Small & Large intestine 1 - د.مازن عبدالله

Question 1

whats the anatomy of the Small intestine ?

Answer 1

• its the largest( it represent 75% of all bowel) part extend from the GD junction to the ileocecal junction
• diameter at the GD is 4cm while it become narrow at the ileocecal junction about 2.5cm
• surface area around 95%

Question 2

how long the large intestine is ?

Answer 2

its 1.5 m

Question 3

what definition of the consiptation in WHO ?

Answer 3

• when the bowel movement is only 3 or less in a week
• when there is strain in quarter or whole bowel movement
• feel incomplete defecation

Question 4

what the type of the consiptation ?

Answer 4

1- megcolon

2- non mega colon

Question 5

what the type of the megacolon conspitation ?

Answer 5

1-Hirschspurge disease
(disease is a condition that affects the large intestine (colon) and causes problems with passing stool. The condition is present at birth (congenital) as a result of missing nerve cells in the muscles of the baby’s colon)

2- non-Hirschburge megrectum and megacolon

Question 6

what the typs of the non megacolon constipation ?

Answer 6

1- slow transit
(reduced motility of the large intestine, caused by abnormalities of the enteric nerves.)

2-normal transit
(colonic motility (the way muscles contract and relax to move contents through the colon) is unaltered; stool moves through the colon at a normal rate.difficulties in stool passage, for example due to harder stools.)

Question 7

whats the Idiopathic megarectum and megacolon ?

Answer 7

(means there is constipation of unknown etiology because the feces accumulation )

• pt will come with history of sever constipation , abdominal pain , abdominal distention and manual evacuation because of the fecal loading
• when we do abdominal exam feel hard fecal mass arise out of the pelvis
• when we do rectal examination we will saw large fecloma in the lumen and the anus is patulous (loose, open)
• we can do sigmidoscopy

Question 8

how to diagnosis pt with megarectum and megacolon ?

Answer 8

• pt will come with history of sever constipation , abdominal pain , abdominal distention and manual evacuation because of the fecal loading
• when we do abdominal exam feel hard fecal mass arise out of the pelvis
• when we do rectal examination we will saw large fecloma in the lumen and the anus is patulous (loose, open)
• we can do sigmidoscopy
• do imaging by “Double contrast barium enema “
  that show the megarectum

-we do “ Anorectal physiology test “
(assess the function of the muscles in your anal canal to see if they are working normally, and also checks the sensitivity of the rectum to small volumes of air and its response to distension)

so the pt will have delayed first sensation
and raised maximum tolerated volume

• full thickness rectal biobsy

Question 9

what the definite diagnosis of the pt with megarectum and megacolon ?

Answer 9

-“Double contrast barium enema “
that show the megarectum

-“ Anorectal physiology test “
pt will have delayed first sensation
and raised maximum tolerated volume

• full thickness rectal biopsy

Question 10

what the treatment of the Idiopathic megarectum and megacolon ? as Hirschsprung’s disease

Answer 10

1-emptying the rectum by washout and manual evacuation under anesthesia

2- develop regular daily bowel habit by using osmotic laxatives or use the suppositories

3- biofeedback therapy in resistance cases
(using electronic or other instruments, and with a goal of being able to manipulate the body’s systems at will)

1- resection of the dilated rectum and colon

2-colectomy (removal of all or part of the colon) with formation of ileorectal anastomosis

3-restorative proctocolectomy استئصال
(removes the entire colon and rectum while preserving the anal sphincter )

4- vertical reduction rectoplasty is a new treatment

5- stoma formation

اما استئصال الجزء المنتفخ / او نستئصل جزء ونسوي اناستموسز /او نشيل VRR الكولون كله / اوتقنيه جديده هي

Question 11

whats the non-megacolon constipation ?

Answer 11

pt will have difficulty in the defcation , abdominal pain , and distention

Question 12

whatre the causes of the non-megacolon constipation ?

Answer 12

1- Medication :
Fe, Ca supplement , opiate ,anticholainaergic ,sympathomimtic ,anti depressent , ca blockers , anti parkinson , antipschotic , anti depressent , antihypertensive , antiarrythemic , beta antagosit , anti histamin, antacid (AL) , anti diarrial

2- Organic stenosis
by colonic cancer or any mass
or inflammmtory ,ischemic , surgical stenosis

3-Endocrine disease
hypothyrodism , hyperparathyrodism, hypopituritism , hypercalcemia , DM, renal faliure , pregnency

4- Neurological as 
Spinal cord injury
spina bifida
cerebrovascular disease
Parkinson’s disease
multiple sclerosis
Autonomic neuropathy

5-Enteric neuropathies: chronic intestinal pseudo-obstruction

6-Myogenic disorders: Myotonic dystrophy, dermatomyositis, scleroderma, amyloidosis, chronic intestinal
pseudo-obstruction

Anorectal disorders: Anal fissures anal strictures

Question 13

GIVE EXAMPLE ABOUT THE MEDICATION THAT CAUSE THE CONSTIPATION ?

