Intestinal diseases 2

Intestinal Resection

Ileal resection Vitamin B12 & Bile salt malabsorption. Watery diarrhea & Fat malabsorption. Lithogenic bile formation: Gallbladder stones. Oxalate renal stones. Investigations Barium Follow through. Tests for B12 & Bile acid absorption. Treatment Parantral Vit.B12 supply. Colystyramine or Aluminium Hydroxide for diarrhea.

Massive Resection ( Short Bowel Syndrome )

Aetiology: Children: 1-Congenital anomalies ( Artesia ,Volvulus ). 2-Necrotizing Enterocolitis. Adults: 1-Crohn ,s disease. 2-Mesenteric infarction. 3-Radiation Enteritis. 4-Volvolus.

Radiation Enteritis & Proctocolitis

Clinical features: A-Acute phase: Nausea , vomiting , cramping abdominal pain & diarrhea. Rectal involvement: rectal mucus , tenesmus & bleeding . B-Chronic complications: Proctocolitis. Small bowel stricture. Fistulae: Recto-vaginal ,colo-vesical. Adhesions. Malabsorption: Bacterial overgrowth, bile salt malabsorption ( Ileal damage ).


Investigations: In acute phase rectal changes at sigmoidoscopy: like ulcerative proctitis. Barium follow through: Small bowel stricture, ulcer & fistulae. Management: Anti- diarrheal agents. Local steroid enemas. Antibiotic. Nutritional supply. Colystyramin ( 4 g ). Endoscopic laser therapy. Surgery for complications.

Motility disordersChronic intestinal pseudo-obstruction

Causes: Primary or Idiopathic: 1-Rare familial visceral myopathies or neuropathies. 2-Congenital aganglionosis. Secondary: 1- Drugs: ex. Opiates ,TCA , Phenothiazines. 2-Smooth muscle disorders: ex. Scleroderma. 3-Myenteric plexus disorders : ex. Paraneoplastic syndrome. 4-CNS disorders: ex. Parkinsonism. 5-Endocrine & Metabolic disorders: ex. hypothyroidism.

Clinical features: Recurrent episodes of nausea , abdominal discomfort & distension. Alternating constipation & diarrhea. Weight loss from malabsorption, fear of eating . Dysphagia. Bladder dysfunction. Investigations: Plain abdominal X-Ray: Distended loops of the bowel + air fluid level. Barium studies: No mechanical obstruction. Laprotomy: to exclude obstruction & to obtain full thickness biopsies of the intestine. Electron microscopy, Histochemistry & especial stain for deficiency of rare & specific syndromes. Management: Treatment of underlying cause. Prokinetic agents ( Domperidone ). Antibiotic. Nutritional & psychiatric support.


Whipple,s disease
Characterized by infiltration of intestinal mucosa by (foamy macrophages) which stain +ve with Periodic Acid Shiff ( PAS ) reagent. Multisystem involvement. EM: G +ve Bacilli ( Tropheryma whippelli) within the macrophages. Villi are widened & flattened . Obstruction of lymphatic cause fat malabsorbtion.

Management

Is often fatal if not treated. Respond to IV Ceftriaxone(2g daily for 2 weeks) followed by oral co-trimoxazole for at least one year. Symptoms resolve within a week & biopsy changes revert to normal in few weeks. Long term follow up is essential. relapse usually occur in CNS which treated by same treatment or Doxycycline & Hydroxychroroquine.

Abdominal Tuberculosis

Caused by M tuberculosis which is swallowed after coughing. Many patients have no pulmonary symptoms & a normal CXR. The area most commonly affected is the ileocaecal region. The presentations & radiological findings may be very similar to Crohns disease.


Abdominal pain can be acute or of several months duration but diarrhea is less common in TB than in Crohns disease.Low grade fever is common.Can affect any part of the GIT & perianal disease & fistula can occur.Peritoneal TB may result in peritonitis with exudative ascites .Diagnosis: High ESR , raised alkaline phosphatase suggest hepatic involvement.Histological confirmation by endoscopy ,laparoscopy or liver biopsy can showed caseated granuloma, culture may help , PCR of biopsy specimen make diagnosis possible.Management: Four Anti –TB drugs Isoniazid, Rifampicin, Pyrazinamide & Ethambutole.

