AP (see familial Colon Cancer Syndromes,GS42 )

• juvenile polyps

• other: leiomyomas, lipomas, and hemangiomas

Table 15. Malignant Tumours of the Small Intestine

Adenocarcinoma Carcinoid/GI NETNeuroendocrine Tumour

Lymphoma Metastatic

Usually SO Carcinoid Syndrome Symptoms - TO yr Mostcommon site of Gl

mclastases in patients

with metastatic melanoma

Epidemiology Highest incidence in

70sM>F

Usually non-Hodgkin’s

lymphoma

Crohn’s.celiac disease,

autoimmune disease,

immunosuppression,

radiation therapy,

and nodular lymphoid

hyperplasia

Classified based on embryologica!origin Usually distal ileum

(foregut. midgut,and hindgut)

Originate from gut cnlciochtomaffin cell patients with celiac

Appendix 46%,distal ileum 28%.

rectum17%

Increased incidence 50-60 yr

M>F

FDR

Flushing

Diarrhea

Right-sided heart failure Crohn’s. FAP,history

of CRC.HNPCC

Risk Factors Melanoma,breast,lung,

ovary,colon,andcervical

cancer

Originlocalion Usually in proximal

small bowel,

incidence decreases

distally

Hematogenous spread

from breast,lung,and

kidney

Direct extension from

cervix,ovaries,and colon

Proximal jejunum in

disease

ClinicalFeatures Early metastasis to

lymph nodes

80% metaslalic at

time of operation

Abdominal pain

(common)

K/V.anemia,Gl bleeding,jaundice,and Fatigue,weight loss,fever Obstruction and bleeding

weight loss (less common) malabsorption,abdominal

Often slow-growing

Usually asymptomatic,incidental finding constipation,and mass

Obstruction,bleeding,crampy

abdominal pain,and intussusception

Carcinoid syndrome (<10%)

Hot flashes,hypotension,diarrhea,

bronchoconslriction.and right heart

failure

Requires liver Involvement:lesion

secretes serotonin,kinins,and

vasoactive peptides directly to

systemic circulation (normally

inactivated by liver)

pain, anorexia, vomiting.

Rarely perforation,

obstruction,bleeding,and

intussusception

Investigations Cl abdomcn/pelvis Cl abdomen/pclvis

Endoscopy

Most found incidentally at surgery for Cl abdomcn/pelvis

obstruction or appendectomy

Cl thorax/abdomen/pelvis

Consider small bowel enterodysis to

look for primary

Serum chromograninAas a tumour

marker

Elevated 5-HIAA (breakdown product

of serotonin) In urine or increased 5-HT

in blood

Some nuclear medicine testing available

but should be done by endocrine

oncologist.Testing includes Galium

D01AIAIE and octreotidescans

Surgical resection

'

chemotherapy

Carcinoid syndrome treated with

octreotide

Metastatic risk 2% if sixe<1cm,90%

if >2 cm

low- grade: chemotherapy Palliation

with cyclophosphamide

High-grade:surgical

resection,and radiation

Palliative:somatostatin,

doxorubicin

5 yr survival 40%

Treatment Surgical resections

chemotherapy

Syr survival 25% (if

node positive)

5 yr survival 70%:20% with liver

melastases

Based on the Ki67 index

Prognosis Poor r T

L J

Indirect Inguinal Hernias:Rule of 5s

Staging System THM TNM Ann Arbor

5%lifetime incidencein males

5x more common than direct Inguinal

hernias

5-10x more common in males than

females

Generally occur by 5th decade of life

+

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GS33 General and Thoracic Surgery Toronto Notes 2023

Short Gut Syndrome

Inguinal Hernias Definition

• reduced surface area (length) of small bowel causing insufficient intestinal absorption leading to

diarrhea, malnutrition, and dehydration

Etiology

• due to surgical resection

• large amount of bowel at once (acute mesenteric ischemia, trauma, malignancies)

• cumulative resections (Crohn’s disease)

• in infant and paediatric patients, the most common causes are necrotizing enterocolitis, abdominal

wall defects, jejunal ileal atresia, and midgut volvulus

MO's don't Lie

MD: Medial to the inferior epigastric a.

