小肠疾病分类和应用SmallIntestinalDisease

1、小肠疾病分类和应用Small Intestinal DiseaseAnatomy and PhysiologyThe anatomy of small intestine length: 35mportions blood supply：superior mesenteric a nerve：autonomic Sympathetic Parasympathetic duodenum:25cm jejunum :2/5 ileum:3/5Four layers : mucosa submucosa muscularis serosaPeyerpatchesVillus mucosa The p

2、hysiology of small intestine secrete alkaline intestinal juicedigestion and absorption endocrine and immune Inflammatory Bowel Disease Crohn DiseaseEtiologyunclearPathology occur in any segment of the peptic tractgranulomatous inflammatory lesion ，involve full-thickness bowel layerClinical manifesta

3、tionoccur in any age 60% cases 50%Tuberculosis of intestineetiology and pathology secondary infection position：ileum-cecum ulcerative type and proliferative typeclinical findings younglow fever, night sweat，fatigue, weightloss,poor appetitechronic abdominal paindiarrhea and constipationcomplicationd

4、iagnosisblood routine,ESR,chest film,barium meal and barium enema,coloscopyhistory and clinical manifestationtreatmentmedical therapysurgical indication complication such as obstruction 、 fistula 、 perforation、bleeding operative ways:resect the partial bowel and anastomosisperforation repairmentBy-p

5、assIntestinal Perforation of Typhoid Fever etiology and pathologyinfection by bacillus typhussite: the last portion of the ileum simple perforation:80-90%clinical findings diffuse peritonitis symptomsacute severe abdominal painmuscle guardness, tenderness and rebound tendernessmajor treatment repair

6、 of the perforationAcute Hemorrhagic Enteritisetiology:unclearmaybe related to toxin of Welch baciluspathology the lesion localized in jejunum or ileumlocal congestion, hemorrhage,necrosis and ulcerationClinical findings occur in children and youngeracute abdominal pain accompanied by nausea, vomiti

7、ng ,diarrhea , hematochezia. distention , tendernesssigns of bowel of strangulationtoxic shockTreatmentmedical treatment (main method)keep internal environment stablefasting, gastrointestinal decompressionantibioticnutritional supportsurgical indication obvious peritonitis bowel bleeding is difficul

8、t to controlintestinal obstructionaggravation after medical therapyDiagnosis NOT clearIntestinal Obstruction definition：a partial or complete blockage of the bowel results in the failure of the intestinal contents to pass throughEtiology and Classification（一）According to the obstructive cause1、 Mech

9、anical ：high incidence intraluminal obstructionExtrinsic bowel tract lesionsIntrinsic bowel wall lesion 1） intraluminal obstruction（1） 胆结石（2） 粪石（3） 毛发团（4） 异物（5 ）肠减压管气囊（6） 寄生虫（7） 腔内憩室2）lesions extrinsic to the bowel（1） 粘连：手术后；先天性；炎症后（2） 疝：腹壁疝；腹内疝（3） 先天性：环状胰腺；腹膜包裹（4） 肿瘤：肠外肿瘤； 肠系膜肿瘤（5） 炎症：腹腔内脓肿；腹腔异物（6）

10、 其他：肠系膜上动脉综合征；3）intrinsic bowel wall lesions（1）肠道闭锁 （2）炎症狭窄，肠套叠，肠扭转（3）肿瘤等2、Dynamic (Paralytic ileus) 1）麻痹性：（1）腹腔手术后； （2）腹部创伤； （3）急性弥漫性腹膜炎 2）痉挛性：（1）急性肠炎； （2）肠道功能紊乱； （3）慢性铅中毒；3、Hematogenesis 血运性肠梗阻 肠系膜血管栓塞或血栓形成致使肠管发生血运障碍4、 Idiopathic Intestinal Pseudo-ObstructionChronic illness, recurrenceHeredityImpa

11、ired motor response to bowel distentionDuodenal,colonic slow waves normalAbsence of radiogaphic findings of mechanical obstructionNon-surgical treatment（二） According to the blood supply of the bowel wall1、simple 只有肠内容物通过受阻，无肠管血 运障碍。 2 、strangulation 梗阻伴有肠管血运障碍，例如：肠系膜血管栓塞（三）按梗阻部位1 高位梗阻：空肠及近段回肠2 低位梗阻：