Answer 13

Opiates (morphine), anticholinergic agents, Tricyclic antidepressants (amitriptyline), antispasmodics (dicyclomine, mebeverine, peppermint oil), Calcium channel blockers (verapamil, nifedipine), Antiparkinsonian drugs, anticonvulsants (carbamazepine), Sympathomimetics (ephedrine), antipsychotics (chloropromazine, clozapine, haloperidol, risperidone), diuretics (furosemide), antihypertensives (clonidine), antiarrhythmics (amiodarone), beta-adrenoceptor antagonists (atenolol), antihistamines, calcium or aluminium containing antacids, Calcium supplements, iron supplements, antidiarrheal (loperamide), 5-HT3-receptor

Question 14

GIVE EXAMPLE ABOUT THE NEUROLOGICAL DISORDER THAT CAUSE THE CONSTIPATION ?

Answer 14

Neurological disorders:
Spinal cord injury, Parkinson’s disease, cerebrovascular disease, paraplegia, multiple sclerosis,
Autonomic neuropathy, spina bifida

Question 15

GIVE EXAMPLE ABOUT THE ORGAIC STENOSIS THAT CAUSE THE CONSTIPATION ?

Answer 15

GIVE EXAMPLE ABOUT THE NEUROLOGICAL DISORDER THAT CAUSE THE CONSTIPATION ?

Question 16

GIVE EXAMPLE ABOUT THE ENTERIC DISORDER THAT CAUSE THE CONSTIPATION ?

Answer 16

chronic intestinal pseudo-obstruction

Question 17

GIVE EXAMPLE ABOUT THE MYOGENIIC DISORDER THAT CAUSE THE CONSTIPATION ?

Answer 17

chronic intestinal pseudo-obstruction

Question 18

GIVE EXAMPLE ABOUT THE ANORECATAL DISORDER THAT CAUSE THE CONSTIPATION ?

Answer 18

Anal fissures anal strictures

Question 19

how to investigate the non-megacolon constipation ?

Answer 19

• history …
• measure the whole gut transit time
  (10–73 hours) (swallow red die)
• defecating protography
  (an examination of the lower bowel and rectum using x-rays. It shows how your rectum functions during the emptying of your bowels.)

-abdominal transit study

Question 20

if 5 marker or few still in the bowel what that means ?

on the abdominal transit study

Answer 20

normal colonic transit

Question 21

if the ring scattered means ?

Answer 21

hypomobility or colonic inertia (also known as slow-transit constipation)

Question 22

if most of the ring gathered ?

Answer 22

pt have obstruction

Question 23

what the treatment of the non megacolon consitipation ?

Answer 23

1- dietary fibers
2- laxatives
3- biofeedback

Question 24

how to dignosis of the iodopathic slow transit constipation ?

Answer 24

• history pt have constipation during the childhood
• by the abdominal transit study when the pt swallow 20 radio-opaque markers on 3 days
• on the 6th day we do X ray
• normally 80% of the markers pass
• after 120h (5day)or six day if retention of more than 80% is abnormal الاحتفاظ

Question 25

what the benefit of the abdominal transit study ?

Answer 25

distinguish the slow whole transit gut from the rectal outlet delay

Question 26

what the treatment of the iodopathic slow transit constipation ?

Answer 26

- Dietary - Biofeedback - Surgery +Total colectomy and ileorectal anastomosis is the preferred procedure, +segmental resection +stoma creation

Question 27

what the Angiodysplasia ?

Answer 27

- its vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. Lesions are often multiple, and frequently involve the cecum or ascending colon, although they can occur at other places - malformation is consist of dilated tortuous submucosal vein but in sever cases it happen in the mucosa

Question 28

in which age group happen the Angiodysplasia ?

Answer 28

in middle and elderly no gender predominant 5-25% in age over 60 may assocaited with aortic stenosis

Question 29

what the clincal feature of the Angiodyslasia ?

Answer 29

1- anemia with minor syptomas | 2-(10-15%) risk of bleeding as malena and hematochezia fresh blood through the anus

Question 30

what the differential diagnosis of the Angiodysplasia ?