-

Directinguinal hernia

U:Lateral to the inferior epigastric a. *

Indirect inguinal hernia

Inguinal Canal Walls -

MALT x 2

2 MRoof 2 muscles (internal

oblique, transversus

abdominis)

2 A Ant wall 2 aponeuroses (external

and internal oblique)

2 L Floor 2 ligaments (inguinal

and lacunar)

2 T Post wall 2T (transversalis fascia,

conjoint tendon)

Prognostic Factors

• residual small bowel length, residual colon length (reabsorption of water and electrolytes and some

reabsorption of nutrients),condition of the remnant small bowel (healthier bowel facilitate better

reabsorption), presence of ileocecal valve (delay transition into colon leading to more reabsorption)

• resection of ileum is less tolerated than resection of jejunum (ileum reabsorbs bile salt and vitamin

Bl2 )

Borders

o

of Hesselbach's Triangle

• Lateral: inferior epigastric artery

• Inferior:inguinal ligament

• Medial:lateral margin of rectus

sheath

Therapy

• medical

• IV fluids in acute management (initial 3-4 wk following resection) and TPN once stabilized to

replenish lost fluid and electrolytes in diarrhea

histamine 2-receptor antagonist or PP1 to prevent gastric acid secretion

antimotility agent to prolong transit time in the small intestine

consider octreotide to decrease G1 secretion and cholestyramine for bile acid absorption

• surgical: non-transplant

• to slow transit time:small bowel segmental reversal, intestinal valve construction, or electrical

pacing of small bowel

• to increase intestinal length:

• LILT'

(longitudinal intestinal lengthening and tailoring) procedure

• ST EP (serial transverse enteroplasty procedure) in dilated small bowels

• surgical:small bowel transplant

indication:life-threatening complication from intestinal failure or long-term T PN, including liver

failure, thrombosis of major central veins, recurrent catheter-related sepsis, and recurrentsevere

dehydration

Shotrldice Technique vs. Other Open Techniques

for Inguinal Hernia Repair

Cochrane 08 Syst Rev 2012:4:10001543

Purpose:1o evaluate the efficacy and safety of

the Shouldxe technique compared lo other non -

laparoscopic techniques.

Results Conclusions: 16 RCTsor quasi-ratidomued

Mis with 2566 hecnias|U21mesh:1608 norr-mesh).

The recurrence rate with Shonldxe was lagher

than mesh (08 3.80, 95% Cl 1.99-7.26) but lower

than non-mesh (OR 0.62, 95% Cl 0.45-0.85).There

was co difference in chronic pain or complications.

In conclusion,with respect tn recurrence rates.

Shouldice herniorrhaphy is the best non-mesh

technique, although infetiot to mesh . However, it

vsatso Roretime consuming andresultsiai slightly

longer postoperative hospital stays.

Abdominal Hernia

•see HM I us Hernia, ( iS23

Definition

•defect in abdominal wall causing abnormal protrusion of intra-abdominal contents long-term Results of a Randomiied Controlled

Trial of a Honoperative Strategy (Watchful

W ailing ) for Men with Minimally Symptomatic

Inguinal Hernias

inn Sorg 2013:258:508-514

Purpose: Ascertain ng the long-term crossover (00)

rate in patients with asymptomatic or minimally

symptomatic inguinal hernias undergoing watchfulwait«g (WW|at their primary treatment modality.

Background : i 2006 RCf comparing WIff with

routine inguinal heima icpoir, concluded that

WW was an acceptable option in the management

of male patients with minimal symptoms(JAMA

200629S(3)28S-292|.This study analyzesthe WW

group after 7 years of follow-up.

Conclusions:The estimated CO rale far the WW

cohort was 68%, while men older than 65 had a rate

of 79%.Therefore, while WW is a safe strategy,it is

.1 I -Kent!v. :! progress,ridelr : ve

surgical management will be indicated.

Epidemiology

•M:l

’

=9:l

•lifetime risk of developing a hernia: males 20-25%, females 2%

•frequency of occurrence:50% indirect inguinal, 25% direct inguinal, 8-10% incisional (ventral), 5%

femoral, and 3-8% umbilical

•most common surgical disease in males

Risk Factors

•activities which increase intra-abdominal pressure

obesity, chronic cough, asthma,COPD, pregnancy, constipation, bladder outlet obstruction,

ascites, and heavy lifting

•congenita] abnormality (e.g.patent processus vaginalis and indirect inguinal hernia)

•previous hernia repair, especially if complicated by wound infection

•loss of tissue strength and elasticity (e.g. hiatal hernia, aging, and repetitive stress)

•family history

Clinical Features

•mass of variable size

•tenderness worse at end of day, relieved with supine position or with reduction

•abdominal fullness, vomiting, constipation

•transmits palpable impulse with coughing orstraining

Investigations

•physical examination usually sufficient

•U/S ± CT (CT required for obturator hernias, internal abdominal hernias, and Spigelian and/or

femoral hernias in obese patients)

# L J

Outcomes of laparoscopic vs. Open Repair o!

