[SURGERY] SMALL INTESTINES – DR.

LICUP

SMALL INTESTINES
Dr. Licup

SMALL INTESTINES
 Site of nutrient digestion and absorption
 Largest reservoir of immunologically active and hormone-
producing cells
 Largest organ of immune and endocrine system
 4 Parts of the Duodenum:
 It produces 75% of our body’s immune system.
 1st Part: Superior
 Diseases are relatively infrequent  2nd Part: Descending
- Importance: Major duodenal papilla
 Except for Small Bowel Obstruction (SBO)  3rd Part: Inferior/Horizontal
 4th Part: Ascending
 Ligament of Treitz = separates the duodenum from
GROSS ANATOMY the jejunum
 Tubular structure extending from pylorus to cecum  Above the ligament = Duodenum
 Measures about 4-6m  Below the ligament = Jejunum
 3 Segments:
 Duodenum
 Jejunum JEJUNUM AND ILEUM
 Ileum  Within the peritoneal cavity
 Since they are within the peritoneal cavity, they
need an attachment  Attached to the mesentery
 Broad-based mesentery (blood supply)
 Proximal 40%  Jejunum
 Distal 60%  Ileum

PLICAE CIRCULARS OR VALVULAE CONNIVENTES

 Duodenum: First part of the small intestines

 Jejunum: Upper 2/5
 Ileum: Lower 3/5
If your patient got stabbed in the left upper
quadrant, the most likely injured part of the small
bowel is the jejunum.
If your patient got stabbed in the right lower
quadrant, the most likely injured part of the small
bowel is the ileum.
 Mucosal folds, visible upon gross inspection
 Visible radiographically
 Distinction between small intestine and colon
 Colon = Haustrations
 Small Intestines = Plicae Circularis
 More prominent in the proximal intestine
PROXIMAL INTESTINES

 There is no distinguishing landmark that separate the

DUODENUM jejunum from ileum, but we could still differentiate
 Most proximal segment jejunum from ileum by the following features:
 Retroperitoneum
 Demarcated from the  Larger circumference
 Stomach by the pylorus  Thicker walls
 Jejunum by the ligament of Treitz  Less fatty mesentery
 Blood Supply: Celiac and Superior Mesenteric Arteries  Longer vasa recta

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 [SURGERY] SMALL INTESTINES – DR. LICUP

SUMMARY  Surgeons sometimes do resection of the small

JEJUNUM ILEUM intestines and anastomose it. When they
Larger circumference Small circumference anastomose it, they use the strongest layer. By
Thicker walls Thinner wall anastomosing the strongest layer, you are going
Less fatty mesentery More fatty mesentery to lessen the possibility of anastomotic leak.
Longer vasa recta Shorter vasa recta
 Muscularis externa
 Serosa
PEYER’S PATCHES
 Aggregates of lymphoid follicles PHYSIOLOGY
 Located mainly in the ileum DIGESTION AND ABSORPTION
 Intestinal epithelium  Absorption and secretion occur
 Lymphoid follicles in the mesentery  Mesenteric
Nodes  Villi  Main absorptive structures
 Jejunum  Where 95% of water is absorbed, as well
as nutrients
SUPERIOR MESENTERIC ARTERY  Ileum  Absorption and digestion into bile acid
 Distal duodenum, jejunum, ileum
 Solutes traverse by active or passive mechanisms:
SUPERIOR MESENTERIC VEIN (Drainage)  Passive Transport of Solutes
- Diffusion or convection
 Small intestines drains to the Superior Mesenteric - Driven by existing electrochemical gradients
Vein  Portal Vein  Liver - Occurs through either transcellular or paracellular
pathways (between cells through the tight junctions)
 Active Transport
LYMPH NODES - Energy-dependent net transfer of solutes in absence or
 Mesenteric Lymph Nodes  Cistern Chyli  Thoracic Duct against an electrochemical gradient
 Left Subclavian Vein - Occurs through transcellular pathways (through the
cell)
INNERVATION
 Parasympathetic and Sympathetic Supplies form Vagus and WATER AND ELECTROLYTES
Splanchnic Nerve  8-9L of fluid/day

