Small Intestine Disease

Introduction

Intestinal obstruction or bowel obstruction is a partial or complete blockage of the intestine or bowel that prevents intestinal content from passing through. The obstruction could be a mechanical or functional in nature. An untreated intestinal obstruction can be fatal.

Signs & Symptoms

Intestinal obstruction can cause wide spectrum of uncomfortable symptoms such as:

• Abdominal pain
• Severe bloating
• Severe abdominal cramps
• Abdominal swelling
• Loss of appetite
• Nausea
• Vomiting
• High fever

Causes

Intestinal obstruction can be caused by something blocking part of the intestine (mechanical) or malfunctioning of the intestine (functional). Sometime after surgery fibrous band of tissues are formed in the abdomen which causes adhesions and blocks the natural passage. Inflamed or infected pouches in the intestine known as diverticulitis, hernias and tumors can also cause blockage of intestinal passage.

Various causes of intestinal obstruction include:

• Adhesions: band of fibrous tissue in the abdominal cavity causes intestinal adhesions
• Colon cancer: Tumors in the intestine
• Volvulus: twisting of the small intestine
• Hernia: portions of intestine protrude into another part of the body
• Inflammatory disease like crohn’s disease: swelling and scar tissue causes a narrowing of the intestine
• Severe constipation leads to impacted bowel
• Paralytic ileus: intestine temporarily ceases contracting and moving its contents along
• Intusscuception: one section of intestine collapses into another
• Ingestion of foreign objects
• Strangulation: decreased blood flow to the intestines usually due to birth defect
• Stricture and inflammation causes narrowing of intestine

Risk Factors

• Abdominal or pelvic surgery
• Inflammatory disease like crohn’s disease
• Abdominal tumors

Complications

• Infection in the abdominal cavity known as peritonitis
• Intestinal obstruction can cut off blood supply to certain part of the intestine which causes the intestinal tissues to die this will result in perforation and can lead to infection

Diagnosis

• Abdominal X-ray: In this procedure you have to swallow a contrast liquid and the x-ray technician visualizes the intestinal tract to look for obstruction.
• Abdominal CT scan: this test help determine if the obstruction is partial or complete and whether it is mechanical or functional obstruction.
• Physical examination: to look for swollen or tender abdomen or if there is a lump in abdomen associated with the signs and symptoms of intestinal obstruction. Typical abdominal sound of obstruction can be heard using stethoscope.
• Colonoscopy: if the obstruction is located in large intestine colonoscopy can be performed to inspect the large intestine.

Treatment

Intestinal obstruction is a medical emergency and requires prompt medical treatment. Appropriate treatment depends on the type and location of obstruction however most intestinal obstructions require surgery.

Crohn’s Disease is a type of inflammatory bowel disease (IBD) that may affect any part of the gastrointestinal tract.

Causes

• Immunity factors
• Environmental factors – Stress, smoking, hormonal contraceptives.
• Genetics
• Micro-organisms

Signs and Symptoms

• Abdominal pain
• Diarrhoea – bloody or non bloody
• Bloating, flatulence
• Fever
• Cachexia
• Anaemia
• Fatigue
• Arthritis
• Erythema nodosum
• Pyoderma gangrenosum
• Arthritis
• Skin rashes
• Ankylosing Spondylosis
• Osteoporosis
• Clubbing

Diagnosis

• CBC
• ESR
• CRP
• Ferritin
• Folates
• Vitamin B12
• ASCA
• ANCA
• Colonoscopy with biopsy
• Capsule Endoscopy
• Barium Follow Through
• Barium Enema

Management

• Lifestyle modifications
• Maintain hydration.
• Avoid smoking.
• High fibre diet.
• Antibiotics
• Anti-inflammatory drugs
• Corticosteroids
• Iron supplements
• Surgery – if disease does not respond to drugs or in case of any complications

Complications

• Bowel Obstruction
• Fistulae
• Abscesses
• Small intestinal cancer
• Malnutrition
• Perforation
• Haemorrhage

Intestine Perforation

It is a complication of underlying duodenal disease like Duodenal ulcer, Duodenal cancer or it may be due to complication of ERCP or UGI endoscopic procedures.

Causes

• Blunt abdominal trauma.
• Penetrating injury to the lower chest or abdomen (e.g. stab injuries).
• Bacterial infections
• Ingestion of aspirin, non steroidal anti-inflammatory drugs (NSAIDs), and steroids.
• Inflammatory bowel disease (IBD).
• Predisposing conditions – Peptic ulcer disease, acute appendicitis, acute diverticulitis, and inflammed Meckel diverticulum.
• Endoscopy related bowel injuries- Endoscopic biliary stenting, Colonoscopy, ERCP.
• Laparoscopic intestinal injury.
• Bowel perforation by intra-abdominal malignancy, lymphoma, or metastatic renal carcinoma – Even benign tumours, such as desmoid tumours.
• Radiotherapy of cervical carcinoma and other intra-abdominal malignancies.
• Perforation secondary to intestinal ischemia (e.g. ischaemic colitis)
• Necrotizing vasculitis.
• Kidney transplantation
• Foreign bodies (e.g. toothpicks).
• Ingestion of caustic substances – Accidental or suicidal ingestion.

