Short gut syndrome ---muhammad saaiq
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SHORT GUT SYNDROME (SGS) :
A MANAGEMENT CHALLENGE!
Muhammad SaaiqDEPARTMENT OF SURGERY ,PIMS , ISLAMABAD.
Surgical Grand Round, Pakistan Institute of MedicalSciences (PIMS), Islamabad. September 23, 2005.
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INTRODUCTION
Adults 90-120 cmChildren 30-60 cm
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CAUSES OF SGS :
INTESTINAL ATRESIAMIDGUT VOLVULUSNEC. ENTEROCOLITIS
CROHN’SMESENTERIC VASCULAR DISEASECARCINOMA
RADIATION ENTERITIS/ REGIONAL ENTERITISTRAUMAILIOJEJUNAL BYPASS FOR OBESITY
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FACTORS AFFECTING SEVERITY
1) EXTENT OF RESECTION / LENGTH OF RESIDUAL SMALL GUT .
2) SITE OF RESECTION .3) STATE OF THE RESIDUAL GUT .4) ILEOCAECAL VALVE .5) COLON .6) ADAPTIVE CAPACITY OF THE
REMNANT GUT.7) GENERAL FACTORS .
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PATHOPHYSIOLOGY :
1) LOSS OF INTESTINAL ABSORPTIVE SURFACE .
2) MORE RAPID INTESTINAL TRANSIT .
3) PRIMARY ILLNESS
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NORMAL LENGTH OF GUT PARTS
PART OF GUT LENGTH MOUTH - PYLORUS 65 cm
DUODENUM 25cm
JEJUNUM&ILEUM 400-600cm
COLON 110cm
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GUT TRANSIT TIME :
PART OF GUT TR. TIMESTOMACH
* FLUIDSOTHERS
30 minFew hours
SMALL GUT 4-6 hoursLARGE GUT 6-12 hours
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DAILY FLUID TURN-OVER IN GIT:
AMOUNT
EXOGENOUS INTAKE 2 LitresENDOGENOUS SECRETIONS :
SalivaryGastricBilePancreaticIntestinal
1.5 L2.5 L0.5 L1.5 L1 L9 L
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CLINICAL FEATURES :
DIARRHOEA / STEATORRHOEA ELECTROLYTE IMBALANCEMALNUTRITIONVITAMIN DEFICIENCY esp. B 12GASTRIC ACID HYPERSECRETIONLIVER DYSFUNCTIONCHOLELITHIASISNEPHROLITHIASISBACTERIAL OVERGROWTH
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ADAPTATION:
1) STRUCTURAL & FUNCTIONAL
CHANGES IN THE GUT .
2) ENTERAL NUTRIENTS ARE MUST .
3) ENTEROGLUCAGON HAS A ROLE
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MANAGEMENT:THE COURSE OF ILLNESS IS DIVIDED INTO THREE PHASES:
1) IMMEDIATE POST-OP PHASE
2) TRANSITION PHASE
3) PHASE OF LONG- TERM COMPLICATIONS
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Manag.Contd:
IMMEDIATE POST-OP PHASE :
Critical care
Sepsis control
Maintenance of Fluid/Elec. Balance
Gastric acid suppression
Total parenteral nutrition
General care
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Manag.Contd:TRANSITION PHASE :
TPN-----EN / Home TPN
Role of Antimotility / Antisecretory agents
Dietary management:
Small frequent meals
Nutrients in simplest form
Separate solid nutrients from liquids
Avoid hyper-osmolar fluids
Restricted fat intake
Avoid high oxalate
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MANAGEMENT OF LONG- TERM COMPLICATIONS :
1) Correction of nutritional derangements
2) Catheter related problems
3) Cholelithiasis
4) Nephrolithiasis
5) Liver dysfunction
6) Bacterial overgrowth
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Manag.Contd:ROLE OF SURGERY :1) Restoration of intestinal continuity
2) Enteroplasty / Lengthening procedure
3) Slowing down rapid transit:
creating artificial valve
construction of anti-peristaltic segment
colonic interposition
construction of recirculatig loop
pacing with electrodes in retrograde fashion
4) Small gut / combined liver & small gut transplant
5) Management of complications
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CONCLUSION
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THANK YOU
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CASE CASE PRESENTATIONPRESENTATION
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NAME : ABCAGE : 14 YRSGENDER : MALE ADDRESS : PIND DAD KHAN DOA : 09/04/2004
PRESENTING COMPLAINTS :SEVER DIFFUSE ABDOMINAL PAIN : 1
DAY VOMITING : 1 DAYCONSTIPATION : 1 DAY
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HISTORY OF PRESENT ILLNESS
PATIENT WAS IN USUAL STATE OF HEALTH DEVELOPS SEVERE GRIPPING DIFFUSE ABDOMINAL PAIN OF SUDDEN ONSET CONTINOUS IN NATURE AGGREVATED BY MOVEMENTNO RELIEVING FACTOR.