WALL HAS FOUR DISTINCT LAYERS  Approximately 2L comes from your oral intake
 The rest of it comes from salivary, gastric, biliary,
pancreatic and intestinal secretions

 Normally  80% absorbed

 1.5L enters the colon

 If less than 1.5L enters the colon  Constipation

CARBOHYDRATE DIGESTION AND ABSORPTION

 Mucosa
 Epithelium: enterocytes (absorptive), goblet cells, paneth
cells, enterochromaffin cells
 Lamina Propia: containing Payer’s patches
 Water and nutrient absorption across the mucosa
 Submucosa
 Strongest layer/connective tissues
 Meissner’s plexus
 45% of energy consumption in average Western diet
 Pancreatic amylase is the major enzyme of starch digestion,
although salivary amylase initiates the process.
 Duodenum/Upper Jejunum  Absorption of
monosaccharides
 10% dietary starch passes unabsorbed into the colon
 Fiber – indigestible  Increases osmotic load to distal small
bowel and Colon  Increases stool mass
 For a constipated person, aside from increasing their
water intake, to increase their stool mass, you should
also advise them to take high fiber diet.

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PROTEIN DIGESTION AND ABSORPTION
 10-15% of energy consumption
 For surgical patients, they need protein to hasten and
increase their wound healing process.
 In the hospital, if they require the patient to have a
high protein diet, they usually give egg whites.
 Protein is denatured and partially digested  STOMACH
(Pepsin)
 Pancreatic enzymes digest proteins to form free amino acids
and oligopeptides
 Digestion continues in the duodenum  Pancreatic
peptidase
 80% of protein absorption occur in the proximal
100cm of the jejunum
FAT DIGESTION AND ABSORPTION
 40%  Fat
 Over 95% of dietary fat is in the form of long chain
triglycerides
 Remainder includes phospholipids such as lecithin, fatty
acids, cholesterol, and fat-soluble vitamins
 94% of the ingested fats are absorbed in the duodenum and
proximal jejunum
 Duodenum and proximal jejunum  Presence of bile
 Bile comes of the 2nd portion of the duodenum 
Used for fat emulsification
VITAMIN AND MINERAL ABSORPTION
 Dietary Vitamin B12 (cobalamin) complexes with intrinsic
factor (mucoprotein secreted by gastric parietal cells)
 Complex dissociates at the surface of cells in the distal ileum
where B12 enters the cells
 In the stomach: Vitamin B12 + Intrinsic Factor  Go
to the ileum  Dissociate  Absorbed into the
circulation
 If you have a patient who underwent gastric
resection/gastric bypass  There would be a problem
with the absorption of Vitamin B12  Give them
vitamin B12 replacement
 Preoperatively if there is no identified vitamin and
mineral deficiencies in you patient  You do not have
to supplement them
 Fat soluble vitamins (ADEK)  Impaired absorption in
absence of BILE
BARRIER AND IMMUNE FACTORS
 The epithelium of the small intestine identifies pathogen
from harmless antigen
 Prevents invasion from these pathogens
[SURGERY] SMALL INTESTINES – DR. LICUP
 Included in this epithelial defense are your:
 IgA
 Mucins
 Impermeability of the brush borders
 Anti-microbial peptides (defensins)
 Gut-associated lymphoid tissues (GALT)
 Gut-associated lymphoid tissue (GALT)
 Contains over 70% of the body’s immune cells
 Inductive sites  Peyer’s patches mesenteric lymph
nodes, smaller isolated lymphoid follicles
 How do you stimulate the GALT?
 By stimulating the small intestines through feeding
 That is why for surgical patients, they are
advised to eat at the soonest possible time to be
able to stimulate the body’s immune system
 IgA
 Prevent the entry of microbes through the epithelium
 Promote excretion of antigens or microbes that have
already penetrated into the lamina propria
MOTILITY
 Contractions of the muscularis propria are responsible for
small intestinal peristalsis
 Contraction of the outer longitudinal muscle layer results in
bowel shortening
 Outer Longitudinal  Shortens
 Inner Circular  Narrows
 Several distinctive patterns of muscularis propria activity 
Include ascending excitation and descending inhibition
 Muscular contraction occurs proximal to a stimulus
 Muscular relaxation occurs distal to the stimulus
 Proximally, there is shortening and narrowing;
Distally, there is lengthening and widening  That is
why peristalsis in ONE WAY
ENDOCRINE FUNCTION
 SI largest hormone-producing organ in the body
 Over 30 peptide hormone genes
 Histamine and dopamine, eicosanoids with hormone-like
activities are produced in the small intestines
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 [SURGERY] SMALL INTESTINES – DR. LICUP