Signs and Symptoms

• Abdominal pain- Sharp, severe, sudden in onset.
• Vomiting
• Hiccoughs
• Board-like rigidity of abdomen with tenderness
• Tachycardia
• Fever
• Absence of bowel sounds

Diagnosis

• CBC
• LFT
• RFT
• Blood culture
• X Ray Abdomen Erect
• Chest PA
• USG Abdomen
• CT Scan
• Laparoscopy

Treatment

• Intravenous access, and crystalloid therapy in patients with clinical signs of dehydration or septicaemia.
• Do not give anything by mouth.
• Intravenous administration of antibiotics.
• Surgery for duodenal perforation

Complications of Duodenal perforation.

• Localized abdominal abscess
• Wound infection
• Mechanical intestinal obstruction
• Postoperative delirium
• Multi organ failure
• Gastrointestinal mucosal hemorrhage
• Fluid and electrolyte imbalance
• Renal failure
• Septic shock

Intestinal Gangrene is caused by inadequate blood flow through the mesenteric vessels, resulting in ischaemia and eventual gangrene of the bowel wall.

Causes

• Acute mesenteric arterial thrombosis
• Acute mesenteric arterial embolism
• Non occlusive mesenteric ischemia
• Mesenteric venous thrombosis

Signs and Symptoms

• Moderate to severe, diffuse, non localized, constant, and sometimes colicky abdominal pain.
  Abdominal distention
• Nausea, vomiting
• Anorexia
• Constipation
• Diarrhoea
• Tachycardia
• Tachypnoea
• Fever
• Hypotension
• Tender mass on palpation.
• Bowel sounds – hyperactive to absent.
• Voluntary and involuntary guarding appears.

Diagnosis

• CBC
• PT, APTT
• X Ray Abdomen erect
• USG Abdomen
• CT Scan
• CT Angiography
• MRI
• MR Angiography

Treatment

• Medicines
• Vasodilators
• Anticoagulants
• Thrombolytics
• Analgesics
• Antibiotics
• Surgery

Complications

• Sepsis and septic shock
• Bowel necrosis necessitating bowel resection
• Multiple organ dysfunction syndrome (MODS)
• Death

Diverticulum means an abnormal sac or pouch that develops at a weak point in the intestines. A Meckel diverticulum is a true congenital diverticulum present in intestine. It develops between the 5th and 7th weeks of fetal growth.Because the condition is present at birth, it is classified as a congenital health issue.

 

Symptoms

• Intestinal obstruction
• Bloody stool
• Abdominal pain
• Anaemia

Diagnosis

• Blood tests
• Stool smear
• USG Abdomen and Pelvis
• Technitium Scan
• UGI scopy
• Colonoscopy
• CT with Angiography

Treatment

• Surgery – Laparoscopic Small Bowel Resection

Complications

• Intestinal Obstruction
• Diverticulitis
• Haemorrhage
• Umbilical anomalies
• Neoplasm

Intussusception is a disease in which part of the intestine enters into an adjacent part of the intestine. It can also lead to decreased blood supply to the intestine and even bowel perforation. It is more commonly seen in children than adults.

 

Cases

• Children – idiopathic
• Adults
• Inflammation e.g.Crohn Disease

Haematoma

• Surgical scars in small intestine and colon

Adhesions

• Tumour

Symptoms

• Severe intermittent abdominal pain
• Diarrhoea mixed with blood and mucus
• Constipation
• Lumpish feeling in abdomen
• Vomiting
• Fever
• Lethargy

Diagnosis

• X Ray Abdomen
• Ultrasound
• Barium Enema
• CT Scan

Treatment

• Correct dehydration by IV fluids
• Nasogastric tube insertion
• Surgery

Complications

• Decreased blood supply to intestines – gangrene
• Bowel perforation
• Peritonitis

Risk Factors

• Age- More commonly seen in age groups above 60.
• Sex- More in males.
• Smoking
• Alcohol
• Celiac Disease
• Crohn’s Disease
• Exposure to radiation
• Cystic Fibrosis
• Koch’s
• Hamartoma
• Fistulous diseases

Symptoms

• Abdominal pain
• Anorexia
• Cachexia
• Anaemia
• Weakness and fatigue
• Nausea, vomiting

Diagnosis

• Medical history and physical exam
• CBC
• CT Scan
• Upper GI Endoscopy
• Colonoscopy
• Barium follow through
• Enteroclysis
• Barium enema
• Capsule endoscopy
• Double-balloon enteroscopy (endoscopy)

Treatment

• Treatment depends on patient’s age, health status and cancer stage.
• Surgery
• Chemotherapy
• Radiotherapy