small + large bowel - british medical association€¦ · · 2016-05-27muscularis mucosae 2 thin...
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Small + Large BowelBMA Revision DayAndrew McCorkell
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Small Intestine
MUCOSA
Epithelium & specialisations
Simple columnarEnterocytes - Villi + Microvilli Goblet cells - secrete mucusPaneth cells - Mucosal defense system Enteroendocrine cells
Lamina Propria Loose CT; surrounds the crypts of Leiberkuhn and
supports villi; capillary network and lacteal found in
core of villus; lymphoid tissue increases proximal
to distal
Muscularis mucosae 2 thin layers of smooth muscleInner circular / outer longitudinal
SUBMUCOSA Loose collagenous and elastic CT; lymphoid tissue
may bulge down from lamina propria; Meissner’s
nerve plexuses; forms core of plicae circulares;
Brunner’s glandsMUSCULARISEXTERNA
2 layers of smooth muscleInner circular / outer longitudinalMyenteric nerve plexus
SEROSA/ADVENTITIA
Serosa present except distal duodenum which has
adventitia
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Duodenum• 1st part of small intestine
• C – shaped structure
adjacent to head of
pancreas
• Retroperitoneal structure
except for 1st part of
duodenum which is
connected to the
hepatoduodenal ligament
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Jejunum• Represents proximal 2/5
• Larger in diameter an thicker
wall than ileum
• Inner mucosa lining of
jejunum is characterised by
numerous prominent folds
that circle the lumen – plicae
circulares
• Less prominent arterial
arcades and longer vasa
recta compared to the ileum
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Ileum• Distal 3/5 with thinner
walls
• Less prominent Plicae
Circulares
• Shorter vasa recta
and more arterial
arcades
• Ends at ileo-caecal
junction
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Function
• Absorption
• Enzymatic Digestion
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Clinical Case 1
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• 72 yr old gentleman presents with central colicky abdominal pain, constipation, increasing abdominal distension and 2x vomiting episodes.
• PMHx - Stage II R Colon Ca. Underwent R Hemicolectomy 6 months ago.
• NKDA + Ramipril 2.5mg/ Simvastatin 20mg/ Omeprazole 20mg
• Retired banker and lives at home with wife in a bungalow.
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• O/E: Patient looks in pain, Mild SOB
• Abdo is distended. Previous right paramedian scar from R Hemicolectomy. End Colostomy LIF appears healthy. Good output. Abdomen tender, no rebound. Hyper-resonant percussion. Bowel sounds high pitched and tinkling.
• Ix: FBP - WCC up
U+E - K 5.4/ Na 135/ Crt 48/ Urea 12
ABG - PO2 8.4/ pCO2 6.7/ pH 7.32/ HCO3 19
Amylase - 120
LFTs - Normal, Albumin 24
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Small Bowel Obstruction
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• Clinical Features:
✴Constipation
✴Abdominal Distension
✴Central abdominal pain
✴Failure to pass Flatus
✴Vomiting
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• Aetiology:
– Tumours
– Hernias
– Adhesions– Others - Strictures/ Inflammation/ Congenital/ post-op ileus/
haemorrhage
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Clinical Case 2
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• 24 year old female attends GP with tiredness, generalized abdo discomfort, weight loss and thinks she looks ‘pale’. Reduced appetite over last 3-4 months. Concerned as she’s had to take time off work. Also complains of an extremely itchy rash on elbows, knees and buttocks.
• PMHx: TIDM
• Non-smoker/ social drinker
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• O/E: Patient appears pale, but comfortable at rest.
• Abdo - Slightly distended, generalized tenderness, BS Normal
• Ix: FBP - Low Hb, Low MCV, Low MCHC
U+E - Normal
CRP - Slightly raised
LFTs - Normal, but low Albumin
Anti-Endomysial Ab +ve/ Anti-transglutaminase Ab +ve/ Ant-gliadin Ab +ve
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Coeliac Disease
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• Commonest Autoimmune condition - 1 in 100
• Auto-immune immunologically mediated reaction against gluten
component of gliadin protein found in wheat, rye and barley.