 Table 28-2 Representative Regulatory Peptides Produced in  Obstructing lesion categorized as:
the Small Intestine 1. Intraluminal (e.g., foreign bodies, gallstones or
meconium)

 Intraluminal = obstruction within the lumen of the

small intestine

2. Intramural (e.g., tumors, Crohn’s disease-associated

inflammatory structures)

 Intramural = obstruction within the walls of the

small intestine
 Octreotide
3. Extrinsic (e.g., adhesions, hernias, or carcinomatosis)
 Long acting analogue of somatostatin neuroendocrine
tumors (e.g., carcinoid syndrome)  Extrinsic = obstruction that results from outside the
 Postgastrectomy dumping syndrome, enterocutaneous small intestine
fistulas
 Acute hemorrhage due to esophageal varices  Intra-abdominal Adhesions
 Cholecystokinin (CCK) – cells of proximal intestines  Post-operative adhesions
 Secretin – S cells of proximal intestines  Up to 75% of the cases of small obstruction
 Motilin – M cells of proximal intestines
 Somatostatin – D cells throughout the gut  If a patient comes to you with small bowel
obstruction, the first thing that you should know is
INTESTINAL ADAPTATION if she/he has had previous abdominal surgery
 Capacity to adapt  Physiologic and pathologic conditions
 Less prevalent etiologies
 Massive small bowel resection (Postresection intestinal
 Hernias
adaption)
 Malignant bowel obstruction
 Within a few hours after bowel resection  Epithelial
 Crohn’s disease
cellular hyperplasia  Villi lengthen, absorptive surface
 Cancer-related SBO  Extrinsic compression or invasion
area increase, digestive and absorptive functions improve
 Few are due to primary small bowel tumors
 Mechanisms under active investigation
 Table 28-3 Most Commonly Encountered Etiologies of SBO
 Jejunal resection generally is better tolerated
 Ileum shows better capacity to compensate

 There is a higher chance that you will have Short

Bowel Syndrome if you cut on the ileum because
jejunum does not compensate as well as the ileum.

 Short bowel syndrome

 When you cut the intestine  Villi will lengthen

 If the villi did not compensate  You will have
malabsorption  Short Bowel Syndrome

SMALL BOWEL OBSTRUCTION

 Most disease of the small bowel are not common  If

you were able to see one, most likely it is a Small Bowel
Obstruction
 75% of SBO cases are secondary to post-operative
adhesions

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 [SURGERY] SMALL INTESTINES – DR. LICUP

 Congenital Abnormalities  Ideally, surgical management must be minimally

 Intestinal malrotation invasive or laparoscopic adhesiolysis  To prevent
 Midgut volvulus recurrence of adhesions
 Congenital bands
 Complete Small Bowel Obstruction
PATHOPHYSIOLOGY  Closed Loop Obstruction
 Obstruction  Gas and fluid accumulate proximal  Surgical emergency!
 Intestinal activity increases  The colicky pain and the  A segment of intestine is obstructed both proximally and
diarrhea distally  Leading to a rapid rise in luminal pressure 
Rapid progression to strangulation  Ischemia, necrosis,
 Initially, what the small intestines will do is become perforation
hyperactive  To remove/bypass the obstruction 
Stop  Hyperactive  Stop, and so on  Colicky pain
and diarrhea
 Accumulation of fluid is secondary to intake. If the
patient does not have any intake, it may be due to
salivary secretion, biliary secretion and gastric
secretions.

