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BENIGN TUMORS

Adenomas (most common benign neoplasm):

True adenomas:
• Associated w/ bleeding and obstruction
• Usually seen in the ileum
• Majority are asymptomatic
Villous adenoma:
• Most common in the duodenum
• "soap bubble" appearance on contrast radiography
• No report of secretory diarrhoea
Brunner's gland adenoma:
• In the duodenum
• No malignant potential
• Mimic PUD

Leiomyoma
• Most common symptomatic benign lesion
• Associated w/ bleeding
• Diagnosed by angiography
• Commonly located in the jejunum
• 2 growth pattern
1. Intramurally --> obstruction
2. Both intramural and extramural (Dumbbell shape)

Lipoma
• Most common in the ileum
• Causes obstruction (lead point of an intussusception)
• Bleeding due to ulcer formation
• No malignant degeneration

Peutz-Jeghers Syndrome
Inherited syndrome of:
• Mucocutaneous melatonic pigmentation (face, buccal mucosa, palm, sole, peri-anal
area)
• Gastrointestinal polyp (enteric jéjunum and ileum are most frequent part of GIT
followed by colon, rectum and stomach)
Symptoms
• colicky and, pain (due to intermittent intussuception)
• Haemorrhage
Treatment
• Segmental resection of the bowel causing obstruction or bleeding
• Cure impossible due to widespread intestinal involvement

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MALIGNANT NEOPLASM

Adenocarcinoma
• Most common CA of small bowel
• Most common duodenum and proximal jejunum
• Half involve the ampulla of Vater

Carcinoid
• From Enterochromaffin cells or Kultchitsky cells
• Arise from foregut, midgut and hindgut
• Appendix (46%)>Ileum (28%)>Rectum (17%)
Aggressive behaviour than the appendiceal carcinoid
• Appendix - 3% metastasise; ileum - 35% metastasise
• Appendix - solitary; Ileum - 30% multiple
20-25% w/ carcinoid tumour with lever metastasis develops carcinoid syndrome
• Secretes serotonin, bradykinin and substance P
1. Diarrhoea
2. Flushing
3. Hypotension
4. Tachycardia
5. Fibrosis of endocardium and valves of the right heart

Lymphomas
Most common intestinal neoplasm in children under 10 y/o
• In adult = 10-15% of small bowel malignant tumours
• Most common presentation
1. Intestinal obstruction
2. Perforation (10%)
Criteria of primary lymphomas of the small bowel:
1. Absence of peripheral lymphadenopathy
2. Normal chest x-ray w/o evidence of mediastinal LN enlargement
3. Normal WBC count and differential
4. At operation, the bowel lesion must predominate and the only nodes are associated w/
the bowel lesion
5. Absence of disease in the liver and spleen

TREATMENT

For Benign Lesions

• All symptomatic benign tumours should be surgically resected or removed
endoscopically (EGD/ colonoscopy)
• Duodenal tumors:
1. 1 cm --> endoscopic polypectomy
2. 2 cm --> surgically resected (Whipples - located near the ampulla of Vater)
3. Duodenal adenomas w/ FAP and undergo Whipples for it is usually
multiple and sessile and has 100% degenerate to CA

For Malignant Lesions

Adenocarcinoma
• Wide local resection w/ its mesentery to achieve regional lymphadenectomy
• Chemotherapy has no proven efficacy in the adjuvant or palliative treatment of small
intestinal adenenoCA
Small intestinal lymphoma
• For localised: segmental resection w/ adjacent mesentery
• If w/ diffused involvement: --> chemotherapy rather than surgery, is primary therapy
Carcinoid
• Segmental intestinal resection and regional lympadenectomy
1. <1cm rarely jas LN metastases
2. >3cm 75 to 90% LN metastases
• 30% are multiple, hence entire small bowel should be examined prior to surgery
• If w/ metastatic lesions --> debulking, associated w/ long-term survival & amelioration
of symptoms of carcinoid syndrome
• Chemotherapy --> 30-50% response
1. Doxorubicin
2. 5-fluorouracil
3. Streptozocin
• Octreotide: most effective for management of symptoms of carcinoid syndrome
Metastatic Cancers
• Melanoma associated w/ propensity of metastasis to the small bowel
• Palliative resection/bypass procedure
• Systematic therapy depends on the response of the primary site

