肠疾病肠梗阻、阑尾炎.ppt

Intestine Diseases,Sun Libo China - Japan Union Hospital,Review of Anatomy and Physiology,I.Small Intestine Macroscopic anatomy Treitz ileocecal valve. 2/5 jejunum, 3/5 ileum Mesentery : fat, blood vessels, lymphatics, and nerves. superior mesentery artery and vein Microscopic anatomy 4 layers : mucosa , submucosa, muscularis, and serosa.,Physiology of the small intestine 1. Digestion digests and absorbs 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 Intestine 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 colon,splenic flexure , descending colon, and sigmoid colon. Blood supply: Superior mesentery artery the right colon . Inferior mesentery artery the left colon. Microscopic anatomy 4 layers : mucosa, submucosa, muscularis, and serosa.,Physiology of large intestine 1. Digestion electrolytes and water from the ileal fluid 2. Secretion Alkaline mucus and some gastroenteral hormones 3. Motility Retrograde peristalsis (dominates in the right colon) Segmental contraction (in the transverse and descending colon) Mass movement ( a strong ring contraction over long distance in the transverse and descending colon),Major Contents,Inflammatory bowel diseases IBD Intestine Obstruction Vascular lesions of mesentery Short bowel syndrome Polyps Tumor Congenital diseases,Inflammatory bowel diseases IBD 1) intestine tuberculosis 2) typhoid perforation 3) amoebic perforation 4) nonspecific inflammatory diseases (Crohns Diseases, ulcerative colitis ) Surgical intervention perforation , obstruction , or hemorrhage ( bleeding ),Vascular lesions of mesentery ( vascular occlusion or ischemia ),Mesentric arterial embolism or thrombosis cardiac diseases Mesenteric venous thrombosis Hepatic cirrhosis and haemal diseases Character - symptom severe , sign light Diagnosis - angiography Treatment - operation,Short bowel syndrome,Etiology intestine resection not long enough (100cm) digestive and absorption disfunction Treatment 1) nutrition support (TPN) 12 year half compensation recover 2) intestine transplantation immune rejection problem,Polyps and polyposis,Difference 100 or not Place:any where,but common in colon Presentation 1) change of defecation 2) rectal bleeding 3) ileus (obstruction) Treatment Endoscopic electrocautery snare Open operation,Congenital diseases,Classification : atresia ,stenosis,and malrotation Etiology: abnormal growth Diagnosis: 1) newborn 2) intestinal obstruction 3) upper gastrointestinal series or barium enema evidence Treatment operation,Obstruction of Intestine ( Bowel ileus ),Etiology and classification I . Mechanical Obstruction inside ,outside the lumen, or intestine wall lesions . II. Adynamic (paralytic) ileus operation or acute peritonitis . . blood supply? simple or strangulated ileus.,Change in physiology,1. Loss of body fluid : Metabolic acidosis -lower ( distal ) obstruction Metabolic alkalosis -high (proximal) obstruction 2. Infection and toxic symptoms Endogenous infection by bacteria inside the lumen 3. Shock Severe loss of liquid or infection . 4. Respiration and circulation barrier Caused by the distension of intestine .,Clinical findings,Symptoms 1.Abdominal pain . variable , cramping peri-umbilical pain 2.Vomiting especially in proximal ( high ) 3.Abdominal distension . middle or distal bowel obstruction , and paralytic (adynamic ) obstruction 4.Difficulty of defecation and 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 patients . Palpation: mild tenderness Auscultation: Peristaltic rushes, gurgles, and high pitched tinkles are audible. Incarcerated hernia ?,Adjuvant examination,Laboratory findings early normal late hemoconcentration , leukocytosis electrolyte abnormalities. Serum amylase is often elevated . X-ray findings Plain films ladderlike pattern of dilated small bowel loops with air fluid levels . Contrast media orally or by a nasogastric tube . proximal Barium enema distal,diagnosis and questions,Diagnosis : 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) the 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 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. 4) Traditional Chinese medicine therapy .,2. Operation . removing the cause of obstruction intestine resection bypass operation. intestine stoma,Intestine Tumor,I. Small Intestine Tumors Introduction 1) The morbidity 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 findings -not typical 1. abdominal pain : discomfort , dull pain , or colic pain 2. hemorrhage ( bleeding ) from digestive tract. 3. intestine obstruction 4. abdominal mass 5. intestine perforation 6. carcinoid syndrome : presentation: cutaneous flushing , diarrhea, asthma, and cardic valvular disease Reason: active substances secreted by carcinoids, such as histamine ,bradykinin, and prostaglandins .,Diagnosis Besides clinical findings, following examinations are helpful: Upper gastrointestinal series: a barium swallow examination Endoscopy examination : duedenoscopy, intestinoscopy Angiography Urinary levels 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 bowel obstruction. Adjuvant therapy- chemotherapy and radiotherapy. ?,II Large Intestine Tumors 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 Microscopically Polypoid (mass) 1. adenocarcinoma spreading type 2. mucous carcinoma ulcerating type 3. undifferentiated carcinoma .,Stage: Dukes classification According the invasion extent of lumen wall , lymphnodes ,and distant metastasis , it is classified as stage A. inside the intestine wall B. outside the intestine wall but lymph node (-) C. out side the intestine wall lymph node () 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 colon) Palpable abdominal mass. ( Right colon ) Obstructive symptoms . ( Left colon ) Unexplained weakness or anemia. ( Right colon ),Special examinations Flexible colonscopy or rigid sigmoidscopy (biopsy!) Barium enema CT scan and ultrasonography : to detect the lymph node invasion and hepatic metastasis . Carcinoembryonic antigen ( CEA ) , a tumor marker , useful in diagnosis , prognosis , or evaluation 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 therapy: chemotherapy , radiotherapy immunotherapy , traditional Chinese medicine,3. Treatment of complication A. Obstruction Right colon: carcinoma can be resected and anastomosed 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 resected 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 vessels. lined with colonic epithelium characterized by many lymph follicles. McBurney point , 510 cm in length , 0.50.7 cm in diameter, at any position on a clockwise rotation from the base of the cecum.,Pathophysiology Hyperplasia of the lymphoid follicles(60%) , fecalith (35%) obstruction bacteria multiply endotoxins A epithelium damage exotoxins mucosa ulcerated inflammatory process ischemia necrosisperforation peritonitis,Pathological Classification of acute appendicitis acute simple appendicitis acute purulent appendicitis gangrenous or perforated appendicitis 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 abdominal pain followed by nausea epigastrium umbilicus the right lower quadrant. 2. Temperature, spasm, tenderness and rebound tenderness in the MacBurney point.,Assistant physical examinations 1. Rovsing sign (colon air filling test) 2. Obturator sign 3. Psoas sign 4. Rectal examination,Differential diagnosis 1. 1. Peptic ulcer perforation 2. 2. Ureteral stones 3. 3. Gynecological and obstetric diseases Ectopic pregnancy , ruptured ovarian cyst or follicle acute salpingitis , wisted ovarian cyst 4. 4. acute mesenteric lymphadenitis 5 5. Others : acute gastroenteritis , cholecystitis, children intussusception, cecum tumor,Treatment First choice -appendectomy Incision selection find it cut and ligate mesoappendix pursestring suture resec