Intestinal Abnormalities & Surgeries😍

CT Enterography

• Best for any Small bowel pathology

• Mannitol is given

Types

 

In mesenteritis, ultrasound shows thickened and distorted appearance of the root of mesentery with a halo of sparing surrounding the vessels

Bowel Obstruction

3 - 6 - 9 Rule

• Bone

• Bowel obstruction
• >3 cm dilatation: small bowel obstruction.
• >6 cm dilatation: colonic obstruction.
• >9 cm dilatation: caecal obstruction.

Cardinal Features

• Non passage of flatus & faeces (Obstipation).

• Distention.

• Vomiting.

• Abdominal pain.

Investigations

1. X-ray abdomen: Erect & supine (Initial Ix).

2. CECT: IOC in adults.

3. USG: IOC in children.

X-ray Features

• Image A → Incomplete haustrations of colon → large bowel obstruction.

• Image B → valvulae conniventes of jejunum → small bowel obstruction.

Image C shows multiple air fluid levels

• Erect X-ray

• >3 air fluid levels

• Step ladder pattern

• indicates small bowel obstruction.

 

String of pearl sign: (D)

• Seen in small bowel obstruction.

• Air locules arranged one behind another.

• Dilated bowel pushes air between valvulae conniventes to the periphery.

Supine X-ray

Site of obstruction	Features
Jejunum	Feathery appearance,  valvulae conniventes  (Concertina effect).
Ileum	Featureless (loops of wangensteen).
Large bowel	Incomplete haustrations.

Management of Bowel Obstruction

1. NPO.

2. IV fluids.

3. IV antibiotics & painkillers.

4. Ryle's tube insertion.

5. Sx: Emergency laparotomy.
• First visualised → Caecum
• Caecum is distended: Large bowel obstruction.
• Caecum collapsed: Small bowel obstruction.

Intussusception

• M/c: Ileocolic

• Telescoping of one bowel loop into another.
• Intussuscipiens: Receiving loop.
• Intussusceptum: Loop going inside.
• Narrowest portion → Neck → Obstruction

Definition:

• When 1 portion of the GI tract is telescoped into another.

Types

Clinical Feature:

• Severe colicky pain in abdomen +

• Sausage-shaped palpable mass in the abdomen.

• Telescoping of bowel loop.

• M/c in weaning age group.

• Red currant jelly stools.

Investigations

1. X-ray abdomen: Erect & supine (Initial).

2. USG: Target/Donut/Pseudokidney sign.
• good sensitivity in diagnosis.
• Note: IOC in children.
• Note: IOC in adults: CECT.
 

Barium enema sign:

• Claw sign.

• Coiled spring sign.

Treatment:

• Contrast enema: Xray
• Pincer/claw sign.
• Diagnostic & therapeutic.
• C/I:
• Perforation,
• recurrence or
• 2° to pathological lead point.

• Air enema → Xray

• Saline enema → USG

• Spontaneous resolution occurs in 10% of the patients.

• Hydrostatic reduction under Fluoroscopic or USG guidance.

• Surgical reduction may be required in:
• Refractory shock.
• Suspected intestinal perforation or necrosis.
• Multiple recurrences or peritonitis.

• Pick pocketer () → got coins () with red blood (hematoma) like coiled spring ()

Sigmoid Volvulus

Feature	Sigmoid Volvulus	Caecal Volvulus
Large bowel	Dilated	Collapsed
RF	Elderly with constipation On antipsychotic meds. Long & narrow mesentery. Redundant sigmoid.	Pregnancy Pelvic Sx
Rotation	Anticlockwise > Clockwise	ㅤ
App	Coffee bean sign/ Omega sign/ bent tube appearance Barium enema Bird beak sign/ Bird of prey sign	Embryo sign
Bowels	2 bowel loop	1 bowel loop
Haustrations	Ahaustral	Haustral
Management	Flatus tube/endoscopic detorsion Def: Sigmoidectomy Unstable, peritonitis: Hartmann's procedure	Surgery

• Coffee bean sign/Omega sign

• Bird beak sign/ Bird of prey sign
• on barium enema.