Primary Ventral Hernias

JAMA Ssrg 2013:148:1043-1048

See LaTidmerk Genera I and thoracicSurgery Inals

table (or more information on outcomes of patents

electiWly cmfcrgo. ng laparoscopic ventral Hernia

repair (U7HR) vs. open ventral hernia repair (0VHR|

+

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Classification

• complete: hernia sac and contents protrude through defect

• incomplete: partial protrusion through the defect

• internal hernia:sac herniating into or involving intra-abdominal structure

• external hernia:sac protrudes completely through abdominal wall

• strangulated hernia: vascular supply of protruded viscus is compromised (ischemia)

• requires emergency repair

• incarcerated hernia:irreducible hernia, not necessarily strangulated

• Richter’

s hernia:only part of bowel circumference (usually anti-mesenteric border) is incarcerated or

strangulated so may not be obstructed

a strangulated Richter'

s hernia may self-reduce and thus be overlooked, leaving a gangrenous

segment at risk of perforation in the absence of obstructive symptoms

• sliding hernia: part of wall of hernia sac formed by retroperitonealstructure (usually colon)

Inguinal Region (Male)

(eternal interior epigastric inguinal artery and vein

nng V

Rectus

abdominis

muscle \

Hesselbach'

s

L triangle .

Ingu

gen

IIIHI External

inguinal men)

ring Femoral

artery

Femoral Femoral Anatomical Types ring

• groin

indirect and direct inguinal, femoral

• pantaloon: combined direct and indirect hernias, peritoneum draped over inferior epigastric

vessels

• epigastric:defect in linea alba above umbilicus

• incisional: ventral hernia at site of wound closure, may be secondary to wound infection

• other: Littre’

s (involving Meckel'

s), Amyand'

s (containing appendix), lumbar, obturator, peristomal,

umbilical,Spigelian (ventral hernia through linea semilunaris)

Spermatic

cord

Normal Anatomy

Complications

• incarceration

• strangulation

small, new hernias more likely to strangulate

• femoral > indirect inguinal > direct inguinal

intense pain followed by tenderness

intestinal obstruction, gangrenous bowel,sepsis

surgical emergency

DO NOT attempt to manually reduce hernia if septic or if contents of hernial sac gangrenous. This

will result in reduction of gangrenous contents and subsequent need for laparotomy Indimcl Hernia

Treatment

• surgical treatment (herniorrhaphy) is only to prevent strangulation and evisceration, for symptomatic

relief, for cosmesis;if asymptomatic can delay surgery.Data hasshown that prophylactic surgery does

not affect rate of strangulation in ASYMPTOMATIC patients.

• repair may be done open or laparoscopic and may use mesh for tension-free closure

• most repairs are now done using tension free techniques- a plug in the hernial defect and a patch over

it or patch alone

• observation is acceptable for small asymptomatic inguinal hernias

Postoperative Complications

• recurrence (15-20%)

risk factors:recurrent hernia, ages >50,smoking, BMI >25, poor preoperative functional

status(ASA 23-see Anesthesia. A4), associated medical conditions:T2DM, hyperlipidemia,

immunosuppression, and any comorbid conditions increasing intra-abdominal pressure

less common with mesh/“tension-free” repair

• scrotal hematoma (3%)

painful scrotal swelling from compromised venous return of testes

deep bleeding:may enter retroperitonealspace and not be initially apparent

difficulty voiding

• nerve entrapment

ilioinguinal (causes numbness of inner thigh or lateral scrotum)

« genital branch of genitofemoral (in spermatic cord)

• stenosis/occlusion of femoral vein

acute leg swelling

• ischemic colitis

• minimally invasive repair for ventral and umbilical hernia

r

Figure 11. Schematic of inguinal

(direct and indirect) and femoral

hernias +

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GS35 General and Thoracic Surgery Toronto Notes 2023

Groin Hernias

Robotic Inguinal vs.Transebdominal

Laparoscopic Inguinal Hernia Repair:the RIVAL

Randomired Clinical trial

JAMA Surg.2O20;1SS(5|:3B0- 3fi 7

Purpose:To deter- me whether a robotic approach

to inguinal hernia repair results m improved

postoperative outcomes compared with the

traditional laparoscopic inguinal hernia repairs.

