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.
INTRODUCTION Adults 90-120 cm Children 30-60 cm
CAUSES OF SGS : INTESTINAL ATRESIA MIDGUT VOLVULUS NEC. ENTEROCOLITIS CROHN S MESENTERIC VASCULAR DISEASE CARCINOMA RADIATION ENTERITIS/ REGIONAL ENTERITIS TRAUMA ILIOJEJUNAL 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 MOUTH - PYLORUS DUODENUM JEJUNUM&ILEUM COLON LENGTH 65 cm 25cm 400-600cm 110cm
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
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
CLINICAL FEATURES : DIARRHOEA / STEATORRHOEA ELECTROLYTE IMBALANCE MALNUTRITION VITAMIN DEFICIENCY esp. B 12 GASTRIC ACID HYPERSECRETION LIVER DYSFUNCTION CHOLELITHIASIS NEPHROLITHIASIS BACTERIAL 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
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
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 PRESENTATION
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
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.
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
PERSONAL HISTORY : 7 th CLASS STUDENT WITH GOOD APPETITE PREVIOUSLY, NORMAL SLEEP, NONSMOKERB, NON ADDICTED PAST HISTORY :UNREMARKABLE FAMILY HISTORY : SOCIOECNOMIC HISTORY : MEDICATION HISTORY :
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.
SYSTEMIC EXAMINATION CVS CNS GUS RESPIRATORY MSS ALL ARE UNREMARKABLE
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
PLAN OF MANAGMENT PATIENT KEPT NPO PASSED NG TUBE I/V FLUID I/V ANTIBIOTICS EXPLORATORY LAPROTOMY
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
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