Small Intestine and Appendix - Doc Trinidad - KUMUNOY

SURGERY ROOOOOOOR LECTURER: DOC TRINIDAD, DOC SENIBOR CITIZEN, DOC KUMUNOY also diarrhea. Because of the accumulation, there will be now EWAN KO NA PAANO DISKARTE RITO SA SMALL INTESTINE HAHA...

SURGERY ROOOOOOOR LECTURER: DOC TRINIDAD, DOC SENIBOR CITIZEN, DOC KUMUNOY also diarrhea. Because of the accumulation, there will be now EWAN KO NA PAANO DISKARTE RITO SA SMALL INTESTINE HAHAHA, distention ng bowel à increased intraluminal and intramural pressure PASADAHAN NIYO MGA NAKA-RED, BOLD, PURPLE, KASI AYAN LANG à decreased intestinal motility with fewer contractions. Once naging DIN ITATANONG. MAY TABLE SA BABA PERO APPENDIX ‘YON (‘DI NA sobrang taas na ng intramural pressure à impaired intestinal KAYA SMALL INTESTINE) ARALIN NIYO KASI SGD 10 POINTS ANG microvascular perfusion à intestinal ischemia à necrosis. APPENDICITIS KAYA AYON PRINIORITIZE KO, OKAY?! HINDI SAMPS!!!!!!!!! PATHOPHYSIOLOGY PARTIAL SBO VS COMPLETE SBO Surgical Indications: obstruction, mass, bleeding, perforation, With partial small bowel obstruction, only a portion of the abscess, fistula intestinal lumen is occluded, allowing passage of some ① gas and fluid. The progression of pathophysiologic events described above tends to occur more slowly than with complete ETIOLOGY small bowel obstruction, and development of strangulation Mechanical small bowel obstruction is the most frequently is less likely. encountered surgical disorder of the small intestine. Wide range of etiologies for this condition exist: STRANGULATED BOWEL OBSTRUCTION (Ito rin ‘yung nasa taas if gets mo na INTRALUMINAL skip mo na J )With onset of obstruction, gas and fluid accumulate within the Foreign bodies, gallstones, or meconium intestinal lumen proximal to the site of obstruction. INTRAMURAL The intestinal activity increases in an effort to overcome the obstruction, Tumors, Crohn's disease–associated inflammatory strictures accounting for the colicky pain and the diarrhea that some experience even in the presence of complete EXTRINSIC bowel obstruction. Adhesions, hernias, or carcinomatosis Most of the gas that accumulates originates from swallowed air, although Adhesions related to prior abdominal surgery account for some is produced within the intestine. up to 75% of the cases of SBO. INTRA-ABDOMINAL The fluid consists of swallowed liquids ADHESIONS and GI secretions (obstruction 3 out of 4 small bowel obstructions are caused by stimulates intestinal epithelial water adhesions. secretion). Less prevalent etiologies for small bowel obstruction With ongoing gas and fluid include hernias, malignant bowel obstruction, and Crohn's accumulation, the bowel distends and disease intraluminal and intramural pressures The frequency with which obstruction related to these rise. The intestinal motility is eventually conditions is encountered varies according to the patient reduced with fewer contractions. population and practice setting. With obstruction, the luminal flora of Add ko lang din dito sa etiology, congenital abnormalities causing SBO the small bowel, which is usually sterile, nagiging evident sila during childhood pero may instances na hindi sila changes and a variety of organisms have been cultured nade-detect so they are diagnosed for the first time kapag adults na from the contents. Translocation of these bacteria to sila once they present with abdominal symptoms. Last, may rare regional lymph nodes has been demonstrated, although etiology din which is SUPERIOR MESENTERY ARTERY SYNDROME the significance of this process is not well understood. characterized by compression ng third portion of the duodenum If the intramural pressure becomes high enough, intestinal especially if may chronic symptoms suggestive of proximal SBO. microvascular perfusion is impaired, leading to intestinal Explain ko narin quickly ang pathophysio: since may obstruction, ischemia, and, ultimately, necrosis. This condition is termed magkakaroon ng gas and fluid accumulation sa lumen proximal to the strangulated bowel obstruction. site ng obstruction. Because of that, tataas ngayon ang intestinal activity to overcome the obstruction which will cause colicky pain and KUMUNOY’S IMPROPERTY 1  SURGERY ROOOOOOOR LECTURER: DOC TRINIDAD, DOC SENIBOR CITIZEN, DOC KUMUNOY Important elements to obtain on history include: o Prior abdominal operations (suggesting the presence of CLOSED LOOP OBSTRUCTION adhesions) o Presence of abdominal disorders (i.e. Intra-abdominal A particularly dangerous form of bowel obstruction is cancer or inflammatory bowel disease) HISTORY & PE closed loop obstruction, in which a segment of intestine is o Bulging mass Upon examination, a meticulous search for hernias, particularly in obstructed both proximally and distally i.e. with volvulus the inguinal and femoral regions, should be conducted. In such cases, the accumulating gas and fluid cannot The stool should be checked for gross or