Answer 30

- Diverticulosis, - Ulcerative colitis (UC) - Ischaemic colitis - Radiation colitis - Benign polyps - Malignant tumors DIUR BM

Question 31

how to investigate the Angiodysplasia ?

Answer 31

1- barium enema but not helpful so use the raioactive technetium -99m labelled red cells to locolize source of heamorrage rate>0.1 ml/min 2- colonscopy 3- pill or capsule endoscopy 3- sup or inf mesentric angiogarphy bleeding 0.5-1 ml/min

Question 32

what the treatment of the Angiodysplasia ?

Answer 32

1- stabilize unstable circulation 2-locolize the bleeding by the radioactive technium 99m or colonscopy if uncontrol bleeding surgery is needed by total colectomy with ileocecal anastomsis

Question 33

what the blind loop syndrome ?

Answer 33

is a state that occurs when the normal bacterial flora of the small intestine proliferates to numbers that cause significant derangement to the normal physiological processes of digestion and absorption with stasis of intestinal content

Question 34

what the clinical feature of the blind loop syndrome ?

Answer 34

- steatorrhea, - diarrhea, - anemia, - weight loss, - abdominal pain, - multiple vitamin deficiencies, - joint pain - and occasionally neurological disorders.

Question 35

what the cause of blind loop syndrome ?

Answer 35

any thing cause stasis of the abdominal content as | stricture , stenosis , fistula, blind bouch

Question 36

what the treatment blind loop syndrome ?

Answer 36

surgical extirpation of the cause of the stasis.

Question 37

what the diverticulum ?

Answer 37

bulging sac in any portion of the gastrointestinal tract

Question 38

what the cause of diverticulosis

Answer 38

1- congintal true which include all the layers beside the muscular layer 2-aquired most common false lac of the muscular coat

Question 39

what the clincial picture of the Jejuna diverticula ?

Answer 39

- may be asympomatic - or cause abdominal pain - or cause malabsorption syndrome - can cause inflammation and perforation

Question 40

what the treatment Jejuna diverticula ?

Answer 40

Resection with end-to-end anastomosis

Question 41

what the Meckel’s diverticulum ?

Answer 41

most common congenital anomaly of the GI tract | its a patent intestinal end of the vitellointestinal duct.

Question 42

how Meckel’s diverticulum common ?

Answer 42

affecting approximately 2% of the population 2:1 female predominance. one half of the those who are symptomatic are under 2 years of age

Question 43

what the location of the Meckel’s diverticulum ?

Answer 43

it is commonly 2 feet (60cm) from the ileocaecal valve, | It is 2 inches (3–5 cm) long.

Question 44

what the clincal feature of the Meckel’s diverticulum ?

Answer 44

- Intestinal obstruction by Intussusception or band - Meckel’s diverticulitis ``` -Perforation by : 1-Progression of diverticulitis, 2-Ulceration 3-Secondary to ingested foreign body like fish bone, chicken bone 4-Traumatic ``` -Severe haemorrhage by peptic ulcer and its maroon bleeding

Question 45

how to investigate the Meckel’s diverticulum ?

Answer 45

- small bowel enema very acutate - radioactive techium 99m scintigraphy - Angiography

Question 46

what the treatment of the Meckel’s diverticulum ?

Answer 46

Meckel’s diverticulectomy

Question 47

what the prevelance of diveticulosis ?

Answer 47

is an acquired disorder. disease in the western world is 60% over the age of 60 years. is rare in Africans and Asians, who eat a diet that is rich in natural fibre.

Question 48

most common site for the diverticular disease ?

Answer 48

is an acquired disorder. found in the sigmoid colon in 90% of cases, but the caecum on occasion, the entire large bowel can be affected.

Question 49

Diverticulosis refers

Answer 49

is an acquired disorder. refers to the presence of diverticula without inflammation

Question 50

Diverticulitis refers

Answer 50

refers to inflammation and infection associated with diverticula.

Question 51

The majority of colonic diverticula are false or true

Answer 51

are false diverticula in which the mucosa and muscularis mucosa have herniated through the colonic wall . -They are thought to be pulsion diverticula resulting from high intraluminal pressure

Question 52

how to investigate the diverticulosis ?

Answer 52

- history is asyptomatic -barium enemia . (There is thickening of the circular muscle fibres of the intestine, which develops concertina or saw-tooth appearance on barium enema .)