Caecal Volvulus

• Haustrations present with single loop.

• Embryo sign.

 

MIDGUT Volvulus with malrotation

Conditions	1st R	2nd R	3rd R	ㅤ
Non-Rotation	N	Abnormal	Abnormal	• SI on right side • LI on left side
Malrotation	N	N	Absent	• Subpyloric Caecum Persistence of Ladd band ↳ Duodenal obstruction ↳ Bilious vomiting ↳ Double bubble sign Very short mesentery ↳ High risk of volvulus
Reverse Rotation	N	180° clockwise	ㅤ	• In effect = 90 clockwise Transverse colon is overlapped by: ↳ Superior mesenteric artery ↳ Duodenum • Cause obstruction

• CT

 

• Contrast → Iohexol
• BARIUM NOT USED
• Corkscrew appearance

Adhesive Intestinal Obstruction

• m/c cause of small bowel obstruction (Dynamic).

Causes

1. Post surgery (m/c).

2. Non-surgical causes:
• Crohn's disease.
• PID.
• TB.
• Endometriosis.
• Cancer.

IOC

• CECT.

Management (Mx)

• Conservative for 48-72 hours fails → Surgery (Adhesiolysis).

Ladd's Band

• m/c intestinal malrotation abnormality.

• Runs from Rt hypochondrium to caecum.

• Duodenal compression.

• Mx: Excision of band.

Intestinal Stricture

Causes

1. Cancer.

2. Post radiotherapy.

3. TB.

4. Crohn's disease.

Management (Mx)

• Strictures are close: Resection & anastomosis.

• Strictures are far: Heinke Mikulicz stricturoplasty.

Ileo Cecal TB

• Pulled up caecum.
• Pulled up contracted caecum (due to fibrosis).

• String sign:
• Narrowing of terminal ileum- Stricture.

• Inverted umbrella sign/ Fleischner sign:
• widening of ileocecal valve.

Meckel's Diverticulum

• Rule of 2s: 
• 2% of population
• 2 inches long
• 2 feet from ileocolic junction.
• 2 tissues

• Only True diverticulum: All layers (+).

• Remnant of vitellointestinal duct.

• Present along the antimesenteric border.

• During embryonic development, the diverticulum arises from the same
  embryonic structure as the stomach and pancreas.
• As a result, gastric mucosa and pancreatic tissue may be present in the diverticulum

• Independent blood supply: Safe resection possible.

Vitellointestinal Duct Abnormalities

1. Completely patent: Fecal discharge.

2. Fibrous band formation: Leads to volvulus.

3. Patent umbilical end: Umbilical cyst/polyp → Purulent discharge.

4. Ileal end patent: Meckel's diverticulum.

Duodenal Atresia

• Common in Down's syndrome.

• C/F: Bilious vomiting since birth.

• D/D: CHPS.

• X-ray: Double bubble sign.
• Also seen in annular pancreas with non bilious vomiting

• Mx: Duodenoduodenostomy.

Jejunal Atresia

• X-ray: Triple bubble sign

• Next: Gastrograffin follow through
• To differentiate between Hirschsprung and Jejunal atresia

Appendicitis

Note

• Taenia coli are absent in:
• Appendix
• Caecum
• Rectum

• Appendices epiploicae are absent in:
• Appendix
• Rectum

• Appendix lacks:
• Taenia coli (Sacculations)
• Appendix epiploicae

Surgical Anatomy

• Appendicular artery:
• Branch of lower division of ileocolic artery.

• Appendicular base:
• Junction of 3 taenia coli.

Positions

Blood Supply

• Appendicular artery (end artery).

Nerve Supply

• Parasympathetic fibres: Vagus nerve.