HE HAS 3 BOUTS OF VOMITING WITH IN TWO HOURS OF ONSET OF PAIN , GREENISH IN COLOUR WITH BLOOD TINGE IN IT .
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ASSOCIATED SYMPTOM : ABSOLUTE CONSTIPATIONTWO MONTH BACK HE EXPERIENCED AN EPISODE OF MILD DULL ACHING PAIN IN UMBILICAL REGION LASTED FOR 4 HOURS , CONSULTED DOCTOR LOCALLY WHO ADVISED ANALGESIC THAT RELIEVED HIS SYMPTOM
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PERSONAL HISTORY : 7th CLASS STUDENT
WITH GOOD APPETITE PREVIOUSLY , NORMAL SLEEP , NONSMOKERB , NON ADDICTEDPAST HISTORY:UNREMARKABLEFAMILY HISTORY : SOCIOECNOMIC HISTORY :MEDICATION HISTORY :
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EXAMINATION :GPE :
BP 100/70 PULSE : 104/ MIN T : 100 * F R / RATE : 24 / MIN
ABDOMEN : MILD DISTENSIONTENDER ALL OVER ABDOMEN
BS NEGATIVE PR:UNREMARKABLE.
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SYSTEMIC EXAMINATION
CVSCNSGUSRESPIRATORYMSS
ALL ARE UNREMARKABLE
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INVESTIGATIONS
PLAIN X-RAY ABDOMEN : DILATED GUT LOOP , NO PNEUMOPERITONEUMU/S ABDOMEN : DILATED GUT LOOPS , MINIMAL AMOUNT OF FREE FLUID IN PERITONIAL CAVITYBCP : TLC :12500RFT , SE , LFTs , S.AMYLASE , PT/APTTALL WERE WITH IN NORMAL LIMITS
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PLAN OF MANAGMENTPATIENT KEPT NPO PASSED NG TUBEI/V FLUID I/V ANTIBIOTICSEXPLORATORY LAPROTOMY
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EXPLORATORY LAPROTOMY
INCISION : LOWER MID LINEFINDINGS :
PERITONIAL CAVITY FILLED WITH GANGRENOUS SMALL GUT . 80% OF JEJUNUM , ILEUM BEING TIGHTLY TWISTED TWICE AROUND LONG LOOSE MESENTERY THAT CONTAINED A BENIGN LOOKING LUMP (12 *10*6 cm ) ABOUT3cm FROM MESENTERICBORDER OF THE JUNCTION OF JEJUNUM &ILEUM
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PROCEDURE:
THE GANGRENOUS SMALL GUT ( ABOUT 340 cm) WAS RESECTED LEAVING BEHIND HEALTHY 75cm JEJUNUM & 10cm ILEUM . THE REMNANT STUMPS WERE PARTIALLY ANASTOMOSED & BRING OUT AS COMBINED STOMA THROUGH RIGHT LOWER ABDOMEN
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POST OPERATVE MANAGMENT
I/V ANTIBIOTC TPN ACID SUPPRESSANT
STOMA WAS REVERSED AFTER 8 WEEKS PATIENT STARTED ON ORAL FEED AFTER 1 WEEK .
HE IS NOW TOLERATING ENTERAL FEEDS & GAINING WEIGHT .
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BIOPSY REPORT:HISTOPATHOLOGY REVEALED BENIGN LIPOMA
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LIPOSITES
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CAPSULE OF LIPOMA
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FOUR LAYERS OF GUT ON LIPOMA
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CONGESTION OF GUT WALL
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CONGESTION
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CONGESTED BLOOD VESSELS IN LIPOMA
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THANK YOU