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CARDIFF HEALTHCARE INTERNATIONAL PERSPECTIVES Case 15 Lower GI Tract Brought to you by: Andrew Naguib & Jordan Khoo Anatomy - Overview Retroperitoneal S: suprarenal (adrenal) gland A: aorta/IVC D: duodenum (second and third part) P: pancreas (except tail) U: ureters C: colon (ascending and descending) K: kidneys E: (o)oesophagus R: rectum Foregut – mouth to Duodenum at the Ampulla of Vater Midgut – rest of Duodenum to proximal 2/3 of Transverse Colon Hindgut – distal 1/3 of Transverse Colon to upper portion of the Anal CanalAnatomy – Small BowelAnatomy - ColonAnatomy – Cecum Kabir’sAnatomy - AppendixAnatomy - RectumAnatomy – Anal CanalAnatomy – Blood Supply of the Lower GITPhysiology – Digestion & Absorption Iron First BroPhysiology – Colonic MovementsRadiology – Imaging Techniques Kabir, a 63 year old male presents with abdominal pain, vomiting, constipation and bloating. He reports that he has not opened his bowels in 5 days and cannot recall the last time he has passed wind. His previous surgical history includes a right sided mesh hernia repair and a cholecystectomy. An abdominal radiograph is performed. What is the most likely diagnosis? A Constipation B Large Bowel Obstruction C Small Bowel Obstruction D Toxic Megacolon E Volvulus Kabir, a 63 year old male presents with abdominal pain, vomiting, constipation and bloating. He reports that he has not opened his bowels in 5 days and cannot recall the last time he has passed wind. His previous surgical history includes a right sided mesh hernia repair and a cholecystectomy. An abdominal radiograph is performed. What is the most likely diagnosis? A Constipation B Large Bowel Obstruction C Small Bowel Obstruction D Toxic Megacolon E VolvulusRadiology – Bowel Obstruction Small Bowel Obstruction Large Bowel Obstruction Position Central Peripheral Diameter >3cm >6cm or >9cm for caecum Features Valvulae conniventes – cross Haustra – cross no more than full width of bowel 2/3 of bowel width X-RayBowel Obstruction Small Bowel Obstruction Large Bowel Obstruction 80% of bowel obstructions Less common Factors outside of the bowel - Colonic Tumour - Adhesions (most common cause in - Western world) - Strictures: Diverticular disease, IBD, - Hernias Post-surgical anastomosis - - Factors relating to bowel wall - Volvulus: Sigmoid or Caecal - Crohn’s Disease - - Appendicitis - Hernias - Factors inside the bowel - Adhesions - Malignancy (very rare) - Foreign body ingestion - Gallstone ileusBowel Obstruction Abdominal Pain Vomiting Tinkling Bowel Sounds NG Tube Distention Focal Tenderness Absolute Constipation Drip & Suck Fluid Bowel Ischaemia Replacement Third-Spacing Bowel Perforation Dehydration Urgent Closed-loop Obstruction Surgery Renal Impairment Radiology - Pneumoperitoneum Definition: Air in peritoneal space Causes: ➢ Bowel perforation ➢ Post-surgery ➢ Penetrating Erect chest x-ray ➢ free air under diaphragm Abdominal x-ray ➢ Rigler’s sign: clear outlining of both sides of the bowel wall ➢ Falciform ligament sign: visible falciform ligamentVolvulus Sigmoid Volvulus Caecal Volvulus More common & in older patients Less common & in younger patients High fibre diet/excessive use of laxatives Intestinal malformation/excessive exercise Coffee bean sign Embryo sign Arises from LLQ Arises from RLQ Points towards RUQ Points towards LUQ No haustra visible Haustra still visible Dilation of ascending, transverse & Small bowel obstruction & collapsed distal descending colon large bowelRadiology - Volvulus Ileus Definition: normal peristalsis temporarily stops in small bowel Causes: ➢ Bowel injury ➢ Handling of bowel during surgery ➢ Inflammation or infection Signs & Symptoms: ➢ Vomiting (particularly green bilious vomiting) ➢ Abdominal distention ➢ Diffuse abdominal pain ➢ Absolute constipation ➢ Absent bowel soundsRadiology – Other Areas of Interest CARDIFF HEALTHCARE INTERNATIONAL PERSPECTIVES Thank you for listening Any questions? naguiban@cardiff.ac.uk