SMALL BOWEL NEOPLASMS

Gastrointestinal stromal tumors (25-35%)

• Most common symptomatic small bowel tumours
• Vague symptoms/nonspecifc
• Interstitial cells of Cajal: KIT
• Intramural tumour growth
⁃ Obstruction
⁃ GI Bleeding
• Mitotic rates > per 50 high-power fields increase the risk for recurrence
• (+) CD117 gain-of-function mutation of proto-oncogene KIT, a receptor tyrosine kinase
• Imatinib (Gleevec) is a tyrosine kinase inhibitor
⁃ Has potent activity against the tyrosine kinase KIT
⁃ Used with metastatic disease

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Malignant Lesions
• Whipple in duodenal lesions
• Wide resection including corresponding Mesentery to achieve regional
lymphadenectomy
• Advance diseases - palliative resection or bypass
• Chemotherapy not proven to be effective
Carcinoid
• Resect all visible disease
• Metastatic >3cm
• Chemotherapy - 5FU, doxorubicin, streptozocin
GIST
• Resect
• Target therapy - imatinib (Gleevec)

Acute Radiation Enteritis

• Transient
• 75% of patients undergoing radiation therapy for abdominal and pelvic cancers
• Radiation - induced cell death: apoptosis resulting from the free radical-induced
breaks in double-strantded DNA (4500 cGy)
• Acute injury:
⁃ Villus blunting, a dense infiltrate of leukocytes and plasma cells within the
crypts
⁃ With sever cases, mucosal sloughing, ulceration and haemorrhage

CHRONIC Radiation Enteritis

• A progressive occlusive vasculitis
• Leads to chronic schema and fibrosis that affects all layers of the intestinal wall
• Lead to strictures, abscesses and fistulas

MESENTERIC ISCHEMIA

Acute Mesenteric Ischemia

• Pathophysiology
• Arterial embolus (most common-50%; heart; usually lodged distal to origin of the
middle colic)
• Arterial thrombosis: occlusion occurs at proximal near its origin
• Vasospasm (non-occlusive mesenteric schema - NOMI): usually in critically-ill
patients receiving vasopressors
• Venous thrombosis: (5-15%) and 95% SMV
⁃ Primary - no etiologic factor identified
⁃ Secondary - inheritable or acquired coagulation disorder
•
• Chronic Mesenteric Ischemia
• Develops insidiously allows for collateral circulation to develop
• Rarely leads to infraction
• Usually die to arteriosclerosis
• Usually two mesenteric arteries are involved

Manifestation
Acute Mesenteric Ischemia
• Severe abdominal pain out of proportion to the degree of abd.
tenderness (hallmark)
⁃ Colicky at the mid-abdomen
• Nausea/vomiting, diarrhoea
• abd. distention, peritonitis, passage bloody stool
Chronic Mesenteric Ischemia
• Postprandial abd. pain "food-fear", (most common)

Detection
• No lab test positive for the detection of acute mesenteric schema prior to the onset of
intestinal infarction
• The presense of its hallmark = indication for immediate celiotomy
• Angiography - most reliable
⁃ 74-100% sensitivity and 100% specificity
⁃ The gold stander for the diagnosis of arterial mesenteric schema.
• CT Scanning is used to:
⁃ Disorder other abd. condition causing abd. pain
⁃ Evidence of occlusion or stenosis of mesenteric vasculature
⁃ Evidence of schema in the intestine and mesentery
⁃ Test of choice for acute mesenteric venous thrombosis