Results:ttpieopeiatnre. t nreekand 30- day

assessmentsthere wtre no differences between

the groups on wound events,readmissions, pain, or

quahty ollife. However, the robotic appioach was

associated with increased cost,operative time,and

surgeon frustration compared to the laparoscopic

approach.

Conclusions: there is no benefit ol the robotic

appioach compared with the laparoscopic approach.

Table 16. Groin Hernias

Direct Inguinal Indirect Inguinal Femoral

Epidemiology 1% of all men Most common hernia in men and women Affects mostly females

M t

Etiology Acquired weakness of transvcrsalrs

fascia

"Wear and tear"

Increased intra abdominal pressure

Congenital persislenccof processus

vaginalis in 20% of adults

Pregnancy weakness of pelvic floor

musculature

Increased intra -abdominal pressure

Ihrough Hesselbach'striangle

Medial to inferior epigastric artery

Anatomy Originates in deep inguinal ring

lateral to inferior epigaslricartery

Usually does not descend into scrolal Often descends into scrotal sac (or labia

majora)

Into femoral canal, below inguinal

ligament but may override it

Medial to lemotal vein within femoral

canal

Surgical repair

sac

Surgical repair

3- 4% risk of recurrence

Surgical repair

«1% risk of recurrence

treatment

Prognosis

Table 17, Superficial Inguinal Ring vs. Deep Inguinal Ring*

Superficial Inguinal Ring Deep Inguinal Ring

Opening in external abdominal aponeurosis: palpable superior and

lateral to pubic tubercle

Medial border:medial crus of enter nal oblique aponeurosis

lateral border:lateral crusof external oblique aponeurosrs

Opening in transversalisfascia:palpable superior tomid-inguinal

ligament

Medial border: inferior epigastric vessels

Superior-lateral bolder:internal oblique and transversus abdominis

muscles

Roof:intercrural fibres Inferior border:inguinal ligament

'see BasicAnatomy Review.Figure 2.63

Appendix

Appendicitis

Epidemiology

• 6% of population, M>I

:

(1.4:1)

• 80% between ages 5-35

Psoas

/yfe major

1!

_!L :

Pathogenesis

• luminal obstruction -> bacterial overgrowth -> inflammation/swelling -> increased pressure ->

localized ischemia •-> gangrene/perforation -> localized abscess (walled off by omentum) or peritonitis

• etiology

children or young adult:hyperplasia of lymphoid follicles, initiated by infection

adult:fibrosis/stricture,fecalith, or obstructing neoplasm

other causes: parasites or foreign body

L A

V

/

Retrocecal

'

164%)

V

Ileal

' sub-ileal

<1% )

t 1

—"

Inferior (1%)

Pelvic (32%)

Paracolic

I2%r

~

liiacus muscle L

Obturator

internus

muscle

^

g Natalie Cormier 2015, after Wensi Shcng 2010,

•

Clinical

most reliable

Features

feature is progression of signs and symptoms o • low-grade fever (38‘G), rises if perforation

• abdominal pain then anorexia, N/V

• classic pattern: pain initially periumbilical;constant, dull, poorly localized, then well-localized pain

over McBurney’s point

• due to progression of disease from visceral irritation (causing referred pain from structures of the

embryonic midgut, including the appendix) to irritation of parietal structures

Figure 12. Appendix anatomy

• signs

inferior appendix: McBurney'

s sign (see sidebar), Rin sing'

s sign (palpation pressure to left

abdomen causes McBurney'

s point tenderness). McBurney’s sign is present whenever the opening

of the appendix at the cecum is directly under McBurney's point; therefore McBurney'ssign is

present even when the appendix is in different locations

retrocecal appendix: psoas sign ( pain on flexion of hip against resistance or passive

hyperextension of hip)

• pelvic appendix: obturator sign (flexion then external or internal rotation about right hip causes

pain)

