next up previous index Surgical Topics
Next: Large Intestine Up: Small Intestine or Large Previous: Small Intestine or Large   Index

Small Intestine

Post operative adhesions

The most common cause of small bowel obstruction seen in adults in hospital. [MPM+87,TW95] Many will settle on conservative management and do not need further surgery. Most clinicians advocate a drip and suck policy for several days if there is no evidence of a complication. More recently some have advocated a therapeutic triail of 100 ml of Gastrografin by mouth to differentiate partial from complete obstruction. [BDJ+03]

Stuck onto a tumor or inflammatory mass somewhere
It is not unusual to encounter a patient with obstruction due to a normal part of bowel becoming stuck onto a tumor or other inflammatory mass. It may be necessary to resect the main pathology en bloc with the adherent loops of bowel and then do multiple reconstructions.

Hernia; External or Internal

External hernia are common, internal herniae are rare. A common clinical situation is an elderly lady who is admitted with small bowel obstruction. The presence of a femoral hernia as the cause of the ladies problem is often missed by several of the first doctors to examine the patient. Remember to specifically check for evidence of herniation through the hernial orifices in patients with intestinal obstruction. Especially remember to check for the presence of femoral herniae in elderly ladies who present with intestinal obstruction. It is usually recommended that femoral herniae are repaired even if they are asymptomatic because they have a greater chance of causing problems than inguinal herniae.

Volvulus is twisting of the bowel. Small intesintal volvulus is seldom diagnosed pre-operatively. There is a high rate of necrosis of the bowel when it is discovered. Suspicion should be high when the patient has severe pain and there is any evidence of peritonitis. If the bowel is obviously dead, it is not wise to release the volvulus as this may aggravate the patients illness by release of inflammatory mediators and toxins into the general circulation. However, if the bowel is dubious it is best to release the volvulus, untwist it and place the bowel in warm packs for a period to see if there is improvement. If there is no improvement resection is best. If there is some improvement but the bowel still appears somewhat dubious, it may be possible to do a second look laparotomy after 24 hours and then do resection if necessary.

As mentioned above, this is mainly a problem encountered by paediatric surgeons.

Benign Strictures
The commonest benign stricture of the small intestine is due to Crohn's disease. It may be difficult to be sure if the stricture is due to inflammation with oedema or is a fibrotic stricture. Surgery may be delayed until medical therapy has been maximised. Infliximab (anti tumor necrosis factor alpha) may increase fibrosis. The surgeon may have to perform an enterotomy and pass a Foley catheter up and down the bowel to identify all the strictured areas. The balloon is inflated with 2.5 ml of saline and any areas of hold up represent strictures, it is best to treat these by stricturoplasty rather than resection, to preserve intestinal length and avoid the short bowel syndrome.

Other causes of benign stricture of the small bowel, include ischaemia, and healing from injury, for instance due to radiation, a foreign body, recurrent impaction in a hernial orifice and post anastomotic.

Tumors of the small intestine
Small intestinal tumors are much rarer than colonic tumors. They may be benign (leiomyoma, stromal) or malignant (lymphoma, carcinoid, adenocarcinoma). If polypoid (Peutz Jaegers) they may present by Intussusception.

next up previous index Surgical Topics
Next: Large Intestine Up: Small Intestine or Large Previous: Small Intestine or Large   Index
Adrian P. Ireland