• Sympathetic fibres: T₁₀ - T₁₁ fibres.
• T₁₀ fibres also innervate umbilicus (present at L₃-L₄ level).
• Therefore in any Midgut Pathology
• Pain referred to umbilicus.

• Retrocaecal (m/c) : 74%

• Pelvic : 21%

• Subcaecal : 1.5%

• Post-ileal : 0.5%

• Pre-ileal : 1%

• Paracaecal : 2%
• L/c: most difficult to diagnose.

Symptoms

1. Pain abdomen.

2. Nausea & vomiting (m/c).

3. Anorexia.

4. Fever.

Signs

• McBurney's point tenderness.

Modified Alvarado (MANTRELS) Score

• Score >7: Likely appendicitis.

• Mnemonic: Two → Tenderness → Total count

Investigations

• 1st investigation: USG.

• Best investigation: CECT (visualizes retrocecal appendix).

• Distended appendix >6mm with surrounding fluid.

• Inflamed appendix is non compressible.

1. CECT: IOC in adults.
• CECAL BAR SIGN
• ARROW HEAD SIGN

2. USG: IOC in children.
• Blind ending tubular structure.
• Probe tenderness.
• Periappendiceal fluid collection.

Management (Appendicectomy)

• Appendicitis → Appendicectomy → No need to bury the base

• Inflamed base → Dont crush the base → Bury with purse string suture

• Gangrenous base /caecal wall gangrene → Right hemicolectomy.

• Appendix not inflamed → Rule out Meckel's diverticulum (Distal 2 feet of ileum).

Incisions Used

1. McBurney's incision:
• grid iron:
• muscle splitting.
• Rutherford morrison:
• muscle cutting.

2. Lanz/skin crease/bikini incision:
• Better cosmesis.
• muscle splitting

3. Lower midline abdominal incision: For perforated appendix.

4. Gibson's incision
• Above inguinal ligament (→ E)
• To identify ureter (for Renal transplant).

Structures Passed (for Lap. appendicectomy incisions)

1. Skin.

2. Superficial Fascia.

3. External oblique aponeurosis.

4. Muscles.

5. Peritoneum.

Complications

1. Wound infection (m/c).

2. Bleeding.

3. Portal pyemia.

4. Stump appendicitis (If stump > 4mm).

Appendicitis in Pregnancy

• m/c non obstetrical emergency.

• C/F: Pain in RIF (Can be higher up also).

• Lx: USG, if unconfirmed → MRI.

• Mx: Lap. appendicectomy in all trimesters.
• D/t ↑ Risk of preterm labor/abortions.

Yersinia enterocolitica

• Causes inflammation of:
• Terminal ileum
• Appendix
• Cecum
• Mesenteric lymphadenopathy

• Most Common differential diagnosis of acute appendicitis

Acute Mesenteric Lymphadenitis

• Mimics acute appendicitis

• Presents with:
• Acute right lower quadrant abdominal pain
• Enlarged mesenteric lymph nodes
• Normal appendix

• Diagnosis:
• Made during abdominal exploration
• Reveals normal appendix with enlarged mesenteric lymph nodes

• Common in:
• Children
• Young adults

Appendicular Perforation

• Omentum dysfunction.

• Seen in:
• Children.
• Elderly.
• Adhesions.
• Pregnant females.
• Immunocompromised patients.

Appendicular Lump

• Mx:
• Ochsner-Sherren regime (Conservative).
• Mnemonic: Sherin nte appendix lu ochu

Management and Outcomes

• Outcomes:
• Recovers:
• Discharge.
• Interval appendicectomy after 6 weeks.
• Deteriorates (↑ Pain, fever & lump size):
• Suspect abscess.
• Extraperitoneal drainage (Pigtail catheter).

Diverticular Disease

Diverticulosis

• m/c Site: Sigmoid colon

• Asymptomatic diverticuli.

