腸疾病腸梗阻、闌尾炎

1、Intestine Diseases,Sun Libo China - Japan Union Hospital,Review of Anatomy and Physiology,I.Small IntestineMacroscopic anatomyTreitz ileocecal valve. 2/5 jejunum, 3/5 ileumMesentery : fat, blood vessels, lymph

2、atics, and nerves. superior mesentery artery and vein Microscopic anatomy4 layers : mucosa , submucosa, muscularis, and serosa.,,,Physiology of the small intestine1. Digestion digests and absorbs

3、 nutrients from ingested food.2. Secretion Alkaline mucus and some gastroenteral hormones 3. Motility The movement is composed of segmental contraction and peristalsis ( short, weak, propulsive),II. Large Intest

4、ine Macroscopic anatomy 1.5 m long , end of ileum rectum..Right colon: cecum , ascending colon , hepatic flexure, and proximal transverse colon Left colon: the distal transverse

5、 colon,splenic flexure , descending colon, and sigmoid colon.Blood supply: Superior mesentery artery the right colon . Inferior mesentery artery the left colon.Micr

6、oscopic anatomy 4 layers : mucosa, submucosa, muscularis, and serosa.,,,,Physiology of large intestine1. Digestion electrolytes and water from the ileal fluid 2. Secretion Alkaline mucus and some gastroenteral h

7、ormones3. Motility Retrograde peristalsis (dominates in the right colon) Segmental contraction (in the transverse and descending colon) Mass movement ( a strong ring contraction over long dis

8、tance in the transverse and descending colon),,,Major Contents,Inflammatory bowel diseases [ IBD] Intestine Obstruction Vascular lesions of mesenteryShort bowel syndrome Polyps Tumor Congenital diseases,Inflammato

9、ry bowel diseases [ IBD] 1) intestine tuberculosis 2) typhoid perforation 3) amoebic perforation 4) nonspecific inflammatory diseases (Crohn’s Diseases, ulcerative colitis )Surgical

10、 intervention perforation , obstruction , or hemorrhage ( bleeding ),Vascular lesions of mesentery ( vascular occlusion or ischemia ),Mesentric arterial embolism or thrombosis cardiac diseases

11、Mesenteric venous thrombosis Hepatic cirrhosis and haemal diseasesCharacter --- symptom severe , sign light Diagnosis --- angiography Treatment --- operation,,,Short bowel syndrome,Etiology

12、intestine resection not long enough (＜100cm) digestive and absorption disfunction Treatment 1) nutrition support (TPN) 1~2 year half compensation recover

13、 2) intestine transplantation immune rejection problem,,,Polyps and polyposis,Difference ＞100 or notPlace:any where,but common in colonPresentation 1) change of defecation 2) rec

14、tal bleeding 3) ileus (obstruction)Treatment Endoscopic electrocautery snare Open operation,Congenital diseases,Classification : atresia ,stenosis,and malrotation Etiology: abnormal growth Diagno

15、sis: 1) newborn 2) intestinal obstruction 3) upper gastrointestinal series or barium enema evidence Treatment operation,Obstruction of Intestine ( Bow

16、el ileus ),Etiology and classification I . Mechanical Obstruction inside ,outside the lumen, or intestine wall lesions .II. Adynamic (paralytic) ileus operation or acute peritonitis . Ⅲ. blood supply? simple or s

17、trangulated ileus.,Change in physiology,1. Loss of body fluid : Metabolic acidosis --lower ( distal ) obstruction Metabolic alkalosis --high (proximal) obstruction2. Infection and toxic symptoms Endogenous

18、infection by bacteria inside the lumen3. Shock Severe loss of liquid or infection .4. Respiration and circulation barrier Caused by the distension of intestine .,Clinical findings,Symptoms 1.Abdominal pain .

19、 variable , cramping peri-umbilical pain 2.Vomiting especially in proximal ( high ) 3.Abdominal distension . middle or distal bowel obstruction , and paralytic (adynamic ) obstruction4.Difficulty of defecation an

20、d gas expelling. varies according to it is complete or not,Signs 1. Generally Dehydration , and shock at the late stage 2. Locally Inspection: Peristalsis in dilated loops may be visible in thin

21、 patients . Palpation: mild tenderness Auscultation: Peristaltic rushes, gurgles, and high pitched tinkles are audible. Incarcerated hernia ?,Adjuvant examination,Laboratory findin

22、gsearly normal late hemoconcentration , leukocytosis electrolyte abnormalities. Serum amylase is often elevated .X-ray findings Plain films ladderlike pattern of dilated sm

23、all bowel loops with air – fluid levels . Contrast media orally or by a nasogastric tube . proximal Barium enema distal,,,diagnosis and questions,Diagnosis

24、 : based above clinical findings and adjuvant examination Questions : (1) is or not ? (2) Mechanical or paralytic ( adynamic) ? (3) Simple or strangulated ? (4) high or lower ? (5) complete or not ? (6) th

25、e reason of obstruction ?,Indication of strangulation,1)  severe colic pain 2) shock 3) peritonitis 4) visible or palpable dilated intestine loops 5) bowel bleeding 6) medical treatment is not successful

26、 7) X-ray shows distended bowel loops that is not change with time.,Treatment,1.Conservative therapy 1) Nasogastric suction. 2)  Fluid and electrolyte resuscitation. 3)  Antibiotics used before operation.

