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. 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 Lesions Intrinsic to Intestinal Wall

9. Intraluminal/ Obturator Lesions • Gallstone • Enterolith • Bezoar • Foreign body

10. What’s 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 • US:4th most common cancer (after lung, prostate, and breast cancers) • 2nd most common cause of cancer death (after lung cancer) • 2001:130,000 new cases of CRC 56,500 deaths caused by CRC

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

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 65%–75% of polyps and 40%–65% 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. What’s 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

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