• Type: False diverticula (mucosal herniation)

• Formation: Along mesenteric border
• NOTE: Meckel's → True diverticula → Anti mesenteric border

• Demographics: 4th – 5th decade

• Association: Constipation

• m/c Cause of: Massive lower GI hemorrhage

• IOC-Barium enema.
• Saw tooth appearance.

Diverticulitis

• Left side (Sigmoid colon) > Right side

Complications of Diverticular Disease

• Bleeding: Right > Left (SMA > IMA distribution)

• Diverticulitis

• Colorectal cancers (potential long-term link)

Clinical Features of Diverticulitis

• Left lower quadrant pain

• Diarrhea

• Fever

• Raised TLC (Total Leukocyte Count)

Radiology

• Inflammation of diverticulum.

• Patient presents with pain.

• IOC-CECT.

• Hinchey's classification.

 

Hinchey Staging System (Based on CECT - IOC)

• Stage I: Colonic inflammation with pericolic abscess
• 1a → Pericolonic Phlegmon and inflammation
• 1b → Pericolonic abscess ＜4cm

• Stage II: Colonic inflammation with pelvic abscess

• Stage III: Purulent peritonitis

• Stage IV: Fecal peritonitis
• Mnemonic: DaVinci → Dive Hinchey → Abcess→ PP → FP

Management by Stage:

• Stage I & II: Pigtail catheter drainage (for abscess).

• Stage III & IV: Laparotomy + Hartmann procedure (colostomy)

Imaging Note on Diverticular Disease

• Barium enema/colonoscopy is avoided
• ↑↑ increased risk of perforation during acute diverticulitis.

Angiodysplasia

Features & Clinical Aspects

• 2nd m/c Cause of: Lower GI bleed

• Pathology: Dilated arterioles

• m/c Site: Cecum

• Demographics: Seen in elderly (5th – 6th decade)

• Heyde Syndrome: Angiodysplasia + Aortic stenosis

Management

• Investigation: Colonoscopy, Capsule endoscopy

• Treatment: Coagulation/cauterization

Ileostomy

Types of Stoma

End Stoma

• One bowel end brought out.

Double Barrel Stoma

• Two bowel ends brought out.

• Not joined to each other.

Loop Stoma

• Two bowel ends brought out.

• Are joined (often a loop over a rod).

Complications of Stoma

• Necrosis: Earliest complication

• Skin Excoriation: m/c complication

• Parastomal Herniation: m/c long-term complication

• Fluid & electrolyte imbalance

• Bowel obstruction

• Prolapse

• Retraction

Short Bowel Syndrome (SBS)

Definition

• <200 cm of small intestine remaining.

• Net Secretors: <100 cm of SI.

• Net Absorbers: >100 cm of SI.

• Prognosis: Good if ileocaecal junction is saved.

Causes

• MCC CHILD → NEC/ Jejunal atresia

• MCC ADULT → Crohn's disease (m/c) > Mesenteric Ischemia

• Superior mesenteric artery (SMA) syndrome

• Trauma

Clinical Features

• Malabsorption

• Diarrhea

• Weight loss

• Bacterial overgrowth

Management

• TPN (Total Parenteral Nutrition)

• Small intestine transplantation

• Teduglutide (GLP2 analogue)

Bowel Lengthening Procedures

• Bianchi procedure, Kimura procedure
• B (Bowel) anch (Bianchi) thavana valikkum → to lengthen

• STEP (Serial Transverse Enteroplasty)

Faecal Fistulae

• Take a SNAP (SNAP protocol) of feces from abdomen guys

Factors Favoring Spontaneous Closure

• Origin:
• Esophageal
• Duodenal
• Jejunal stump

• Enteric Wall Defect: <1 cm

• Fistula Tract Length: >2 cm

• No abdominal wall defect

• Good Nutrition: Albumin >2.5 g/L

• Low Output Fistula: <200 mL/day

No F.R.I.E.N.D Factors (Factors Preventing Closure):

• Foreign body

• Radiation

• Inflammation, Infection, IBD

• Epithelialization of fistula tract

• Neoplasm

• Distal obstruction

Fistula Output

• High Output Fistula: >500 mL/day

Management

Spontaneous Closure Likely

• Conservative management

Spontaneous Closure Unlikely
SNAP Protocol → Enterocutaneous fistula

• Skin care, Sepsis control

• Nutrition

• Anatomical delineation (imaging)

• Planned surgery

Prognostic Grouping of Fistula

Notes

• Metabolic derangements in fecal fistula:
• Fluid + electrolyte imbalance.