McBurney's Sign

Tenderness 1/3 the distance from the

ASIS to the umbilicus on the right side

r i

L.J

Complications +

• perforation (especially if >24 h duration)

• abscess, phlegmon

• sepsis

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GS36 General and Tlioracic Surgery Toronto Notes 2023

Investigations

• laboratory

mild leukocytosis with left shift (may have normal WBC counts)

higher leukocyte count with perforation

p-hCG to rule out ectopic pregnancy

urinalysis

• imaging

U/S: may visualize appendix, but also helps rule out gynaecological causes - overall accuracy 90-

94%, can rule in but CANNOT rule out appendicitis (if >6 mm, SENS/SEEC/NEV/PFV 98%)

• CT scan: thick wall, enlarged (>6 mm), wall enhancement, appendicolith, and inflammatory

changes- overall accuracy 94-100%, optimal investigation

AntibioticsversusAppendectomyfor Acnte

Appendicitis- Longer-Term Ontcomes

N EnglJ Ued 202T;38S|25|:2395. Epub 2021Oct 25

Purpose:Compare Ibe efficacy of antibioticsis.an

appendectomy for acute appendicitiswild respect to

long-term outcomes.

Method: Pe'

domned trial comparing antibiotic

treatment mth appendectomy in patients with

appendicitis.

Results: he 30-day general health status of

patientstreated with antibiotics was comparable to

the appendectomy group.However, 29 percentof

medially-treated patients required appendectomy by

90 days,longer-term data from thistrial nowconfirm

h gi rates of subsequent appendectomy after indial

medical therapy:40 percent at one year, 46 percental

two years,and 49 percent at threeand foot years.

Conclusions:Sutgery should continue to be

recommended foi uncomplicated appendicrtisand

antibiotic therapy should be reserved for thosewho

are medially unfit for or decline surgery.

Treatment

• hydrate,correct electrolyte abnormalities

• appendectomy (gold standard)

laparoscopic is standard

complications:intra-abdominal abscess, appendiceal stump leak

perioperative antibiotics: cefazolin + metronidazole, if uncomplicated perioperative dose is

adequate

• consider treatment with postoperative antibiotics for perforated appendicitis

• for patients who present with an abscess (palpable mass or phlegmon on imaging and often delayed

diagnosis with symptoms for >4-5d), consider radiologic drainage + antibiotics xl4 d ± interval

appendectomy once inflammation has resolved = (controversial)

• medical management with antibiotic therapy should be reserved for those who are unfit for or refuse

surgery

• colonoscopy in those >50 yr to rule out concurrent etiology (neoplasm)

Prognosis

• mortality rate: 0.09-0.24%

Inflammatory Bowel Disease

• see Gastroenterology', G22

Principles of Surgical Management

• medical management remainsfirst line, but surgery can alleviate symptoms, address complications,

and improve quality of life

• conserve bowel: resect aslittle as possible to avoid short gut syndrome

• perioperative management

optimize medical status: may require TEN (especially if >7 d NEC)) and bowel rest

hold immunosuppressive therapy preoperative, provide preoperative stress dose of corticosteroid;

if patient had recent steroid therapy, taper steroids postoperative

VTE prophylaxis:LMWH or heparin (IBD patients at increased risk of thromboembolic events)

Crohn’s Disease

•see Gastroenterology. G23

Treatment

•surgery is for symptom management; it is NOT curative, but over lifetime -70% of Crohn'

s patients

will have surgery

•indications for surgical management

failure of medical management

SBO (due to stricture/inflammation):indication in 50% ofsurgical cases

abscess,fistula (enterocolic, vesicular, vaginal, cutaneous abscess), quality of life, perforation,

hemorrhage, chronic disability, failure to thrive (children), and perianal disease

•surgical procedures

resection and anastomosis/stoma if active orsubacute inflammation, perforation,or fistula

• surgery should be attempted in the elective setting ideally off steroids

•resection margin only has to be free of gross disease (microscopic disease irrelevant to prognosis)

stricturoplasty - widens lumen in chronically scarred bowel: relieves obstruction without

resecting bowel (contraindicated in acute inflammation )

Complications of Treatment

•anastomotic leak

•dehydration

•short gutsyndrome (diarrhea,steatorrhea, malnutrition)

•fistulas

•gallstones (if terminal ileum resected, decreased bile salt resorption > increased cholesterol

precipitation)