 Most of the gas  Swallowed air/within the intestine

 Bowel distends  Intraluminal and intramural pressures rise

 Initially there is hyperactive bowel sounds  Later

there will be hypoactive or no bowel sounds

 Intestinal motility  Reduced with fewer contractions

 Obstruction  Luminal flora of the bowel (sterile) 
Infected
 Translocation of these bacteria to regional lymph nodes
 Inside the distended bowel, the intestinal content
must be sterile  But since it is not drained, it
becomes infected  Then that infection inside the
bowel will go to the mesenteric nodes = Translocation
of bacteria
 From the nodes, it will disseminate to the different
parts of the body  That is why small bowel
obstruction, antibiotics are usually given  To
prevent translocation of bacteria
 Strangulated bowel obstruction  Intramural pressure
increases, microvascular perfusion is impaired  Ischemia
 Necrosis
 (+) Air-fluid leveling
 Stepladder sign  Sign of SBO
CLINICAL PRESENTATION
 Symptoms: Colicky abdominal pain, nausea, vomiting and
obstipation
 Vomiting with proximal obstructions than distal
 Character of vomitus is important
 Fecaloid  Distal Obstruction
 Not bile-stained  Obstruction around the 1st or
2nd portion of intestines
 Bile stained  Obstruction on the 3rd portion
onwards

 Distended bowel  Impingement of blood vessels   Continued passage of flatus and/or stool beyond 6-12
Compromised blood circulation  Ischemia  hours
Gangrene  Necrosis  Perforation  Signs: Abdominal distention (pronounce if ileum)
 Bowel sounds may be hyperactive initially
TYPES SBO ILEUS
 Partial Small Bowel Obstruction  Hyperactive bowel  Hypoactive from the
 Only a portion is occluded sound initially, then start till the end
 Allowing passage of some gas and fluid later hypoactive
 Usually treated medically  If it already happened 3
 Laboratory Findings
times  Undergo surgery
 Intravascular volume depletion

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 [SURGERY] SMALL INTESTINES – DR. LICUP

 Hemoconcentration, electrolyte abnormality 2. Obstruction occurring in the early postoperative period

 Strangulated 3. Intestinal obstruction due to Crohn’s disease
 Severe abdominal pain 4. Carcinomatosis

 Jejunum  Most likely: Left upper quadrant pain ILEUS

 Ileum  Most likely: Right lower quadrant pain  Impaired intestinal motility
 Signs and symptoms of intestinal obstruction in the absence
 Tachycardia
of a lesion-causing mechanical obstruction
 Localized abdominal tenderness
 Ileus is a temporary motility disorder that is reversed if
 Fever
corrected
 Marked leukocytosis
 Table 28-4: Common Etiologies
 Diagnosis
 History & PE

 History of post-abdominal surgery

 Hernias
 Stool checked for gross of occult blood  Intestinal
strangulation
 CT scanning is 80-90% sensitive and 70-90% specific
 Closed-loop Obstruction  U-shaped or C-shaped dilated
bowel loop
 Abdominal series consist of:
- Radiograph: Upright/supine position
- CXR (Upright)

 To know if there is pneumoperitoneum  Signify

perforation
 Most likely there is a perforation of the
stomach or duodenum or perforation of the
colon