Treatment
With signs of peritonitis --> Celiotomy check for viability of the bowel
• Necrotic --> segmental resection
• Questionable viability --> second look laparotimies
Surgical revascularisation (embolectomy/thrombectomy/mesenteric
bypass)
• Not done if:
1. Segment is necrotic
2. Is too unstable patient
• Done pt diagnosed w/ emboli or thrombus-induced acute mesenteric schema w/o
sings of peritonitis
• May give thrombolysis (streptokinase, urokinase, recombinant tissue
plasminogen activator)
• Useful in partially occluded vessels and has given within 12 hours after onset of
symptoms

SHORT BOWEL SYNDROME

• Presence of less than 200cm of residual small bowel in adult patients

• Functional definition: insufficient intestinal absorptive capacity results in the clinical
manifestations of:
1. Diarrhoea
2. Dehydration
3. Malnutrition
• Etiologies (adult):
1. Acute mesenteric ischemia
2. Malignancy
3. Crohn's disease
• Etiologies (paediatric):
1. Intestinal atresias
2. Volvulus
3. Necrotising enterocolitis

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Pathophysiology
• Clinically significant malabsorption occurs when greater than 50% to 80% of the small
intestine has been resected
• Lifelong TPN dependence:
⁃ <100cm of residual small intestine
⁃ (+) intact and functional colon
⁃ <60 cm of residual small intestine
• Intestinal adaption is 1-2 years post operation

Medical Therapy
• Mix of primary condition causing intestinal resection
• Correct fluid and electrolyte imbalance due to severe diarrhoea
• TPN, enteral nutrition is gradually introduced, once ileus is resolved
• H2 receptor antagonist --> to reduce gastric acid secretion
• Antimotility agents (loperamide HCL or diphenoxylate)
• Octreotide - to reduce volume of gastrointestinal secretion
• TPN complication
1. Catheter sepsis
2. Venous thrombosis
3. Liver and kidney failure
4. Osteoporosis

Surgical Therapy
Non-transplant
• Goal is to increase nutrient and fluid absorption by either slowing intestinal transit or
increasing intestinal length
• Slow intestinal transit:
1. Segmental reversal of the small bowel
2. Interposition of a segment of colon
3. Construction of small intestinal valves
4. Electrical pacing of the small bowel
⁃ Limited case report
⁃ Frequently associated w/ intestinal obstruction

TYPHOID ILEITIS
PICTURE PAGE 42

• Caused by Salmonella typhi

Diagnosis
• High grade fever - prolonged
• Constitutional symptoms
• Leucopenia
⁃ Peritonitis with leucopenia: crippled immune system
• Bleeding
• Perforation: pneumoperitoneum (Xray)
• Culture from blood or faeces
• Agglutinins against O and H antigen

Treatment
Medical
• Chloramphenicol
• Trimethropin-sulfamethoxazole
• Amoxycillin
• Quinolones
Surgical
• Perforations/hemorrhage
• Segmental resection (w/ primary anastomosis or ileostomy)

Small Bowel Perforation

• Latrogenic injury incurred during GI endoscopy is the most common
⁃ ERCP induced duodenal (0.3% to 2.1%)
• CT: duodenal perforations
• (+) pneumoperitoneum for free perforations, but more commonly retroperitoneal air,
contrast extravasation and paraduodenal fluid collection

GITB
▪ Swallowed bacilli from active PTB
▪ Granuloma in the ileocecal junction: structure (obstruction)
▪ Lesions
⁃ Hypertrophic: common
⁃ Ulcerative
⁃ Mixed

INTESTINAL TUBERCULOSIS

1. Ulcerative Type
2. Hyperplastic Type

PHOTO PAGE 47

Therapy
• Course of anti-TB drugs
• Surgery for complications
⁃ Stricture formation
⁃ Haemorrhage
⁃ Perforation