27、4)  Traditional Chinese medicine therapy .,2. Operation .removing the cause of obstruction intestine resection bypass operation.intestine stoma,Intestine Tumor,I. Small Intestine Tumors Introduction1) The mo

28、rbidity is rare , occupied nearly 2% of the tumors in gastrointestinal tract. 2) Most (3/4) are malignancies. 3) The diagnosis before operation is difficult , so the treatment is often delayed.,Clinical findin

29、gs ---------not typical 1.  abdominal pain : discomfort , dull pain , or colic pain 2. hemorrhage ( bleeding ) from digestive tract.3. intestine obstruction 4. abdominal mass5. intestine perforation 6. carcino

30、id syndrome : presentation: cutaneous flushing , diarrhea, asthma, and cardic valvular disease Reason: active substances secreted by carcinoids, such as histamine ,bradykinin, and prostagl

31、andins .,DiagnosisBesides clinical findings, following examinations are helpful:Upper gastrointestinal series: a barium swallow examination Endoscopy examination : duedenoscopy, intestinoscopy Angiography Urinary l

32、evels of 5-hydroxyindoleacetic acid (5-HIAA) , a metabolite of 5-hydroxytryptophan .Operative exploration .,Treatment First choice ----resection of tumor. If it is can not be resected , bypass operation

33、 bowel obstruction. Adjuvant therapy---- chemotherapy and radiotherapy. ???,,,II Large Intestine Tumors

34、 Introduction common in males at 41- 50 ages. Etiology is not clear, ( familial polyposis, ulcerative colitis, colon adenoma , and colorectal polyps? ) Pathology and Classification Macroscopically

35、 MicroscopicallyPolypoid (mass) 1. adenocarcinoma spreading type 2. mucous carcinoma ulcerating type 3. undifferentiated carcinoma .,Stage: Dukes classification According the invasion extent

36、 of lumen wall , lymphnodes ,and distant metastasis , it is classified as stageA. inside the intestine wallB. outside the intestine wall but lymph node (-)C. out side the intestine wall lymph no

37、de (＋)D. distant metastasis,Clinical findings Change in bowel habits---the most early symptom. frequency , constipation and gross blood . (Left colon)Abdominal discomfort or pain. (Left and right

38、 colon) Palpable abdominal mass. ( Right colon )Obstructive symptoms . ( Left colon )Unexplained weakness or anemia. ( Right colon ),,Special examinationsFlexible colonscopy or rigi

39、d sigmoidscopy (biopsy!)Barium enemaCT scan and ultrasonography : to detect the lymph node invasion and hepatic metastasis . Carcinoembryonic antigen ( CEA ) , a tumor marker , useful in diagnosis , prognosis , or eva

40、luation of response to treatment .,Treatment Surgical resection of lesion and its regional lymphatic nodes the first choice . second choice colostomy or bypass operation 2. Adjuvant

41、 therapy: chemotherapy , radiotherapy immunotherapy , traditional Chinese medicine,,,3. Treatment of complicationA. Obstruction Right colon: carcinoma can be resected and anastom

42、osed in a single stage in most cases.Left colon : surgical decompression (colostomy)followed later by elective resection . B Perforation The involved segment of colon is r

43、esected if possible , colostom , secondary anastomosis is performed after inflammation subsides.,Appendicitis,Anatomy a separate mesoappendix with an appendicular artery and vein that are the branches of the ileocolic v

44、essels.lined with colonic epithelium characterized by many lymph follicles. McBurney point , 5~10 cm in length , 0.5~0.7 cm in diameter, at any position on a clockwise rotation from the base of the cecum.,Pathophysiolo

45、gy  Hyperplasia of the lymphoid follicles(60%) , fecalith (35%) obstruction → bacteria multiply→ endotoxins A epithelium damage exotoxins mucosa ulcerated

46、 inflammatory process ischemia → necrosis→perforation → peritonitis,,,,,,Pathological Classification of acute appendicitis Ⅰ acute simple appendicitisⅡ acute purulent appendicitis Ⅲ gangrenous or perforated

47、appendicitis Ⅳ peri-appendix abscess,Clinical Diagnosis of acute appendicitis diagnosis 1. history and the physical findings 2. labrartory examinations. WBC  Typical symptoms and signs: 1. generalized abdomin

48、al pain followed by nausea epigastrium umbilicus the right lower quadrant. 2. Temperature, spasm, tenderness and rebound tenderness in the MacBurney point.,,,,Assistant physical examination

49、s 1. Rovsing sign (colon air filling test) 2. Obturator sign 3. Psoas sign 4. Rectal examination,Differential diagnosis1. 1. Peptic ulcer perforation2. 2. Ureteral stones3. 3. Gynecological and ob

50、stetric diseases Ectopic pregnancy , ruptured ovarian cyst or follicle acute salpingitis , wisted ovarian cyst 4. 4. acute mesenteric lymphadenitis 5 5. Others : acute gastroenteritis , cholecys

51、titis, children intussusception, cecum tumor,Treatment  First choice ----appendectomyIncision selectionfind itcut and ligate mesoappendixpursestring suture resect it and residue management tying the pursestri

52、ng closure,Complication1. 1. caused by acute appendicitis itself abscess in abdominal cavity internal and external fistular pylephebitis2. 2. caused by appendectomy b

53、leeding incision infection adhesive ileus (obstruction) appendicular residue inflammation fecal fistular,Special features of acute appendicitis,1. Appendicitis in infants and young children

54、 Diagnosis ---- difficult Perforation and mortality ---- highTreatment--- operation in time2.  Appendicitis in pregnancy  Pain position --- highTenderness and rebound tenderness --not

55、 obvious Treatment --- first choice is operation 3. Acute appendicitis in the elderPain and tenderness --- not obvious, symptom and sign are not coincidentTreatment --operation should be performed in time.,Chronic a

56、ppendicitis (CP) Etiology and pathology  Most CP comes from acute ones Most have fecalith or hyperplasia of the lymphoid follicles Diagnosis  1. Acute appendicitis history 2. Pain is not typical