- Triad of dilated small bowel loops (> 3 cm in diameter)

air-fluid levels, paucity of air in the colon
 Sensitivity x-ray from 70-80%

THERAPY
 Most Common: Electrolyte imbalance 
 6 Ns in Treating SBO: Hypokalemia
 NPO (Nothing per orem)
 Intestinal motility return to normal within first 24 hours
 NSS  IV fluid hydration
after laparotomy
 NGT (Nasogastric tube)
 Gastric and colonic motility returning to normal by 48 hours
 aNtacids
and 3-5 days respectively
 aNtibiotic
 iNdwelling Folley Catheter (IFC)  Intra-abdominal abscesses or electrolyte abnormalities

 Post-operative: Consider intra-abdominal abscess 

 Fluid resuscitation  Isotonic fluid
 IFC to monitor urine output
 Central-venous or pulmonary-artery catheter monitoring
 Broad-spectrum antibiotics (bacterial translocation)
 NG tube  Decompression
 Complete Small Bowel Obstruction
 In general, the treatment is surgery
 Advocated non-operative approaches if closed loop
obstruction is ruled out
 Conservative Therapy
1. Partial small bowel obstruction
Drain the abscess
 Percutaneous (UTZ-guided) = Single
 Open-technique = Multiple or near the major blood
vessels
CLINICAL PRESENTATION
 Inability to tolerate liquids and solids by mouth
 Nausea
 Lack of flatus or bowel movements
 Vomiting and abdominal distention