•kidney stones (loss of calcium in diarrhea -> increased oxalate absorption and hyperoxaluria > stones)

Crohn

m's 3 Major Patterns

• Ileocecal 40% (RIOpain,fever,

weight loss)

• Small intestine 30% (especially

terminal ileum)

. Colon 25% (diarrhea)

Findings in Crohn’s

• "Cobblestoning” on mucosal surface

due to edema and linear ulcerations

• “Skip lesions": normal mucosa in

between

• "Creeping fat":mesentery infiltrated

by fat

• Granulomas:25-30%

r-t

L J

+

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Prognosis

• recurrence rate at 10 yr:ileocolic (25-50%),small bowel (50%), colonic (40-50%)

• re-operation at 5 yr:primary resection (20%), bypass (50%),strictureplasty (10% at 1 yr)

• 80-85% of patients who need surgery lead normal lives

. mortality: 15% at 30 yr

Ulcerative Colitis

•see Gastroenterology.G25

Treatment

•indications for surgical management

failure of medical management (including inability to tapersteroids)

complications: hemorrhage, obstruction, perforation, toxic megacolon (emergency), failure to

thrive (children)

reduce cancer risk (1-2% risk per yr after 10 yr of disease)

•surgical procedures

proctocolectomy and ileal pouch-anal anastomosis (1PAA) ± rectal mucosectomy (operation of

choice)

proctocolectomy with permanent end ileostomy (if not a candidate for ileoanal procedures)

colectomy and 1FAA ± rectal mucosectomy

in emergency: total colectomy and ileostomy with Hartmann closure of the rectum,rectal

preservation

Complications of Treatment

•early:bowel obstruction, transient urinary dysfunction,dehydration (high stoma output),

anastomotic leak

•late:stricture,anal fistula/abscess, pouchitis, poor anorectal function, reduced fertility

Prognosis

•mortality: 5% over 10 yr

•total proctocolectomy will eliminate risk of cancer

•perforation of the colon is the leading cause of death from UC

LARGE INTESTINE

Large Bowel Obstruction

Mechanical Large Bowel Obstruction

Etiology

Top 3Causes of LBO (in order)

• Cancer (>60%)

. Volvulus (10-15%)

. Diverticulitis(10%)

Table 18. Common Causes of LBO

Intraluminal Intramural Extramural

Constipation

Foreign bodies

Adenocarcinoma

Diverticulitis (edema, stricture)

IBD stricture

Radiation stricture

Volvulus

Adhesions

Hernias (sigmoid colonin a large groin hernia)

In a patient with a clinical LBO consider

impending perforation when:

• Cecum i12 cm in diameter

• Tenderness present over cecum

Clinical Features (unique to LBO)

• open loop (10-20%)

• incompetent ileocecal valve allows relief of colonic pressure as contents reflux into ileum,

therefore clinical features similar to SBO

• closed loop (80-90%) (dangerous)

competent ileocecal valve,resulting in proximal and distal occlusions

massive colonic distention -» increased pressure in cecum -» bowel wall ischemia -> necrosis ->

perforation

n

L

Investigations

• GBG with differential, BUN, electrolyte panel, creatinine,CEA if patient is suspected to have

malignancy, and lactate for level of ischemia

• imaging: AXK and CT scan +

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Treatment

• supportive management: IV fluids, gastrointestinal decompression

• surgical intervention (75% of cases)

volvulus: initial decompression with flexible sigmoidoscopy, operative reduction or sigmoid

resection dependent on severity

colorectal obstruction:ostomy alone (fecal diversion),colectomy with primary anastomosis, or

Hartmann procedure

• may pursue stenting as a bridge to surgery or palliation

Prognosis

• overall mortality: 10%

• cecal perforation t feculent peritonitis: 20% mortality

Table 19. Bowel Obstruction vs. Paralytic Ileus

SBO LBO Paralytic Ileus

Early,may be bilious

Colicky

Abdominal Distention (pros SBO).** (distal SBO)

Constipation

Bowel Sounds

N/V Late, may be feculent

Colicky

Present

Abdominal Pain Minimal or absent

Normal.Increased

Absent if secondary ileus

(delayed presentation)

Ait-fluid lewis

“ladder" pattern (plicae

circulares)

Proximal distention (>3 cm)

no colonic gas

Normal,increased (borborygmi)

Absent ilsecondary ileus (delayed presentation)