Question 53

saw-tooth appearance | on barium enema means

Answer 53

diverticulosis because there is thickening of the circular | muscle fibers of the intestine

Question 54

whats the diverticulitis ?

Answer 54

inflammation of one or more diverticula

Question 55

whats the incidance of diverticulitis ?

Answer 55

incidence 10 to 25% of people with diverticulosis

Question 56

whats the complication of diverticulitis ?

Answer 56

1- Intestinal obstruction because of fiberosis or adherent loop in small intestine 2- Recurrent inflammation 3- Perforation lead to peritonitis and abcess formation 4-Haemorrhage in 17% of cases 5- Fistula formation (vesicocolic, vaginocolic, enterocolic, colocutaneous) occurs in 5% of cases, with vesicocolic being the most common.

Question 57

what the chance of hemarrage and fistula in diverticulitis ?

Answer 57

hemorage is more 17% while fistula 5% most common with the bladder

Question 58

what the clincal feature of the diverticulitis ?

Answer 58

syptoams ------------------- -may be uncomplicated diverticulitis as such as distension, flatulence and a sensation of heaviness - or may be complicated as left iliac fossa pain with or without peritonitis. Fever, malaise and leucocytosis pass loose stools or may be constipated; pneumaturia (flatus feces in the urine as urinary symptoms may herald the formation of a vesicocolic fistula signs ------------- abdominal examination show that -lower abdominal tenderness on the left -sigmoid is paplpe (common site )and tender on rectal exam revel a tender mass

Question 59

how to dignosis the divriticulitis ?

Answer 59

- depond on the syptomas and signs -radiograpgy -ct to see the bowel thickening , abcess and extraluminal disease -barium enemas and sigmoidoscopy in stable acute pt -water soluble enemas for large bowel obstruction - colonoscopy - cystoscopy

Question 60

what the mangemant for non complicated diverticulitis ?

Answer 60

-diet containing roughage النخاله as bread, flour, fruit and vegetables - Bulk formers such as bran, Celevac, Isogel and Fybogel - Antispasmodics for painful diverticular disease pt will recover without surgery, 50 to 70% will have no further episodes. Risk of complications increases with recurrent disease.

Question 61

what the mangemant for complicated diverticulitis ?

Answer 61

Acute diverticulitis -treated by bed rest and intravenous antibiotics (usually cefuroxime and metronidazole). -surgery is to control sepsis in the peritoneum and circulation

Question 62

Indications for operation in case of diverticulitis ?

Answer 62

- peritonitis and failure to resolve on conservative treatment - young patients with more than two attacks of inflammation

Question 63

what the type of surgery in the diverticulitis ?

Answer 63

1- The ideal operation one-stage resection. This involves removal of the affected segment and restoration of continuity by end-to-end anastomosis. 2- If there is obstruction, inflammatory oedema and adhesions or the bowel is loaded with faeces, Hartmann’s operation is the procedure of choice 3-perforation, peritonitis soon becomes general and may be purulent, with a mortality rate of about 15%. Gross faecal peritonitis carries a mortality rate of > 50% a primary resection and Hartmann’s procedure b primary resection and anastomosis after on-table lavage in selected cases; c exteriorisation of the affected bowel 4-Fistulae can be cured only by resection of the diseased bowel and closure of the fistula. 5- Haemorrhage from diverticulitis must be distinguished from angiodysplasia. On-table lavage and colonoscopy may be necessary to localise the bleeding site. If the source cannot be located, then subtotal colectomy and ileostomy is the safest

Question 64

what the type of ideal surgery for the divericultis ?

Answer 64

a one-stage resection. This involves removal of the affected segment and restoration of continuity by end-to-end anastomosis.

Question 65

what if there is obstruction, inflammatory oedema and | adhesions or the bowel is loaded with faeces ?

Answer 65

Hartmann’s operation is the procedure of choice

Question 66

In acute perforation, peritonitis ?

Answer 66

may be purulent, with a mortality rate of about 15%. Gross faecal peritonitis carries a mortality rate of > 50% ``` a primary resection and Hartmann’s procedure b primary resection and anastomosis after on-table lavage in selected cases; c exteriorisation (The act of removing something from a body. )of the affected bowel ```

Question 67

if fistula ?

Answer 67

cured only by resection of the diseased bowel and closure of the fistula

Question 68

if Haemorrhage?

Answer 68

must be distinguished from angiodysplasia . On-table lavage( washout the fecal load in the obstructed colon) and colonoscopy may be necessary to localise the bleeding site. If the source cannot be located, then subtotal colectomy and ileostomy is the safest