Intestinal diverticula:
Intestinal diverticula:
Hollow out-pouching that can occur
anywhere from the esophagus to the recto-
sigmoid junction( but not usually the
rectum).
Classification:
1. Congenital: All 3 coats of the bowel are
present in the wall eg. Meckel’s
2. Acquired: No muscularis present.
Meckel’s diverticulum:
Remnant of the vitello-intestinal duct.
Occurs in 2% of people, 2 inches long, and present 2
feet from the ileo-cecal valve. 20% have hetero-
topic epithelium ( gastric, colonic or pancreatic).
Should be looked for when a normal appendix is
found at surgery for suspected acute appendicitis.
If found incidentally at surgery, can be left provided
it has a wide mouth and the wall is not thickened.
Found at anti-mesenteric border.
True diverticulum
.
Clinical presentation:
1. Hemorrhage: If gastric mucosa present, peptic ulcer can
occur and present as maroon color rectal bleeding or
melaena.
2. Diverticulitis: Resembles acute appendicitis and if
perforated resembles perforated duodenal ulcer.
3. Intussusception.
4. Chronic ulceration: Causes umbilical pain.
5. Intestinal obstruction: It acts as a band causing
obstruction either due to its direct effect volvolus around
it.
6. Perforation.
# Littre’s hernia is an inguinal or femoral hernia that
contains a Meckel’s diverticulum
.
Diverticular disease of the large intestine:
Found in the left colon in around 75% of people over
70yrs old in the Western wall. Most frequent in the
sigmoid but diverticula are found in the cecum and can
affect the whole colon but not the rectum. Interestingly,
in South-east Asia, right- sided diverticular disease is
more common.
Etiology:
Refined Western diet deficient in dietary fibers
which results in herniation of mucosa through the
muscularis at points where blood vessels
penetrate the bowel wall. The rectum has a
complete muscle coat and wide lumen and thus
very rarely affected. It is rare in Africa and Asia
where the diet is high in fiber.
Clinical features:
Majority are asymptomatic or might cause heaviness,
flatulence and indigestion that resembles irritable bowel
syndrome.
Complications:
1. Diverticulitis
2. Abscess
3. Peritonitis
4. Intestinal obstruction: Due to stricture or adhesions.
5. Haemorrhage
6. Fistula ( colo-vesical, colo-vaginal, entero-colic and
colocutaneous).
Fever, malaise and leukocytosis can differentiate between
diverticulosis and diverticulitis.
Hinchey classification:
I Mesenteric or peri-colic abscess
II Pelvic abscess
III Purulent peritonitis
IV Fecal peritonitis
Investigations:
1. Chest X ray and plain X ray abdomen can show air
under the diaphragm in case of perforation.
2. CT/MRI : Water-soluble contrast enema can be used.
3. Barium enema and colonoscopy should be avoided in
the acute phase for fear of causing perforation and
peritonitis. Barium enema can show ‘ saw-tooth’
appearance.
4. Colo-vesical fistula can be evaluated by cystoscopy
and biopsy.
Treatment:
I Medical:
1. Diverticulosis: High fiber diet and bulk-forming
laxatives are highly-recommended along with
anti-spasmodics.
2. Diverticulitis: Intravenous antibiotics are used
to cover gram negative bacilli and anaerobes.
3. Abscess can be drained percutaneously.
II Surgical:
Resection of the involved segment . Hartmann’s
operation is the safest option. Primary
anastomosis can be performed in selected cases.
Mesenteric Ischemia:
Acute or chronic, arterial or venous. Occlusion of
the superior mesenteric artery origin occurs due to
thrombosis while emboli lodge at the middle colic
artery. Inferior mesenteric involvement is usually
silent due to the better collateral circulation.
Sources:
1. Left atrium due to atrial fibrillation.
2. Ventricular wall in case of myocardial
infarction.
3. Atheromatous plaque of aortic aneurysm.
4. Mitral valve vegetation of infective
endocarditis.
Predisposing factors to thrombi:
1. Atherosclerosis.
2. Thrombangitis obliterans.
Primary thrombi of the superior mesenteric
vein are associated with:
1. Factor v Leiden gene defect.
2. Portal hypertension.
3. Portal pyaemia.
4. Sickel cell disease.
5. Oral contraceptive pills.
If the main trunk of the SMA is involved, the
infarction will cover an area just distal to the
duodeno-jejunal junction till the splenic flexure
but usually only a branch is involved.
