Most commonly congenital anomaly of the small intestineQ?
Rule of two in Meckel’s diverticulum?
- • 2% prevalenceQ
- • 2 inch in lengthQ
- • Half of these who are symptomatic are <2 yrsQ of age
- • 2 feet proximal to ileocecal valveQ
Location of Meckels diverticulum?
Antimesenteric border of the ileum - 45 to 60 cm proximal to the ileocecal valve
MC heterotopic tissue in Meckels diverticulum?
Gastric mucosa (50%)Q >Pancreatic mucosa (5%) >colonic mucosa (rarely)
MC clinical presentation of meckels diverticulum?
GI bleeding (25-50%)Q
MC complication of Meckel diverticulum?
- In children and young adults: BleedingQ
- In adults: Intestinal obstructionQ
Most accurate diagnostic test for Meckels diverticulum in children?
- in children: Scintigraphy with sodium 99mTc-pertechnetateQ. The 99mTc-pertechnetate is preferentially taken up by the mucus-secreting cells of gastric mucosa and ectopic gastric tissue in the diverticulumQ.
- It is less accurate in adults because of the reduced prevalence of ectopic gastric mucosaQ.
Treatment of Meckels diverticulum?
- Symptomatic - Diverticulectomy or resection of the segment of ileumQ bearing the diverticulum.
- Asymptomatic diverticula found in children during laparotomy should be resectedQ.
- Incidentally found Meckel’s diverticulum should be removed at any age up to 80 years as long as no additional conditions (e.g., peritonitis) made removal hazardousQ.
Can Meckel’s diverticulum be resected as appendix?
Meckel’s diverticulum that is broad based should not be amputated at its base and invaginated in the same way as a vermiform appendix, because of risk of stricture. Furthermore, this does not remove hetrotopic epithelium where it is present.
Most common site of diverticulum formation in GIT?
- Colon – MC
- Duodenum – second MC
Etiopathogenesis of blind loop syndrome?
- Underlying cause: Bacterial overgrowth in stagnant areas of the small bowel produced by stricture, stenosis, fistulas, or diverticulaQ
- Bacterial overgrowth competes for vitamin B12, producing systemic deficiency of vitamin B12 and megaloblastic anemiaQ.
- Fat soluble vitamin deficiency
Treatment of blind loop syndrome?
- Parenteral vitamin B12 therapy + Broad-spectrum antibiotic (tetracycline or amoxicillin-clavulanate)Q.
- For most patients, a single course of therapy (7-10 days) is sufficient, and the patient may remain symptom-free for months.
- Surgical correction of the condition producing stagnation and blind loop syndrome produces a permanent cure and is indicated in those patients who require multiple rounds of antibiotics or are on continuous therapyQ
What is primary and secondary intestinal tuberculosis?
Primary - Ingestion of contaminated foodQ
Secondary – swallowed contaminated sputum
In which layer of bowel, the earliest lesion of intestinal tuberculosis found?
- In submucosaQ
- MC site is terminal ileum and ileocecal junctionQ
Features of ulcers in Tuberculosis?
- Deep and transversely placedQ in the direction of lymphatics
- Multiple ulcers - most often in terminal ileumQ
MC symptom of GI tuberculosis?
Barium studies in GI Tuberculosis?
- • Earliest feature is spasm and hypermotility with edema of valveQ
- • Thickening of valve lips with narrowing of the terminal ileum (Fleishner or umbrella signQ)
- • Symmetric, annular, napkin ring stenosisQ and obstruction or shortening and pouch formation in advanced disease
- • Pulled up cecumQ
- • Loss of ileocecal angle with dilated terminal ileum imparting goose neck deformityQ
- • Narrowing of terminal ileum due to irritability, along with shortened rigid cecum called as “Sterlein sign”Q
- • Persistent narrow stream of barium in the bowel indicates stenosis known as String signQ
- String sign and Sterlein sign are also seen in Crohn’s disease and are not specific for TBQ
Indications of Surgery in GI Tuberculosis?
