and abdominal
pain

Treatment: Primarily Surgical

adjuvant therapy recommended with positive

margins

GastroIntestinal Stromal Tumors (GIST)

most common sarcoma of the GI tract
Clinical presentation is variable
Tumors are often asymptomatic
Patients may have common, nonspecific symptoms,
resulting in underdiagnosis or misdiagnosis
All GIST have the potential to become malignant
- Risk is based on size and mitotic index at
presentation

GIST-CLINICAL PRESENTATION
Often asymptomatic, especially when small

May be symptomatic if large

signs/symptoms related to location and size of tumor
Vague GI pain or discomfort
GI hemorrhage
Anemia
Anorexia, weight loss, nausea, fatigue
Acute intraperitoneal bleeding or perforation

GIST- SITES OF GROWTH

Other (rectum, esophagus,

mesentery, retroperitoneum

Colon
10% 15%

50%
Stomach

25%
Small
intestine

GIST
2 major histologic patterns, which overlap with many
non-GIST sarcomas and other malignancies
Spindle cell
Epithelioid
In the past, GIST were usually classified as:
Leiomyoma
Leiomyoblastoma
Leiomyosarcoma
Many patients previously diagnosed with one of these
tumors actually had a GIST

GIST DIAGNOSIS
Initial workup should include imaging:
CT of abdomen and pelvis with oral/IV contrast
Consider 18FDG-PET
Endoscopic ultrasound
Liver function tests
Complete blood counts

Surgical assessment
Resectable vs non-resectable
Primary tumor only vs metastatic

ENDOSCOPY & EUS

ULCERATED GASTRIC GIST

FDG - PET
FDG - PET (Fluorodeoxyglucose- positron emission
tomography)
Provides the status of glucose metabolism in
tumors
GIST are highly metabolically active
Easy detection highly-sensitivebut not specific for
metabolically active GIST
Staging workup
Evaluate the extent of the disease
Assess for metastatic disease

CT- Massive stromal gastric tumor

GIST FDG-PET Imaging

Hepatic, abdominal and pelvic metastases

GIST- TREATMENT
Surgery remains the principal treatment for resectable
primary GIST
Standard sarcoma chemotherapy is ineffective
Limited response rate ~5%
Median time to progression 3-4 months
No impact on survival

Comorbidity due to tumor localization limits effectiveness

of radiation therapy

SURGICAL CONSIDERATIONS
Complete gross resection with the intact pseudocapsule is
the goal of resection
Careful tumor handling is critical
Rupturing of the pseudocapsule can cause tumor
bleeding and/or dissemination

Unlike adenocarcinomas, GIST tend to displace, not

invade, surrounding organs
Negative microscopic margins are desirable

Lymphadenectomy is un-necessary, as GIST rarely

metastasize to the regional lymph nodes

RECURRENCE AFTER SURGERY

Recurrence is common

majority of high-risk patients have recurrence of GIST

following surgery
Median time to recurrence is 7 months to 2 years

Only 10% of patients remain disease-free after extended

follow-up
Recurrent disease should be treated as metastatic
disease

GIST TREATMENT OPTIONS

Intermediate and high-risk GIST have a high rate of
recurrence
Recurrent disease should be treated as metastatic
disease
Traditional chemotherapy and radiation therapy are
ineffective for GIST
Patient follow-up is necessary
Neoadjuvant therapy may enhance resectability
Adjuvant therapy may reduce recurrence

JEJUNAL STROMAL TUMOR w/ MUCOSAL

ULCERATION

SMALL BOWEL DIVERTICULOSIS

Duodenal diverticula- 90% are asymptomatic
70% -periampullary region- cholangitis, pancreatitis, CBD
stones
Jejunal diverticula-rare, may cause obstruction,

bleeding, perforation, bacterial overgrowth within the

diverticulum
-Meckels diverticulum- within 40 cm. of the ileocecal valve
- may cause bleeding, obstruction, acute inflammation
TREATMENT
Resection with Enterorrhapy

Mechanical Obstruction of the Small

Intestine
impairment in normal flow of luminal contents

intrinsic or extrinsic

early diagnosis key to management

SMALL BOWEL OBSTRUCTION

Responsible for 12 to 16% of admissions to the

surgical service in patients with acute abdominal
pain.
Mechanical blockage with failure of passage of
bowel contents

Etiology: SBO

Extraluminal

Adhesions- > 60%, especially after pelvic surgery

Neoplastic -20%. Majority are metastatic that have

peritoneal implants
Hernias-10%. Most common are ventral, inguinal or
internal

Abscesses

Causes of Intestinal Obstruction

Neonate
Atresia
Midgut
Volvulus
Meconium
ileus

Infant

Young
Adult

Adult

Adhesions
Adhesions
(70%)
Groin Hernia
Groin
Intussusception
Hernia
(10%)
Groin Hernia

Meckels
Diverticulum

Cancer
(5%)