12、结肠及远段回肠（四）按梗阻程度1 不完全性肠梗阻2 完全性肠梗阻（五）按病程缓急1 急性肠梗阻2 慢性肠梗阻（六）特殊类型：闭袢性肠梗阻 粘连肠套叠嵌顿扭转、粪性蛔虫性Pathology and Pathophysiologypathology （acute） proximal bowel distention luminal pressure venous return hindrance congestin,edema, exudation pressure artery return hindrance necrosis and perforationChronic intestinal

13、 obstruction incomplete long time bowel wall hypertrophyintestinal pattern and peristaltic wavesPathophysiology the loss of body fluid：water and electrolyte disorder and metabolic imbalance (The intestinal tract secretes up to 8.0L/d ) infection and intoxication ：the damage of intestinal barrier and

14、 bacteria translocation, toxin absorptionshock：dehydration、blood concentration、hypovolemia 、metabolic disorder、bacteria infection and intoxication respiratory and circulation dysfunction：abdominal pressure increasedabdominal compartment hypertension临床表现症状痛、呕、胀、闭痛呕胀Clinical Manifestation Abdominal pa

15、in Vomiting Distention Failure to pass gas and stool单纯性机械性肠梗阻 反复发作的、节律性的、阵发性腹部绞痛绞窄性肠梗阻 腹痛间歇不断缩短 持续性腹痛 疼痛程度不断加重麻痹性肠梗阻 持续性胀痛 VomitingEarly reflectivityParalysis overflowHigh position early and frequentlyLow position late and few Distention 高位-不明显 低位-显著，遍及全腹 闭袢性(closed loop)腹周膨胀 结肠闭袢 腹胀不对称 肠扭转Failure t

16、o pass gas and stool完全性肠梗阻 停止排便排气高位肠梗阻 早期梗阻以下的残留气体和粪便仍可排出肠套叠和血运性肠梗阻（绞窄） 可排出血性或果酱样便ExaminationAbdominal signs： Abdominal bulge, gastrointestinal patterns and peristaltic waves, tenderness and rebound tenderness, positive shift dullness, high pitched bowel sound or bowel silence in late stage and bowe

17、l paralysis Digital rectal examination Lab test：the results with the change of the primary disease itself Early stage: normal or slight abnormal Late stage: disorder of many serum markersX-ray： Supine and upright abdominal radiographs with stepladder pattern of air-fluid levels and no colonic gas no

18、te: The barium enema is need if the intussusceptions ,sigmoid rotation or colon tumor are suspicious. In small-bowel obstruction, radiologic evaluation has several goals. It is carried out to confirm the diagnosis, distinguish between simple and strangulating obstruction, differentiate the various c

19、auses of obstruction, estimate the degree of obstruction, and exclude the possibility of colonic obstruction or paralytic ileus Diagnosis is it intestinal obstruction? history clinical findings X-ray examination is it mechanical or dynamic？ history X-ray findingsSimple or Strangulation （Very Importa

20、nt）Acute and persistent severe abdominal painEmergently and early shock Severe peritoneal irritation signAsymmetric distention ，palpable massBleeding content of vomitus , discharge and abdominal paracentesisX-ray shows isolated ansa interstinalis Medical treatment failureThe Obstructive Site: Low or

21、 HighHigh:vomitting occur in early stage and show slight abdominal distentionLow: severe abdominal distentionX-ray findingsComplete or Incompletecomplete: severe and acuteincomplete: chronic and slightThe Cause of ObstructionAlways very difficult to identificateHistory is very importantTreatmentPrin

22、ciples： Correct the systemic pathophysiologic disorder Relieve obstruction。Basic TreatmentNaso-gastric suctionCorrect body fluid disorderPrevent infection and intoxicationGeneral treatment:sedation,spasmolysisRemove the ObstructionSurgeryIndications：strangulation、caused by tumor and congenital bowel

23、 malformation, can not relieved by medical therapyAims：utility the simplest methods to remove the obstruction and recover the continuity of the bowel in the shortest timeMethodsRemove the cause ： Such as adhesion remove,foreign body taken out、replacement of intussusception and volvulusIntestinal res

24、ection and anastomosis: tumor,stenosis,necrosis How to judge the intestinal necrosis in the operation ? The bowel wall is black No peristaltic capability and tension No pulsation of mesenteric terminal arteriole Bypass operation: The lesion is difficult to remove Enterostomy or Intestinal exterioriz

