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Small Bowel, SBO, IBD
Outline Small bowel physiology
Absorption Barrier
SBO physiology Hyperperistalsis Decreased absorption Increased secretion Clinical aspects
Small Bowel, SBO, IBD
Outline (cont’d) Crohn’s disease
Epidemiology Pathology Indications for operation
Ulcerative colitis Epidemiology Pathology Indications for operation
Small Bowel, SBO, IBD
Small Bowel Physiology Absorbs water, electrolytes, nutrients
Varies between jejunum and ileum Compromised in certain disease states
Requires glutamine as energy source Barrier function
Requires enteral nutrition for maintenance Compromised by lack of feeding ?Leads to nosocomial infection
Small Bowel, SBO, IBD
SBO Physiology Global hyperperistalsis Decreased absorption of H2O & lytes Increased secretion of protein rich fluid Hypoperistalsis in late stages
Small Bowel, SBO, IBD
SBO Physiology Pain and tenderness doesn’t differentiate type Simple SBO
Usually partial Differentiation by plain X-ray or CT May resolve
Strangulated SBO Usually complete Often “closed loop” Requires urgent operation
Crohn’s Disease
Epidemiology Disease of young adults
Peak incidence in late teens and 20’s Smaller peak in 50’s & 60’s
Incidence varies amongst ethnic groups Cause unknown
?Autoimmune ?Infectious ?Genetic
Crohn’s Disease
Pathology Full-thickness involvement Thickened bowel wall and mesentery 50% with non-caseating granulomas May involve any portion of GI tract
Crohn’s Disease
Pathology (cont’d) Ileal involvement most common Colon-only involvement seen Peri-rectal disease common Extra-intestinal manifestations Surgery not curative Malignancy uncommon
Crohn’s Disease
Indications for Operation Abscess Certain fistulae Obstruction Intractability
Crohn’s Disease
Surgical Considerations Important aspect of overall care Bowel conservation important
Limited resection Resect, don’t bypass
Long-term risk of short-gut is low J-pouch not an option in colonic disease
Ulcerative Colitis
Epidemiology Similar to Crohn’s disease Early and late incidence peaks Variable incidence among ethnic groups
Ulcerative Colitis
Pathology Involves only mucosa and submucosa Involves only colon and rectum Serosa normal Normal bowel wall thickness Normal mesentery
Ulcerative Colitis
Pathology (cont’d) Extraintestinal manifestations Malignancy
Duration of disease Extent of disease
Ulcerative Colitis
Presentation Diarrhea, often bloody Abdominal pain Constitutional symptoms Weight loss Fulminant colitis Toxic megacolon
Ulcerative Colitis
Indications for Operation Bleeding (uncommon) Unresponsive fulminant colitis Toxic megacolon Intractability Inability to wean steroids Cancer prevention
Ulcerative Colitis
Surgical Aspects Colectomy curative Total proctocolectomy with ileostomy Ileo-anal pouch pull-through