Causes

Symptoms
Signs
Plain films

SBO
Colonic
Adhesions and
Cancer
Groin Hernias Inflammation
cramps and
cramps and
vomiting
vomiting less
regular
frequent
interval
mild-moderate moderatemarked
distension
distension
dilated loops
dilated airwith air-fluid filled colon
levels, paucity
w/w/o SB
distally
distension

CAUSES: SBO
Intramural

Neoplasms
Adenocarcinomas: 50%, distal duodenum or proximal
jejunum- cause hemorrhage or ulceration
Lymphomas: 20%, non-Hodgkins. Ileum> jejunum>
duodenum. Occasionallyobstruct

Carcinoid: >50% in distal ileum. Most asymptomatic

Leiomyosarcoma: >5 cm in diameter. Obstruction,
bleeding, perforation is common.

CAUSES: SBO

Inflammatory
Crohns 5%. Acute inflammation and edema or
chronic strictures.

Infectious
Congenital
Malrotation, duplication, congenital bands
Others: Traumatic, Intussusception, radiation

CAUSES: SBO

Intraluminal
Gallstones, enteroliths, Bezoars, foreign bodies

Presentation & Pathophysiology

Classical presentation:

colicky abdominal pain, nausea, vomiting, abdominal

distention and obstipation

Vomiting more common in proximal obstruction

Feculent vomiting indicates distal or late obstruction

Presentation & Pathophysiology

Diarrhea

In both partial or complete obstruction, diarrhea may be

present early in the course because of increased motility
and contractile activity of bowel in order to propel
luminal contents beyond point of obstruction

Increased or decreased bowel sounds: Increased early,

may see peristaltic waves; later
Decreased or none, once bowel is exhausted

Hypotension and shock:

- Bowel dilates with accumulation of water and electrolytes
in the lumen and within the wall of the bowel (third
spacing) leading to dehydration andhypovolemia

Compromised ventilation:
- Increased abdominal pressure, decreased venous return,
elevationof diaphragm

Fever:
- Strangulated bowel; Closed loop obstruction has
increased intraluminal pressures with decrease in
mucosal blood flow.

Bacterial translocation: E. coli, Strep faecalis, and

Klebsiella
Guaiac positive: malignancy, intussusception or
infarction

Electrolyte Imbalance

Proximal obstruction may have hypokalemia,

hypochloremia and alkalosis
Distal obstruction- less dramatic electrolyte
abnormalities

Hemoconcentration as evidence of dehydration

Radiology

Plain film:
- diagnostic in 50-60% of cases
- small bowel distention, multiple air-fluid levels, and
decreased colonic gas and stool
- Widely available and low cost

Barium swallow and/or enema:

- Not useful in high grade obstruction, contrast diluted
by fluid in bowel leads to poor mucosal detail.

Prolonged transit time

Enteroclysis
Sequential infusion promotes antegrade flow beyond point
of obstruction

- Positive predictive value 100%; level of obstruction in

89%;cause of obstruction in 86%.
CT: High grade obstruction 81% sensitivity, 63% with all
grades
- able to show cause of obstruction in 93-95% of cases
- Reliable in showing signs of closed loop, ischemia and
infarction

Treatment

Non-operative:
- 60-85% resolution
- NG tube decompression, fluid resuscitation, bowel rest
- Serial exams and electrolyte management
- IFC
- Broad spectrum antibiotics

Operative

Complete obstruction usually does not resolve.

Incidence of strangulation increases significantly
after 12-24 hours
- manifested by fever, tachycardia, focal tenderness,
leukocytosis

Operative treatment depends on etiology i.e. lysis of

adhesions, small bowel resection, etc.

Patho-physiology of Postoperative Small Bowel

Obstruction

Adhesions

Internal herniation

Inflammation

Prevention and Treatment of Small Bowel

Obstruction

NG tube

gastrograffin challenge

the decision to operate

PLAIN ABDOMINAL X-RAY

CT SCAN

POSTOPERATIVE ILEUS
Postoperative Ileus

Defined as the prolonged inhibition of coordinated

movements of the gastrointestinal tract
Possible indicators: Nausea and vomiting,
abdominal distension, pain and the absence of flatus
and stool

Pathophysiology of Ileus

Extensive inflammatory response within the intestinal

muscularis after bowel surgery ( Sido, et al)
Direct relationship between the inflammatory reaction
and the macrophages of the intestinal muscularis that
participate and functional smooth muscle impairment
(Behrendt, et al)
found an induction of cyclooxygenase-2 m RNA and
protein in resident macrophages that decreased jejunal
circular muscle contractility through prostaglandins
(Schwartz, et al)

Prevention and Treatment of Ileus

Ceruletide, erythromycin, metoclopramide, somatostatin

have all been studied as treatment for postoperative ileus
with no conclusive results

demonstrated a relationship between patient

expectations after surgery and outcome (Disbrow, et al. )
showed benefits of gum chewing on postoperative bowel
motility believed to be related to sham feeding (Asao, et
al.)