• Maximum output (fluid and electrolyte output)
• pancreatic and biliary fistula:
• Opening in Duodenum > Jejunum
• Opening after pancreatic and biliary juices.

1. What is the primary cause of severe malnutrition among the options provided below?
   A. Pancreatic fistula
   B. Duodenal fistula
   C. Distal ileal fistula
   D. Colonic fistula

Laparoscopy

• Minimally Invasive Surgery.

Pneumoperitoneum:

• Gas: CO2 (Non-combustible).

• Pressure: 10-14 mmHg.

• Air in peritoneal cavity due to ruptured hollow viscus organ (perforation, post laparoscopy).

• On CT, jet black appearance shows air.

---

---

Physiological Effects:

• Sinus Bradycardia: 
• M/c arrhythmia in laparoscopy
• Due to peritoneal stretching → Vagal stimulation

• Decreased SBP, CO, Reflex tachycardia
• Due to IVC compression.

• Increased Airway resistance & Positive End-Expiratory Pressure (PEEP): 
• As diaphragm is pushed up, decreasing thoracic volume.
• So use with caution in COPD

• Decreased Urine output: 
• Due to compression of renal artery.

• Increased Intracranial pressure.

Instruments:

• Veress Needle: 
• Used in closed method to create pneumoperitoneum,
• has a beveled edge.
• Involves blind puncture of peritoneum

• Sharp Trocar:



• Inserted after Veress needle, used to insert other instruments.
• If bowel injury:
• Keep in place & convert to open procedure.

• Hasson’s Cannula:
• For open method.

• Optiport/Visiport: 



• Transparent end, can hold camera, clear ends.
• Prevent bowel injury

• Laparoscopic Instruments:



• Has insulation (black coating).
• If insulation breaks → Capacitance coupling → Bowel injury (burns).
• Prevention: Plastic trocar.

Other Minimally Invasive Procedures:

SILS (Single Incision Laparoscopic Surgery):

• Multiple instruments can be inserted from a single port.

Robotic Surgery (Da Vinci System):

• Advantages:
• Finer dissection.
• Better movement (7 degrees of freedom).
• Tremor reduction.

• Disadvantages:
• Expensive.
• Loss of tactile feedback.

NOTES (Natural Orifice Transluminal Endoscopic Surgery):

• Scarless

• Examples:
• Per-oral Endoscopic Myotomy (POEM).
• Transanal Total Mesorectal Excision (TATME).
• Transoral Gastroplasty (TOGA).

Pseudomembranous Colitis:

 

• It is a type of superinfection.m

• MC bacteria involved: Clostridium difficile.

• Cause:
• Long-term use of antibiotics.
• Alters gut flora.

• Clinical features: Watery diarrhoea.

• Diagnosis:
• Toxigenic culture: Culture media: 100% sensitivity
• Cefoxitin cycloserine fructose agar (CCFA).
• Cefoxitin cysteine yeast extract agar (CCYA).
• Detection of toxins via ELISA and PCR.

• MC antimicrobials implicated are:
• 3rd Gen. Cephalosporins > Clindamycin > Ampi or Amoxycillin > FQ.

• Accordion sign — Thick edematous bowel.

• Treatment:



• DOC :
• Oral Fidaxomicin (Low chances of relapse).
• Alternative :
• Oral vancomycin
• Oral Metronidazole.
• Monoclonal Ab against toxin :
• Bezlotoxumab.