SHORT GUT SYNDROME (SGS) : A MANAGEMENT CHALLENGE!

Transcription

1 SHORT GUT SYNDROME (SGS) : A MANAGEMENT CHALLENGE! Muhammad Saaiq DEPARTMENT OF SURGERY,PIMS, ISLAMABAD. Surgical Grand Round, Pakistan Institute of Medical Sciences (PIMS), Islamabad. September 23, 2005.

2 INTRODUCTION Adults cm Children cm

3 CAUSES OF SGS : INTESTINAL ATRESIA MIDGUT VOLVULUS NEC. ENTEROCOLITIS CROHN S MESENTERIC VASCULAR DISEASE CARCINOMA RADIATION ENTERITIS/ REGIONAL ENTERITIS TRAUMA ILIOJEJUNAL BYPASS FOR OBESITY

4 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.

5 PATHOPHYSIOLOGY : 1) LOSS OF INTESTINAL ABSORPTIVE SURFACE. 2) MORE RAPID INTESTINAL TRANSIT. 3) PRIMARY ILLNESS

6 NORMAL LENGTH OF GUT PARTS PART OF GUT MOUTH - PYLORUS DUODENUM JEJUNUM&ILEUM COLON LENGTH 65 cm 25cm cm 110cm

7 GUT TRANSIT TIME : PART OF GUT STOMACH * FLUIDS OTHERS SMALL GUT LARGE GUT TR. TIME 30 min Few hours 4-6 hours 6-12 hours

8 DAILY FLUID TURN-OVER IN GIT: AMOUNT EXOGENOUS INTAKE ENDOGENOUS SECRETIONS : Salivary Gastric Bile Pancreatic Intestinal 2 Litres 1.5 L 2.5 L 0.5 L 1.5 L 1 L 9 L

9 CLINICAL FEATURES : DIARRHOEA / STEATORRHOEA ELECTROLYTE IMBALANCE MALNUTRITION VITAMIN DEFICIENCY esp. B 12 GASTRIC ACID HYPERSECRETION LIVER DYSFUNCTION CHOLELITHIASIS NEPHROLITHIASIS BACTERIAL OVERGROWTH

10 ADAPTATION: 1) STRUCTURAL & FUNCTIONAL CHANGES IN THE GUT. 2) ENTERAL NUTRIENTS ARE MUST. 3) ENTEROGLUCAGON HAS A ROLE

11 MANAGEMENT: THE COURSE OF ILLNESS IS DIVIDED INTO THREE PHASES: 1) IMMEDIATE POST-OP PHASE 2) TRANSITION PHASE 3) PHASE OF LONG- TERM COMPLICATIONS

12 Manag.Contd: IMMEDIATE POST-OP PHASE : Critical care Sepsis control Maintenance of Fluid/Elec. Balance Gastric acid suppression Total parenteral nutrition General care

13 TRANSITION PHASE : TPN-----EN / Home TPN Manag.Contd: 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

14 MANAGEMENT OF LONG- TERM COMPLICATIONS : 1) Correction of nutritional derangements 2) Catheter related problems 3) Cholelithiasis 4) Nephrolithiasis 5) Liver dysfunction 6) Bacterial overgrowth

15 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

16 CONCLUSION

17 THANK YOU

18 CASE PRESENTATION

19 NAME : ABC AGE : 14 YRS GENDER : MALE ADDRESS : PIND DAD KHAN DOA : 09/04/2004 PRESENTING COMPLAINTS : SEVER DIFFUSE ABDOMINAL PAIN : 1 DAY VOMITING : 1 DAY CONSTIPATION : 1 DAY

20 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 MOVEMENT NO RELIEVING FACTOR. HE HAS 3 BOUTS OF VOMITING WITH IN TWO HOURS OF ONSET OF PAIN, GREENISH IN COLOUR WITH BLOOD TINGE IN IT.

21 ASSOCIATED SYMPTOM : ABSOLUTE CONSTIPATION TWO 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

22 PERSONAL HISTORY : 7 th CLASS STUDENT WITH GOOD APPETITE PREVIOUSLY, NORMAL SLEEP, NONSMOKERB, NON ADDICTED PAST HISTORY :UNREMARKABLE FAMILY HISTORY : SOCIOECNOMIC HISTORY : MEDICATION HISTORY :

23 GPE : EXAMINATION : BP 100/70 PULSE : 104/ MIN T : 100 * F R / RATE : 24 / MIN ABDOMEN : MILD DISTENSION TENDER ALL OVER ABDOMEN BS NEGATIVE PR:UNREMARKABLE.

24 SYSTEMIC EXAMINATION CVS CNS GUS RESPIRATORY MSS ALL ARE UNREMARKABLE

25 INVESTIGATIONS PLAIN X-RAY ABDOMEN : DILATED GUT LOOP, NO PNEUMOPERITONEUM U/S ABDOMEN : DILATED GUT LOOPS, MINIMAL AMOUNT OF FREE FLUID IN PERITONIAL CAVITY BCP : TLC :12500 RFT, SE, LFTs, S.AMYLASE, PT/APTT ALL WERE WITH IN NORMAL LIMITS

26 PLAN OF MANAGMENT PATIENT KEPT NPO PASSED NG TUBE I/V FLUID I/V ANTIBIOTICS EXPLORATORY LAPROTOMY

27 EXPLORATORY LAPROTOMY INCISION : LOWER MID LINE FINDINGS : 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

28 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

29 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.

30 BIOPSY REPORT: HISTOPATHOLOGY REVEALED BENIGN LIPOMA

31 LIPOSITES

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33 CAPSULE OF LIPOMA

34 FOUR LAYERS OF GUT ON LIPOMA

35 CONGESTION OF GUT WALL

36 CONGESTION

37 CONGESTED BLOOD VESSELS IN LIPOMA

38 THANK YOU