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 Bowel sounds are characteristically diminished or absent
DIAGNOSIS
 Ileus beyond 3-5 days postoperatively or occurs in the
absence of abdominal surgery, diagnostic evaluation is
needed
 Opiates impair intestinal motility
 Serum electrolytes
 Abdominal radiographs/CT scan
THERAPY
 Limiting oral intake
 Correcting the underlying inciting factor
 Vomiting or abdominal distention are prominent  NGT
 IV fluid and electrolytes
 TPN, early ambulation
 Administration of NSAIDS such as ketorolac
 Reduction in opioid dosing
 Table 28-6 summarizes some of the measures used to
minimize postoperative ileus
CROHN’S DISEASE
 Chronic, idiopathic transmural, inflammatory disease
 Propensity to affect to distal ileum
 Any part can be involved
 Eastern European Jewish population are at 2-4 fold higher
risk
 Slightly more prevalent in females than in males
 Third decade
 Higher socioeconomic status
 Breastfeeding to be protective
 More prevalent among smokers
CLINICAL PRESENTATION
 Abdominal pain, diarrhea, weight loss
 Depends on which segment of the GIT is affected
 Patients with Crohn’s disease can be classified by their
predominant clinical manifestation as having primarily
a. Fibrostenotic disease
b. Fistulizing disease, and
c. Aggressive inflammatory disease
 Affects the small bowel in 80% of cases, and colon alone 20%
[SURGERY] SMALL INTESTINES – DR. LICUP
 Therapy  No curative therapies
 Goal of treatment is to palliate symptoms
 Medical therapy is used to induce and maintain disease
remission
 Surgery is reserved for specific indications
 Nutritional support enteral regimens or parenteral
nutrition
 Table 28-8: Indications for Surgical Intervention in
Crohn’s Disease
- Acute onset of severe disease
- Failure of medical therapy
- Obstruction
- Hemorrhage
INTESTINAL FISTULA
 Fistula  Abnormal communication between two
epithelialized surfaces
 Internal Fistula (e.g., enterocolonic fistula or colovesicular
fistula)
 Non-resectable Cecal Tumor  Fluid from the ileum
cannot go to the ascending colon  What you can do
is to create an internal fistula  Connect the ileum to
the ascending colon and make an enterocolonic
fistula, bypassing the cecal tumor
 External Fistula (e.g., enterocutaneous fistula or
rectovaginal fistula)
 You can also make an external fistula 
enterocutaneous fistula (ileostomy) Ileum to the
skin
 Low-output fistulas  Drain less than 200mL of fluid per day
 Low-output fistulas are treated medically
 Lessen passage of fluid  Give TPN, low-residue
diet (colocutaneous fistula), elemental diet
(enterocutaneous fistula)
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 High-output fistulas  Drain more than 500mL of fluid per
day
 High-output fistulas are treated surgically unless you
can convert it to a low-output fistula
 Give Octerotide or Somatostatin  Decrease output
 Iatrogenic, post-operative complications, Crohn’s disease or
cancer
DIAGNOSIS
 CT
 Intra-abdominal abscess should be sought and drained
percutaneously
 Small bowel series
 Fistulogram
THERAPY
 Treatment proceed sequence of steps
1. Stabilization  Fluid and electrolyte, nutrition is provided,
antibiotics, drainage, ostomy appliances or fistula drains
2. Investigation  Diagnosis
3. Decision  Available treatment
 Timing of Surgical Intervention
 2-3 months of conservative therapy
 90% of fistulas that are going to close
 If fistulas fails to resolve during this period  Surgery
SMALL BOWEL NEOPLASM
(NOT DISCUSSED BUT NEEDS TO BE STUDIED)
 Adenomas, most common benign neoplasm
 Other benign tumors include fibromas, lipomas,
hemangiomas, lymphangiomas, and neurofibromas
 Lesions are most frequently encountered in the duodenum
during EGD
 Benign neoplasms account for 30 to 50% of small bowel
tumors and include adenomas, lipomas, hemartomas, and
hemangiomas.
 Primary small bowel cancers are rare
 Adenocarcinomas comprise 35-50% of all cases, carcinoid
tumors comprising 20-40% of cases, and lymphomas 10-15%
of cases
GIT STROMAL TUMORS (GISTS)
 Most common mesenchymal tumors
 Comprise up to 15% of small bowel malignancies
 Formerly classified as leiomyomas, leiomyosarcomas, and
smooth muscle tumors
 Frequent site for metastases
 5th or 6th decade of life
 Reported Risk Factors
 Consumption of red meat
 Ingestion of smoked or cured foods
 Crohn’s disease
 Celiac sprue
[SURGERY] SMALL INTESTINES – DR. LICUP
CLINICAL PRESENTATION
 Most are asymptomatic until they become large
 Partial SBO
 Associated signs and symptoms of crampy abdominal pain
and distention, N/V
 Obstruction  Luminal narrowing or intussusceptions
 Hemorrhage, indolent, is 2nd most common presentation
 PE may be unrevealing
 Jaundice secondary to biliary obstruction or hepatic
metastasis (if duodenal area is affected there will be a
painless jaundice)
 Cachexia, hepatomegaly, and ascites may be present with
advanced disease
 Adenocarcinomas, as well as adenomas are most common
in duodenum
THERAPY
 Benign symptomatic neoplasm  Surgically resected or
removed endoscopically
 EGD  Lesions should be biopsied
 In general:
 <1cm  Endoscopic polypectomy
 Lesions > 2cm  Removed surgically
 Surgical Options:
 Transduodenal polypectomy and segmental duodenal
resection
 Pancreaticoduocenectomy (Whipples)
 The surgical therapy of jejuna and ileal malignancies 
Wide local resection
 Adenocarcinomas  Wide excision of corresponding
mesentery
 Locally advanced or metastatic disease  Palliative
intestinal resection or bypass
RADIATION ENTERITIS
(NOT DISCUSSED BUT NEEDS TO BE STUDIED)
 Radiation-induced injury to the small intestine
 2 distinct syndromes: Acute & Chronic Radiation Enteritis
 Acute Radiation Enteritis  Transient, in approximately
75%
 Chronic Radiation Enteritis  In 5-15%
THERAPY
 Most cases of acute radiation enteritis are self-limited
 Supportive therapy
 Rarely reduction in or cessation of radiation therapy
 Surgery only done if needed  Difficult with high morbidity
 Limited resection of diseased intestine
MECKEL’S DIVERTICULUM
(NOT DISCUSSED BUT NEEDS TO BE STUDIED)
 Most prevalent congenital anomaly of GIT
 2% of the general population
 3:2 M:F prevalence ratio
 True Diverticula  Contains all layers of normal intestine
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 [SURGERY] SMALL INTESTINES – DR. LICUP

