Post on 25-May-2015
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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.
INTRODUCTION
Adults 90-120 cmChildren 30-60 cm
CAUSES OF SGS :
INTESTINAL ATRESIAMIDGUT VOLVULUSNEC. ENTEROCOLITIS
CROHN’SMESENTERIC VASCULAR DISEASECARCINOMA
RADIATION ENTERITIS/ REGIONAL ENTERITISTRAUMAILIOJEJUNAL BYPASS FOR OBESITY
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 .
PATHOPHYSIOLOGY :
1) LOSS OF INTESTINAL ABSORPTIVE SURFACE .
2) MORE RAPID INTESTINAL TRANSIT .
3) PRIMARY ILLNESS
NORMAL LENGTH OF GUT PARTS
PART OF GUT LENGTH MOUTH - PYLORUS 65 cm
DUODENUM 25cm
JEJUNUM&ILEUM 400-600cm
COLON 110cm
GUT TRANSIT TIME :
PART OF GUT TR. TIMESTOMACH
* FLUIDSOTHERS
30 minFew hours
SMALL GUT 4-6 hoursLARGE GUT 6-12 hours
DAILY FLUID TURN-OVER IN GIT:
AMOUNT
EXOGENOUS INTAKE 2 LitresENDOGENOUS SECRETIONS :
SalivaryGastricBilePancreaticIntestinal
1.5 L2.5 L0.5 L1.5 L1 L9 L
CLINICAL FEATURES :
DIARRHOEA / STEATORRHOEA ELECTROLYTE IMBALANCEMALNUTRITIONVITAMIN DEFICIENCY esp. B 12GASTRIC ACID HYPERSECRETIONLIVER DYSFUNCTIONCHOLELITHIASISNEPHROLITHIASISBACTERIAL OVERGROWTH
ADAPTATION:
1) STRUCTURAL & FUNCTIONAL
CHANGES IN THE GUT .
2) ENTERAL NUTRIENTS ARE MUST .
3) ENTEROGLUCAGON HAS A ROLE
MANAGEMENT:THE COURSE OF ILLNESS IS DIVIDED INTO THREE PHASES:
1) IMMEDIATE POST-OP PHASE
2) TRANSITION PHASE
3) PHASE OF LONG- TERM COMPLICATIONS
Manag.Contd:
IMMEDIATE POST-OP PHASE :
Critical care
Sepsis control
Maintenance of Fluid/Elec. Balance
Gastric acid suppression
Total parenteral nutrition
General care
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
MANAGEMENT OF LONG- TERM COMPLICATIONS :
1) Correction of nutritional derangements
2) Catheter related problems
3) Cholelithiasis
4) Nephrolithiasis
5) Liver dysfunction
6) Bacterial overgrowth
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
CONCLUSION
THANK YOU
CASE CASE PRESENTATIONPRESENTATION
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
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 .
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
PERSONAL HISTORY : 7th CLASS STUDENT
WITH GOOD APPETITE PREVIOUSLY , NORMAL SLEEP , NONSMOKERB , NON ADDICTEDPAST HISTORY:UNREMARKABLEFAMILY HISTORY : SOCIOECNOMIC HISTORY :MEDICATION HISTORY :
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.
SYSTEMIC EXAMINATION
CVSCNSGUSRESPIRATORYMSS
ALL ARE UNREMARKABLE
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
PLAN OF MANAGMENTPATIENT KEPT NPO PASSED NG TUBEI/V FLUID I/V ANTIBIOTICSEXPLORATORY LAPROTOMY
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
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
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 .
BIOPSY REPORT:HISTOPATHOLOGY REVEALED BENIGN LIPOMA
LIPOSITES
CAPSULE OF LIPOMA
FOUR LAYERS OF GUT ON LIPOMA
CONGESTION OF GUT WALL
CONGESTION
CONGESTED BLOOD VESSELS IN LIPOMA
THANK YOU