• Genetic susceptibility with HLA haplotypes (HLADQ2/8) – those with
Type 1 diabetes mellitus and autoimmune thyroid disease have an
increased incidence
• Geographical clustering – common among west Ireland
• Can affect an individual at any age from childhood to old age
• Villous destruction by T-cells impairs small bowel absorption and
symptomatology is proportional to the length of bowel involved.
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Colon
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Large Intestine
MUCOSAEpithelium &
specialisations
Simple columnar - except at recto-anal junction —> SSKE
Brush border + goblet cells
Lamina Propria Loose CT (surrounds the crypts) and lymphoid tissue – abundant in
appendix (MALT)
Muscularis mucosae 2 thin layers of smooth muscle
Inner circular / outer longitudinal
SUBMUCOSA Loose collagenous and elastic CT; lymphoid tissue may bulge down from
lamina propria; nerve plexuses;
MUSCULARISEXTERNA
Inner circular layer
Outer longitudinal as 3 ribbon-like bands - Taeniae Coli
Outer longitudinal – uniform thickness in appendix and rectum
SEROSA/ADVENTITIA
Ascending and descending colon are retro-peritoneal i.e. serosa only on anterior surface
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'The main functions of the colon and
rectum are to absorb water and
nutrients from what we eat and to
move food waste out of our body.'
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• The colon receives partially digested food, in a liquid
form, from the small intestine.
• Bacteria (bowel flora) in the colon break down some
materials into smaller parts
• The epithelium absorbs water and nutrients. It forms the
remaining waste into semi-solid material, faeces.
• The epithelium also produces mucus at the end of the
digestive tract, which makes it easier for stool to pass
through the colon and rectum.
• Sections of the colon use peristalsis to move the stool to
the rectum.
• The rectum is a holding area for the stool. When it is
full, it signals the brain to move the bowels and push the
stool from the body through the anus.
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Clinical Case 3
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• 67 year old lady presents to GP with change in bowel habit approx 8 weeks with intermittent diarrhoea and constipation. She has passed some blood PR and generally feels quite tired. Hasn’t taken part in FOB screening.
• PMHx: Hypertension
• FHx: Nil of note
• Social Hx: Social alcohol and non-smoker
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• O/E: She appears comfortable at rest, but has yellow sclera.
• Abdomen - Palpable mass in RIF and palpable liver edge that feels nodular. PR examination reveals some blood on gloved finger.
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• Ix: FBC - Low Hb
U+E - Normal
LFTs - ALP/ ALT/ GGT/ AST raised
CEA – Raised
Fe Profile – Fe def anaemia
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Colonoscopy
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Sigmoid Colon Carcinoma -Stage IV
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Colorectal Cancer
• 3rd commonest Cancer in UK
• 2nd commonest cause of death by cancer
• 1 in 20 Females/ 1 in 16 Males in NI
• 2/3 Colon + 1/3 Rectum
• National Screening Programme - FOB (60-
74 yrs every 2 years)
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Risk Factors
• Genetic: FAP/ HNPCC/ Peutz-Jeghers/ Gardners Syndrome
• Pre-existing: IBD/ CRC/ Pelvic Cancers/ Previous CTX/ Colorectal polyps
• General: Increasing age/ FHx/ Lifestyle/ Geographical
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Pathophysiology
Adeno-Carcinoma Sequence
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Red Flag Criteria
•40-60yrs old, rectal bleeding and change in bowel habit > 6weeks
•>60 yrs old, rectal bleeding only for > 6weeks
•>60 yrs old change in bowel habit only for > 6weeks
•Palpable abdominal mass
•Palpable rectal mass
•Fe2+ deficiency anaemia (Men <11g/dL, Women <10g/dL)
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Right Sided Tumour Left Sided Tumour Rectum
• Mass in RIF• ‘Appendicitis’ type
pain • Fe def anaemia Blood
mixed in stool• Diarrhoea• Mucus
• Mass in LIF• Change in bowel
habit – constipation• PR bleeding• Colicky abdo pain
• Tenesmus• Urgency• Incomplete
evacuation + straining• Increased frequency• Bright red PR
bleeding Constipation or diarrhoea
• Palpable mass PR
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Questions?