Clinical features:
Sudden onset of abdominal pain in a
patient with AF or atherosclerosis. The pain
is dis-proportionate to the physical findings
and shock rapidly develops.
Investigations:
1. Increased WBC count.
2. Plain X ray abdomen: Absence of
gas in the involved intestine and
presence of gas bubbles in the
mesenteric veins is rare but
pathognomonic.
Treatment:
1. Embolectomy or revascularization of the SMA may be
considered in the early stages.
2. Resection of all involved intestine.
3. Middle colic artery involvement is treated by
transverse colectomy with exteriorization of both ends
or by extended right hemicolectomy.
Ischaemic colitis occurs most commonly at the splenic
flexure and classified by Mariston into: 1. Gangrenous 2.
Transient 3. Stricturing.
Angiodysplasia:
Vascular malformation that causes haemorrhage ,
typically in patients > 60yrs. Occurs most commonly in
the ascending colon and cecum. There is an
association with aortic stenosis ( Heyde’s syndrome).
Investigations:
1. Colonoscopy
2. Capsule endoscopy
3. Radioisotope scanning ‘ Te 99- labeled RBC’
4. Angiography
Treatment:
1. Colonoscopic cauterization
2. Surgical resection of the involved
area and if the area is not clear, sub-
total colectomy may be performed.
Stomas:
Artificial opening made in the colon ( or small intestine) to divert feces
and flatus outside the abdomen where they can be collected in an
external appliance .
Colostomy or ileostomy
Temporary or permanent
Temporary are usually fashioned as loop
An ileostomy is spouted, a colostomy is flush
Ileostomy effluent is liquid, colostomy is solid
Ileostomy patients are more likely to develop fluid and electrolyte
problems
Ileostomy is usually sited in the RIF while colostomy in the LIF
Whenever possible, patients should be counseled and sited by stoma
care nurse before surgery
Temporary loop colostomy is made by bringing a mobilized loop of colon
to the surface ( transverse or sigmoid)
Colostomy closure is most easily and safely made if the stoma is mature,
typically after 2 months
End ileostomy:
Formed after:
Abdomino-perinear resection
Hartmann’s procedure
Stoma site should be away from the ASIS and scars and
through the lateral wall of the rectus sheath.
Loop ileostomy:
Often used to de-function a low rectal anastomosis or an ileal
pouch. The advantage over loop colostomy is the ease to bring
it out and it is odourless.
End ileostomy:
Formed after a sub-total colectomy and may be
reversed later on or may be permanent after a
procto-colectomy.
# A spout should project at least 4 cm from the skin
surface.
A diaposible appliance is placed over the ileostomy
so that it is snug fit at the skin level.
Ileostomy output can amount to 4-5 Li/ day
Caecostomy:
In late cases of obstruction, the caecum may be distended
and ischaemia that rupture of the caecum is anticipated.
This can occur spontaneously giving rise to fecal peritonitis
or at operation. In thin patients, it may be possible to carry
out direct suturing of the perforated caecum to the
abdominal skin of the RIF. In others following on-table
lavage, via the appendix stump, an irrigating catheter can
be left in place ( tube caecostomy).
Complications of stoma:
• Skin irritation
• Prolapse
• Retraction
• Ischaemia
• Stenosis
• Para-stomal hernia
• Bleeding
• Fistula
Entero-cutaneous fistula:
An abnormal connection between the small
intestine and skin.
Causes:
• Crohn’s disease
• Radiotherapy
• Trauma
• Iatrogenic: Following anastomotic leak or
injury during dissection.
Classification:
High and low output if discharging above or below
500ml/ day.
Reasons for failure of fistula healing:
• High output fistula
• FRIEND: Foreign body, radiotherapy, infection,
epithelialization, neo-plasia and distal obstruction.
Principles of management of entero-cutaneous
fistula( SNAP):
S: elimination of sepsis and skin protection.
N: nutrition.
A: anatomical assessment by the radiologist.
P: Planned definitive surgery.