25、ation The patients condition cannot tolerance the complicated operation or the obstructive lesion is difficult to treat 手术方式 A.解除梗阻原因的术式 如粘连松解术如肠切开取异物，肠扭转复位术。B.肠切除肠吻合术 C.短路手术D.肠造口和肠外置术Medical treatment Indications： simple adhesive obstruction, paralysis or dynamic ileus、obstruction because of ascari

26、d or stoolmass,inflammatory obstruction and early stage of intussusceptionNotes： The state of illness should be monitor closedly during medical treatmentCommon typesAdhesive Obstruction（40%60%） Obstruction due to adhesionsEtiology and pathologyCongenital Secondary DiagnosisMechanical obstruction+ hi

27、story of abdominal operation, infection or trauma *如何区分广泛粘连梗阻与局部束带梗 阻？Prophylaxis: more significance减少组织损伤，减轻组织炎症反应 Treatment: simple, incomplete medical therapystrangulation surgical therapy Intestinal Volvulus(3600) Obstruction due to volvulusEtiologyAnatomic factors: Excessive long mesenterium Ad

28、hesionPhysical factors: Enteric bodyDynamic factors: Abnormal bowel motivation Alter the body position suddentlySlight4800Clinical findingsclosed loop： acute / severeSmall bowel: younger, motion after meal pain in the periumbilicus Sigmoid: aged, constipation habitsTreatment: It is a severe mechanic

29、al obstruction emergent operation Obstruction by foreign body（肠蛔虫、粪块等）A simple mechanical bowel obstruction 蛔虫成团+肠管痉挛Treatment :medical therapy and necessary surgery Bowl AscariasisChildren,countrysideMedical therapyIntussusceptionObstruction due to intussusceptionEtiology anatomy:cecum too free pat

30、hological factors:polyp ,tumor abnormality of intestineTypes intestine-intestine intestine-colon colon-colonClinical findings80%,2y childrenAbdominal pain ,currant-jelly stool, sausage-shaped massCoil-spring signAir or Barium enema ReductionTreatment:Gas or barium enema(youngers).Operation :manual r

31、eduction bowel resection肠系膜血管缺血性疾病etiology and pathology1.superior mesenteric artery embolus2.superior mesenteric arterial thrombosis3.superior mesenteric venous thrombosis4.others: non-mesenteric vascular ischemiaischemia necrosisClinical manifestationhistory of coronary heart disease or atrial fib

32、rillationacute abdominal crampsevere symptom and slight abdominal sign in the early stageDiagnosisabdominal film, angiography (DSA)Treatment:Key point: Early diagnosis and reasonable therapyVasodilating agentSurgical therapy Embolectomy Vascular bypass Intestinal resection and anastomosisCase1: Male

33、,25 years old, complains of abdominal pain and distention for 2 days. PE: P 80, abdominal bulge, intestinal patterns and peristaltic waves, high-pitched bowel sound. Past history: He underwent appendectomy 3 month ago. Diagnosis and treatment?Case2: male,68 years old, complains of abdominal bowel mo

34、tion for 3month,abdominal distention and stop pass gas and feces for 2 days. PE: P 90, Bp 130/70mmHg, abdominal bulge, intestinal patterns and peristaltic waves, high-pitched bowel sound. Diagnosis and treatment? Which examintation should be undergone for diagnosis?Short Bowel SyndromeDefinition: Sh

35、ort Bowel Syndrome (SBS) is defined as malabsorption resulting from anatomical or functional loss of a significant length of the small intestine . PathophysiologyThe majority of carbohydrate , protein ,fats, vitamins, bile salts absorption takes place in the small bowel. 100cm severe influencebody f

36、luid disorder and malnutrition Clinical findings First symptom:diarrhea,the severity relates to the length of residual bowel Weight loss, fatigue, malnutrition ,body fluid disorderTreatmentCorrect imbalance of metabolism and electrolyte Nutritional support total parenteral nutrition partial parenter

37、al nutrition enteral nutrtionThe first stage (2month) TPN and correct the fluid disorderThe second stage (12y) PPN+ENThe third stage EN or PPN+EN May be sustain one life It need long-term regular nutrition monitoring to prevent problems associated with fluid, macro- and micro-nutrient malabsorption . Since they are at high risk for dehydration and bacterial overgrowth, they need prompt medical attention any time they have symptoms of gastroenteritis.Intestinal Tumor小肠肿瘤Lowe