Decreased.absent

AXR Findings Air-fluid levels

“Picture frame"appearance

Proximal distention distal decompression

No small bowel air if competent ileocecal valve

Coffee bean sign (sigmoid volvulus)

Air throughoutsmall bowel

and colon

Functional Large Bowel Obstruction:Colonic PseudoObstruction (Ogilvie’s Syndrome)

Definition

• acute pseudo-obstruction

• distention of colon without mechanical obstruction in distal colon

• exact mechanism unknown, likely autonomic motor dysrcgulation

Associations

• most common: trauma, infection, and cardiac (MI, CHI'

)

• disability (long-term debilitation, chronic disease, bed-bound nursing home patients, and

paraplegia), drugs (narcotic use, laxative abuse, and polypharmacy), and other (recent orthopaedic

or neurosurgery, post-partum, electrolyte abnormalities including hypokalemia, retroperitoneal

hematoma, and diffuse carcinomatosis)

Clinical Features

• classically presents with abdominal distention (acute or gradual over 3-7 d)

• abdominal pain, N/V, constipation or diarrhea

• watch out for fever,leukocytosis, and presence of peritoneal signs(suggestive of colonic ischemia or

perforation)

Investigations

• AXR:cecal dilatation (if diameter £12 cm, increased risk of perforation)

Treatment

• treat underlying cause

• NFC), NG tube

• decompression: rectal tube,colonoscopy, neostigmine (cholinergic drug),orsurgical (ostomy/

resection)

• surgery (extremely rare): if perforation, ischemia, or failure of conservative management

Prognosis

• most resolve with conservative management

r-i

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Diverticular Disease

Definitions

• diverticulum:abnormal outpouching from the wall of a hollow organ

• diverticulosis: presence of multiple diverticula

• diverticulitis:inflammation of diverticula

• true (congenital) diverticuli:contain all layers of colonic wall,often right-sided

• false (acquired) diverticuli: contain mucosa and submucosa, often left-sided

FALSE DIVERTICULUM ,

(mucosal herniations) V

TRUE DIVERTICULUM

(full wall thickness) 11

Y,

Mucosa' x— Antimesentenc

tenia /

Circular muscle

I MesocolonMesenteric teniaSBR I

Figure 13. Diverticular disease -cross-sections of true and false diverticula

Diverticulosis

Epidemiology

• 5-50% of Western population, lower incidence in non-Western countries,M=F

• prevalence is age dependent: <5% by age 40, 30% by age 60, 65% by age 85

• 95% involve sigmoid colon (site of highest pressure)

Pathogenesis

• risk factors

lifestyle:diet (low-fibre, high fat, red meat), inactivity, and obesity

muscle wall weakness from aging and illness(e.g.Ehlers-Danlos, Marfan’s)

• high intraluminal pressures cause outpouching to occur at points of greatest weakness, most

commonly where vasa recta penetrate the circular muscle layer leading to an increased risk of

hemorrhage

Clinical Features

• uncomplicated diverticulosis:asymptomatic (70-80%)

• episodic abdominal pain (often LLQ), bloating,flatulence, constipation,diarrhea

• absence of fever/leukocytosis

• no physical exam findings or poorly localized LLQ tenderness

• complications:

diverticulitis (15-25%):25% of which are complicated (i.e. abscess,obstruction, perforation,

fistula)

bleeding (5-15%): PAINLESS rectal bleeding, 30-50% of massive LGIB

diverticular colitis(rare):diarrhea,hematochezia,tenesmus,and abdominal pain

Diverticulosis vs.Diverticulitis

Diverticulosis represents the presence of

diverticuli (bulging pouches) within the

colonic wall, whereas diverticulitis is the

inflammation of one or more diverticuli

Treatment

• uncomplicated diverticulosis: high fibre, education

• diverticular bleed

initially workup and treat as any LGIB

if hemorrhage does not stop, resect involved region

Diverticulitis

Epidemiology

• 95% left-sided in patients of Western countries, 75% right-sided in Asian populations

Pathogenesis

• erosion of the wall by increased intraluminal pressure or inspissated food particles -> inflammation

and focal necrosis-> micro or macroscopic perforation

• usually mild inflammation with perforation walled offby pericolic fat and mesentery; abscess,fistula,

or obstruction can ensue

• poor containment resultsin free perforation and peritonitis

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