Multiple studies have demonstrated that patients will

often tolerate feeding within 24 hours after surgery

Postoperative Small Bowel Obstruction

Temporary return of bowel function followed by

distension and obstipation within 4 weeks of laparotomy
(Stewart, et al)
principal indicators: abdominal pain, vomiting,
distension, and obstipation with radiographic
confirmation postoperative small bowel obstruction
(Frykberg & Phillips)

defined as crampy abdominal pain, vomiting and

radiographic findings consistent with intestinal
obstruction after an initialreturn of bowel function
within 30 days after surgery (Ellozy, et al.)

Special forms of Obstruction

Stricture
Crohns Disease
NSAIDs
Radiation therapy
Mesenteric Ischemia
if chronic and progressive, resection is the best
surgical approach

Special forms of obstruction

Internal hernias
abnormalities related to prior operations
congenital defects
surgical repair of the defect with resection of nonviable bowel

Special forms of obstruction

Gallstone ileus
1-2% of cases of intestinal obstruction affecting
patients 60 years and above

stones>2.5 cm., enters GIT by ulceration and

fistulization
cholecystoduodenal fistula most common site of entry
presents with intestinal obstruction and aerobilia
causes distal ileal obstruction

Gallstone ileus

Gallstone ileus

Infectious Diseases
1. TB Enteritis
Primary infection
Secondary Infection
Indication for surgery- obstruction
2. Typhoid enteritis
Diagnosis blood culture
Medical management
Indications for surgery- bleeding, perforation

SBO: FABRIC BEZOARS

ENTEROCUTANEOUS FISTULA

Abnormal communications linking two epithelialized

surfaces.

Enterocutaneous fistula (ECF) is an abnormal

communication between hollow viscera and skin.
Serious and dreaded complication of gastrointestinal (GI)
diseases and their treatments, such as surgery

Small Bowel Fistula

ETIOLOGY

Spontaneous 15% to 25%

Radiation

IBD

diverticular disease

ischemic bowel

appendicitis

perforated duodenal ulcers

malignancies

ETIOLOGY

Postoperative -75% to 85%:

Anastomotic breakdown
unrecognized bowel injuries during dissection or
abdominal closure.
Operations for cancer, IBD, and lysis of adhesions are
most at risk.

CLASSIFICATION
I. Output:

Low:200 ml/24-hour

Moderate: 200 to 500 ml/24-hour

High: 500 ml/24-hour (poorer prognosis)

II. Anatomic location in the GI tract:

Unfavorable: stomach, lateral duodenum, ligament of Treitz,
and ileum

Favorable: Esophagus, duodenal stump, pancreatobiliary,

jejunum.

Anatomic features unfavorable for spontaneous

closure:

Foreign body

Radiation

Inflammation/infection : adjacent abscess or diseased

bowel

Epithelialization of the fistula tract

Neoplasm

Distal obstruction

Also: fistula tract < 2 cm length and enteral defects > 1 cm

DIAGNOSIS
Clinical presentation:

Fever

elevated white blood cell count

increasing abdominal tenderness

prolonged ileus

DIAGNOSIS

Clinical presentation:

signs of wound infection

sepsis

Between the fifth and 10th postoperative days.

Drainage of enteric content (from the surgical wound) either

spontaneously or upon reopening of the wound.

Radiologic studies:

Plain radiography

GI contrast studies

Fistulograms

Ultrasonography

CT scan

Main role is to aid in the anatomic localization of the

fistula.

MANAGEMENT
Divided into three phases:
1. Diagnosis and recognition
2. Stabilization and investigation

control complications within 24 to 48 hrs of recognition of

fistula

main goal is reduction of fistula output.

3. Definitive care
- usually occurs if the fistula fails to respond to medical
treatment after 4 to 6 weeks.

MANAGEMENT

NPO

NG tube

H2 antagonist or PPI

skin protection

drainage of abscess

correction of fluid, electrolyte, and nutritional

imbalances

MANAGEMENT
Malnutrition is present in 5590% of patients with ECF and is responsible
for much of the morbidity and mortality in these patients.

- Malnutrition should be considered if there is a body weight loss of at

least 10% and if there is hypoproteinemia
- mortality in 42% in patients with a serum albumin <2.5 g/dL
- use of TPN is associated with spontaneous closure

Broad spectrum antibiotics

Somatostatin: inhibits gastric, pancreatic, biliary, and

enteric secretions
Octreotide (somatostatins synthetic analogue)

Short Bowel Syndrome

Limited ileal resection increases bile salt load to
colon resulting in mucosal injury and diarrhea

>100 cm. ileal resection results in loss ot total bile

salt pool leading to steatorrhea

Definitive Care:
- usually occurs if the fistula fails to respond to medical
treatment after 4 to 6 weeks.
Operative interventions:
- oversewing of the fistula
- resection of the diseased segment with primary
anastomosis

- exteriorization
- serosal patch with either jejunum or a defunctionalized
Roux.

Thank You