occult blood, the presence of which is suggestive of intestinal strangulation escape either proximally or distally from the obstructed Sensitivity: 70-80% segment, leading to a rapid rise in luminal pressure, and a Specificity: Low (SBO vs Ileus vs colon) False Negative findings: proximal small bowel obstruction, bowel rapid progression to strangulation. filled with fluid but no gas X RAY The diagnosis of small bowel obstruction is usually confirmed with radiographic examination. Its advantages include being readily CLINICAL PRESENTATION available and inexpensive. The symptoms of small bowel obstruction are colicky The abdominal series consists of a radiograph of the ff: o Chest (upright) abdominal pain, nausea, vomiting, and obstipation more o Abdomen (upright and supine) prominent symptom ang VOMITING tapos important din The finding most specific for small bowel obstruction is the triad of: o Dilated small bowel loops (>3 cm in diameter) ang character ng vomitus kasi kapag more feculent mas o Air-fluid levels seen on upright films suggestive of obstruction! o A paucity of air in the colon** CT scanning also offers a global evaluation of the abdomen and Continued passage of flatus and/or stool beyond 6 to 12 may therefore reveal the etiology of obstruction. hours after onset of symptoms is characteristic of PARTIAL The findings of small bowel obstruction include: o A discrete transition zone with dilation of bowel proximally, OBSTRUCTION rather than complete obstruction. decompression of bowel distally, intraluminal contrast that The signs of small bowel obstruction include abdominal does not pass beyond the transition zone, o Colon containing little gas or fluid distention that is most pronounced if the site of obstruction Closed-loop obstruction is suggested by the presence of a U- is in the distal ileum, and may be absent if the site of shaped or C-shaped dilated bowel loop associated with a radial distribution of mesenteric vessels converging toward a torsion obstruction is in the proximal small intestine. CT SCAN point. Bowel sounds may be hyperactive initially, but in late Strangulation: Becoming o Thickening of the bowel wall stages of bowel obstruction, minimal bowel sounds may be o Pneumatosis intestinalis (air in the bowel wall) increasingly heard. the imaging of o Portal venous gas o Mesenteric haziness – “dirty-looking” Laboratory findings reflect intravascular volume depletion choice and o Poor uptake of IV contrast into the wall of the affected bowel & consist of hemoconcentration & electrolyte ideally done The CT scan usually is performed after administration of oral water- with oral soluble contrast or diluted barium (not in perforated/ ischemic abnormalities bowel). contrast! Mild leukocytosis is common. The water-soluble contrast has been shown to have: o Prognostic and therapeutic values Clinical Presentation of Strangulated Obstruction o Appearance of the contrast in the colon within 24 hours is remember na any of these findings should alert the predictive of nonsurgical resolution of bowel obstruction o Does not alter the rate of surgical intervention clinician na baka may strangulation na and need na for o Reduce the overall length of hospital stay surgical interventioin! A limitation of CT scanning is its low sensitivity (65 years old have semester (25%) HIGHEST RATES OF PERFOATION Ø PHYSIOLOGIC LEUKOCYTOSIS OF PREGNANCY Ø DELAYS in presentation and diagnosis Ø CARCINOID – MOST COMMON TUMOR; Ø RUPTURE SHOULD BE SUSPECTED IN THE Appendix is the most common site of GI PRESENCE OF = >39ºC + WBC >18,000 Carcinoid; Usually located at the tip cells/mm3 + Progression of Clinical Signs ABDOMINAL Ø Phlegmon – matted loops of bowel adherent RUPTURE to the adjacent to adherent inflamed appendix, or periappendeceal abscess Ø IV ANTIBIOTICS: Phlegmon + Small Abscesses TUMOR Ø PERCUTANEOUS DRAINAGE: Well localized abscess Ø SURGICAL DRAINAGE: Complex abscess Ø EARLY: Adequate hydration + Correction of electrolyte abnormalities + Correction of pre- existing comorbidities + Pre-operative ITATANONG DAW NI DOC ‘YANG PIC!!! antibiotics ADENOCARCINOMA – RIGHT HEMICOLECTOMY IS Ø OPEN/LAPAROSCOPIC APPENDECTOMY: THE RECOMMENDED TREATMENT Kapag fat daw need ng larger incision so, laparoscopic appendectomy; kapag payat, hindi naman need ng malaking incision so Wait lang sa samps, pero ‘di kaya na ng open; Kapag may ruptured TREATMENT appendicitis, encouraged ang laparoscopic talaga ‘to samps kasi bago approach kasi ma-aavoid ang very large laparotomy; kapag PAYAT + FEMALE + CHILD lecturer!!!!! = LAPAROSCOPIC (Ayan sabi ni doc sa lec) Ø ANTIBIOTICS AS DEFINITIVE THERAPY Ø SURGERY STILL REMAINS THE GOLD STANDARD OF CARE WITH ACUTE APPENDICITIS Ø Conservative therapy with interval appendectomy 6-10 weeks later Ø Principal factors influencing mortality: Rupture occurs before surgical treatment and age of PROGNOSIS patient Ø Death due to uncontrolled sepsis KUMUNOY’S IMPROPERTY 19