 Usually found in ileum within 100cm of ileocecal valve INTUSSUSCEPTION

 60% contain hetertopic mucosa  >60% gastric mucosa
RULE OF TWO
 2% prevalence
 2:1 female preponderence
 Location 2 ft proximal to the ileocecal valve in adults
 ½ of those who are symptomatic are under 2yo
CLINICAL PRESENTATION
 Asymptomatic
 Most common symptoms are bleeding, intestinal
obstruction, and diverticulitis
 Most common disease associated with Meckel’s
diverticulum is appendicitis
THERAPY
 Diverticulotomy with removal of associated bands
 Bleeding, tumor, perforation  Segmental resection
 Incidentally found (asymptomatic)
ACQUIRED DIVERTICULA
(NOT DISCUSSED BUT NEEDS TO BE STUDIED)
 False Diverticula  Lack muscularis layer of the SI
 More common in the duodenum, near the ampulla of vater
 Periampullary, juxtapapillary, or peri-Vaterian diverticula
 Jejunoileal diverticula  Acquired diverticula in the jejunum
or ileum
CLINICAL PRESENTATION
 Asymptomatic
 Intestinal obstruction, diverticulitis, bleeding, abdominal
pain
 Periampullary duodenal diverticula
THERAPY
 Asymptomatic  None
 Bacterial overgrowth  Antibiotics
 Bleeding and diverticulitis  Segmental intestinal resection
 Diverticulotomy  Bleeding and obstruction related to
lateral duodenal diverticula
(NOT DISCUSSED BUT NEEDS TO BE STUDIED)
 One segment of the intestine becomes drawn into the lumen
of the proximal segment of the bowel
 Usually in the pediatric population
 Cecum intussuscepted into the ileum (ileocolic
intussusceptions)
 Treated nonsurgically by radiologic reduction (barium
enema increases pressure which will force the
intussuception to resolve)
 Adult intussusceptions are less common
 Malignant lead point in ½ of cases
 Intermittent abdominal pain and S/S of bowel obstruction
 CT scan  “target sign” may be seen
 Treatment is surgical resection of the involved segment and
the lead point
PNEUMATOSIS INTESTINALIS
(NOT DISCUSSED BUT NEEDS TO BE STUDIED)
 Presence of gas within the bowel wall
 Common in the jejunum
 NOT a disease but merely a sign
 Association with bowel ischemia and infarction
 Necessitate emergent surgical intervention
SHORT BOWEL SYNDROME
(NOT DISCUSSED BUT NEEDS TO BE STUDIED)
 Extent of resection is great enough
 Defined as the presence of <200cm of residual small bowel
 Functional definition, insufficient intestinal absorptive
capacity results in the clinical manifestations of diarrhea,
dehydration, and malnutrition, is more broadly applicable
 In adults, acute mesenteric ischemia, malignancy, and
Crohn’s disease
 In pediatric patient  Intestinal atresias, volvulus, and NEC
 Treatment: TPN, intestinal transplant, or intestinal
transplant
Source: Recordings + Old Book Trans (2011) + Schwartz's
Principles of Surgery, 10th Edition

SMALL BOWEL PERFORATIONS

(NOT DISCUSSED BUT NEEDS TO BE STUDIED)
 Before 1980s, duodenal perforation was due to peptic ulcer
 Iatrogenic injury  GI endoscopy is the most common
 Other etiologies
 infections
 Crohn’s disease
 Ischemia
 Drugs (Potassium and NSAIDs)
 Radiation induced
 Meckel’s and Acquired Diverticulitis
 Neoplasm
 Foreign bodies

LEA THERESE R. PACIS 9