Lower GI surgery

1
Lower GI surgery

• Dr.Ishara Maduka

2
Contents

• Anatomy
• Intestinal obstruction
• Appendicitis
• Inflammatory bowel disease
• Colorectal carcinoma
• Stomas

3
Anatomy revision
4
Intestinal obstruction - Types

• Types according to pathology
• Mechanical obstruction
• Adynamic obstruction
• Types according to site of obstruction
• Small intestinal obstruction
• Large intestinal obstruction

5
Mechanical obstruction

• Obstruction due to external or internal factor
  leading to narrowed lumen with normal peristalsis.

6
Mechanical obstruction - causes
7
Lesions Extrinsic to Intestinal Wall

• Adhesions (usually postoperative)
• Hernia
• External (e.g., inguinal, femoral, umbilical, or
  ventral hernias)
• Internal (e.g., congenital defects such as
  paraduodenal, foramen of Winslow, and
  diaphragmatic hernias or postoperative secondary
  to mesenteric defects)
• Neoplastic
• Carcinomatosis, extraintestinal neoplasm
• Intra-abdominal abscess/ diverticulitis
• Volvulus (sigmoid, cecal)

8
Lesions Intrinsic to Intestinal Wall

• Congenital
• Malrotation
• Duplications/cysts
• Traumatic
• Hematoma
• Ischemic stricture
• Infections
• Tuberculosis
• Actinomycosis
• Diverticulitis

• Neoplastic
• Primary neoplasms
• Metastatic neoplasms
• Inflammatory
• Crohn's disease
• Miscellaneous
• Intussusception
• Endometriosis
• Radiation enteropathy/stricture

9
Intraluminal/ Obturator Lesions

• Gallstone
• Enterolith
• Bezoar
• Foreign body

10
Whats adynamic obstruction

• Adynamic obstruction means failure of progression
  of bowel contents in absence of mechanical
  obstruction but due to absent or ill coordinated
  bowel contractions.

11
Normal peristaltic wave
12
Causes of Adynamic Ileus

• Following celiotomy
• small bowel- 24h, stomach- 48h, colon- 3-5d
• Inflammation e.g. appendicitis, pancreatitis
• Retroperitoneal disorders e.g. ureter, spine,
  blood
• Thoracic conditions e.g. pneumonia, ribs
• Systemic disorders e.g. sepsis, hyponatremia,
  hypokalemia, hypomagnesemia
• Drugs e.g opiates, Ca-channel blockers,
  psychotropics

13
Symptoms and signs of bowel obstruction

• Colicky central abdominal pain
• Vomiting - early in high obstruction
• Abdominal distension - extent depends on level of
  obstruction
• Absolute constipation - late feature of small
  bowel obstruction
• Dehydration associated with tachycardia,
  hypotension and oliguria
• Features of peritonism indicate strangulation or
  perforation

14
Investigations

• Supine abdominal X ray
• Other Ix depending on DD

15
Supine x ray in Intestinal obstruction
16
Treatment

• Adequate resuscitation prior to surgery is
  important
• Surgery in under resuscitated patient is
  associated with increased mortality
• If obstruction presumed to be due to adhesions
  and there are no features of peritonism
• Conservative management for up to 48 hours is
  often safe
• Requires regular clinical review

17

• If features of peritonism or systemic toxicity
  present
• Need to consider early operation
• Exact procedure will depend on underlying cause

18
Appendicitis

• Inflammation of the appendix is called
  appendicitis.
• Patients present with pain in the right iliac
  fossa.

19
Differentials for pain in RIF

• Appendicitis
• Urinary tract infection
• Non-specific abdominal pain
• Pelvic inflammatory disease
• Renal colic
• Ectopic pregnancy
• Constipation

20
Risk
21
Clinical features

• Central abdominal pain moving to right iliac
  fossa
• Nausea, vomiting, anorexia
• Low-grade pyrexia
• Localised tenderness in right iliac fossa
• Features of peritonism rebound tenderness,
  percussion tenderness

22
Investigations

• Appendicitis is a clinical diagnosis
• USS, FBC, UFR can help to exclude differential
  diagnoses

23
Treatment

• Treatment is surgical for confirmed acute
  appendicitis.

24
Inflammatory bowel disease

• IBD

25
IBD

• Chronic inflammatory condition involving the
  bowels which have a protracted, relapsing course.
• 2 pathologies
• Ulcerative colitis
• Crohns disease

26
Clinical features

• Diarrhoea
• PR bleeding
• Weight loss
• Fever during attacks

27
Colorectal carcinoma
28
Epidemiology

• one of the most common cancers in the world
• US4th most common cancer (after lung, prostate,
  and breast cancers)
• 2nd most common cause of cancer death (after lung
  cancer)
• 2001130,000 new cases of CRC 56,500 deaths
  caused by CRC

29
(No Transcript)
30
Adenoma carcinoma sequence
31
Risk factors

• Age
• Adenomas, Polyps
• Sedentary lifestyle, Diet, Obesity
• Family History of CRC
• Inflammatory Bowel Disease (IBD)
• Hereditary Syndromes (familial adenomatous
  polyposis (FAP))

32
Dietary factors implicated in colorectal
carcinogenesis
consumption of red meat animal and saturated
fat refined carbohydrates alcohol
increased risk
33
Contd..
dietary fiber vegetables fruits antioxidant
vitamins calcium folate (B Vitamin)
decreased risk
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
Symptoms and signs
Specific symptoms rectal bleeding change in
bowel habits obstruction abdominal pain
mass iron-deficiency anemia
General symptoms weight loss loss of
appetite night sweats fever
38
Treatment
Surgical resection the only curative
treatment Likelihood of cure is greater when
disease is detected at early stage Early
detection and screening is of pivotal importance
39
Screening for CRC
fecal occult blood test (FOBT) chemical test for
blood in a stool sample. annual screening by
FOBT reduces colorectal cancer deaths by
33 Flexible sigmoidoscopy can detect about
6575 of polyps and 4065 of colorectal
cancers. rectum and sigmoid colon are visually
inspected
40
Surgery

• Hemicolectomy or colectomy depending on the
  location of the tumour.
• A stoma may have to be created either temporarily
  or permanently.

41
Stomas
42
Whats a stoma

• A stoma is a surgically created communication
  between a hollow viscus and the skin
• Includes a colostomy, ileostomy, urostomy,
  caecostomy, jejunostomy and gastrostomy
• Functionally they can be end or loop stoma

43
(No Transcript)
44
(No Transcript)
45
Positioning

• Away from umbilicus, scars, costal margin and
  anterior superior iliac spine
• Ensure compatible with the clothing worn by the
  patient
• Ideally should be marked preoperatively by stoma
  nurse

46
Complications

• Necrosis
• Detachment
• Recession
• Stenosis
• Prolapse
• Ulceration
• Parastomal herniation
• Fistula formation

47

• Retraction

48
Prolapse
49
Thank You