Adverse Food Reaction Food intolerance Lactose intolerance: Lactose Glucose + galactose Primary ( Racial ). Secondary ( Lactase deficiency ): 1-Coeliac disease . 2-Viral gastroenteritis. Clinical features: Asymptomatic. Colicky abdominal pain, abdominal distension, diarrhea. Picture like IBS. ** Lactose hydrogen breath test s useful non invasive confirmatory test ** Treatment: lactose exclusion. Commercial lactase preparations supply.
Lactase


Food allergy:Immune mediated disorders due to IgE Ab & type 1 hypersensitivity reaction.Culprits: are peanuts , milk, Soya …. Etc.Clinical manifestations:Trivial – Life threatening or even fatal anaphylaxis.Oral allergy syndrome: Urticaria & angioedema.Allergic gastroenteropathy.Gastrointestinal anaphylaxis.** Double blind placebo- controlled food challenges are the gold standard **Treatment:Elimination of offending antigen.Antihistamines.Disodium cromoglycate.Treatment of anaphylaxis.

Tumours of the small intestine

Benign Tumours: Adenoma , Leiomyoma , Lipoma & Hamartoma Adenoma usually occur in preampullary area. Usually asymptomatic , occult bleeding , obstruction due to intussusceptions , may be multiple ( FAP ). Hamartoma occur in Peutz-Jegher syndrome ( non malignant )

Malignant tumours

Adenocarcinoma , Carcinoid , Liemyosarcoma, Lymphoma , Kaposi sarcoma in AIDS patients. Adenocarcinoma: FAP Coeliac disease Peutz-Jeghers syndrome Investigations: Barium Follow through Small bowel enema. Enteroscopy Mesenteric angiography CT scan

Carcinoid tumours

Derived from enterochromafin cells & most common in ileum. Lesions >2cm :local extension & metastasis to the liver. In the rectum & appendix usually benign. Carcinoid syndrome Systemic symptoms produced when secretory products of the neoplastic enterochromafin cells reach the systemic circulation ( 5HT, serotonin) Bradykinin are released by hepatic metastasis.

Clinical features

Small bowel obstruction. Intestinal ischemia. Hepatic metastasis: pain , hepatomegaly. Flushing & wheezing. Diarrhea. Cardiac involvement: TR, PS & Heart failure. Facial telangectasia.

Management

Surgical resection. Treatment of Carcinoid syndrome is palliative . Surgical resection of the primary & hepatic secondaries. Octeriotide 200 Mg 8h.

Lymphoma

Non Hodgkin's lymphoma occur with increased frequency in patients with Coeliac disease , AIDS & other immune deficiency states.Mostly B cell origin , while in Coeliac Enteropathy associated T –cell lymphoma.Presentations:Abdominal pain.Malabsorption.Obstruction.Weight loss.PerforationHepatosplenomegaly is rare.

Investigations: Small bowel biopsy. Barium follow through. CT scan. Treatment: Surgical resection. Radiotherapy + Combination chemotherapy. Prognosis: Stage at diagnosis. Cell type. Patient age. Presence of B symptoms

Ischemic Gut Injury

Acute Small Bowel Ischemia: Occlusive: Emboli from the heart. Non-occlusive: Decrease BP HF Arrhythmia. Sudden blood loss Pathology :Transient alteration of bowel function. Transmural haemorrhage: Gangrene.

Clinical features

Abdominal pain+ Abdominal distension + Signs of peritonitis. Investigations: Increased WBC count. Metabolic acidosis. Hyperphosphetemia. Increased S. Amylase. Plain XR: Thumb printing. Mesenteric Angiography:

Treatment

Resuscitation. Correction of heart disease. IV antibiotics. Laprotomy. Embolectomy & vascular reconstruction. Small bowel transplantation.

Chronic Mesenteric ischemia

Atherosclerosis of 2 or more Coeliac axis branches. Clinical features: Post brandial pain. Weight loss. Diarrhea. O/E: Signs of generalized arterial disease Abdominal bruit. Mesenteric angiography confirm the diagnosis. Treatment: Vascular reconstruction.