- • Intestinal obstruction secondary to stricture (MC)Q
- • Free perforationQ
- • Severe GI hemorrhageQ
- Intra-abdominal abscessQ
- • Internal or external fistulaQ
MC site of GI tuberculosis?
MC type of Abdominal tuberculosis?
Superior Mesenteric Artery Syndrome?
Vascular compression of third portionQ of the duodenum by the superior mesenteric artery as it passes over this portion of the duodenum.
SMA normally leaves aorta at angle of?
Acute angle (50-60°)
Treatment of SMA syndrome?
What is Pneumatosis Intestinalis?
- It is an uncommon condition presenting as multiple gas-filled cysts of the gastrointestinal tract.
- Located in the subserosa, submucosa, and, rarely, muscularis layer
- MC site: JejunumQ >ileocecal region >colon
What are the consequences of removal of Ileocecal valve?
- Bacterial overgrowthQ from the colon → diarrhea and malabsorptionQ
- Decrease in intestinal transit timeQ
Which is tolerated better, proximal or distal bowel resection?
Proximal bowel resection is tolerated much better than distal resectionQ, because the ileum can adapt and increase its absorptive capacity more efficiently than the jejunumQ
What are intestinal lengthening operations?
- Bianchi ProcedureQ: Longitudinal intestinal lengthening and tailoring
- STEP: Serial transverse enteroplasty procedureQ
Why is there gastric hypersecretion in small bowel resection?
May be related to reduced hormonal inhibition of acid secretion or increased gastrin levels due to reduced small intestinal catabolism of circulating gastrin.
Hypergastrinemia and gastric hypersecretion – greatly contribute to diarrhea after a massive small bowel resection
Dose of radiation for radiation enteritis?
- Serious late complications are unusual if the total radiation dosage is <4000 cGyQ
- Morbidity risk increases with dosages >5000 cGyQ
What are the late effects of radiation injury?
- Damage to the small submucosal blood vesselsQ
- Progressive obliterative arteritis and submucosal fibrosisQ
- Thrombosis and vascular insufficiencyQ
Most effective radioprotectant?
Operative procedures of radiation enteritis?
Bypass or resection with reanastomosis
MC cause of ileal perforation in tropical countries (India)Q?
When do Perforation of a typhoid ulcer occur?
- Usually during the third weekQ
- Occasionally the first sign of the disease
- Ulcers – are longitudinal
Principle of bowel anastomosis?
- −−Gentle handlingQ of the bowel
- −−Adequate hemostasisQ
- −−Meticulous approximationQ of well-vascularized bowel
- −−Tension-free anastomosisQ
Technique of one layer and two layer bowel anastomosis?
- Two layer anastomosis - Inner layer absorbable 3-0 or 4-0 running full-thickness stitchQ • Outer layer is an inverting, usually 3-0, seromuscular stitch, which may be running or interrupted nonabsorbableQ
- One layer anastomosis - Full-thickness technique, interrupted or running with nonabsorbable sutureQ
Factors preventing spontaneous closure of fistula?
- • High output (>500 mL/day)Q
- • Severe disruption of intestinal continuityQ (>50% of bowel circumference)
- • Active inflammatory bowel diseaseQ of bowel segment
- • CancerQ
- • Radiation enteritisQ
- • Distal obstructionQ
- • Undrained abscess cavityQ
- • Foreign bodyQ in the fistula tract
- • Fistula tract <2.5 cm longQ
- • Epithelialization of fistula tractQ
Most common cause of enterocutaneous fistula?
Preferred operation for enterocutaneous fistula?
Fistula tract excision and segmental resection of the involved segment of intestine and reanastomosisQ.
MC site of intestinal atresia?
MC cause of neonatal intestinal obstruction?
What are types of Small Intestinal Duplication?
- Cystic - More common (75%)Q, Do not have communication with the lumenQ of the normal small intestine, Manifested as partial small bowel obstructionQ
- Tubular - Less common (25%), Parallel to the normal bowel lumenQ, Higher incidence of communicationQ with the existing lumen of the small intestine, Significant incidence of ectopic gastric mucosaQ, BleedingQ is a common manifestation