NOTES

NOTES
INTESTINAL DISEASES

GENERALLY, WHAT ARE THEY?

PATHOLOGY & CAUSES TREATMENT
▪ Diseases preventing adequate digestive ▪ See individual diseases
system function
▫ Often involve inflammation, stasis,
obstruction, necrosis MNEMONIC: APPENDICITIS
▪ Various structural, functional etiologies Right lower-quadrant pain
common differential
Appendicitis/ Abscess
SIGNS & SYMPTOMS Pelvic inflammatory disease
(PID)/ Period pancreatitis
▪ Abdominal symptoms etiologically- Ectopic/ Endometriosis
dependent Neoplasia
▪ Abdominal pain, distension, constipation, Diverticulitis
bowel-habit change, hematochezia,
Intussusception
nausea, vomiting
Crohn’s Disease/ Cyst (ovarian)
▪ Bulging abdominal mass (in hernia)
IBD
Torsion (ovary)
DIAGNOSIS Irritable Bowel Syndrome
Stones
DIAGNOSTIC IMAGING
▪ CT scan, MRI, ultrasound

OTHER DIAGNOSTICS
▪ Right lower-quadrant pain common
differential (see mnemonic)

OSMOSIS.ORG 263
 APPENDICITIS
osms.it/appendicitis

PATHOLOGY & CAUSES SIGNS & SYMPTOMS

▪ Lumen obstruction → vestigial vermiform ▪ Abdominal pain
appendix inflammation ▫ Often begins in umbilical area →
▪ Located at cecum base (near ileocecal McBurney’s point (abdomen’s right
valve) lower-quadrant; one-third distance from
▪ Obstruction → intraluminal content anterior superior iliac spine, umbilicus)
stasis → ↑ luminal, intramural pressure → progressive inflammation
→ thrombosis, occlusion small vessels, ▫ Rovsing’s sign: left lower-quadrant
lymphatic flow stasis → ischemia, necrosis palpated → right lower-quadrant pain
▪ Excessive multiplication (gut flora) behind ▫ Psoas sign: right leg extended in left-
obstruction → immune system response side position → retrocecal appendix
→ fibropurulent reaction → parietal ▫ Obturator sign: right leg internally
peritoneum irritation rotated in supine position → pelvic
▪ Visceral nerve fiber stimulation → appendix
abdominal pain ▪ Fever, anorexia, nausea, vomiting, diarrhea/
constipation
CAUSES ▪ In case of peritonitis
▪ Obstruction ▫ Rebound tenderness at McBurney’s
▫ Lymphoid hyperplasia (adolescence, point
viral infection), fecalith, foreign body ▫ Abdominal guarding (peritoneal
(e.g. undigested seeds), pinworm irritation)
infection, tumor (benign, malignant)

DIAGNOSIS
RISK FACTORS
▪ 10–30 years old, family history, biologically- DIAGNOSTIC IMAGING
male, cystic fibrosis comorbidity (children)
CT scan with IV contrast
COMPLICATIONS ▪ Increased appendix diameter
▪ Appendix-supplying vessel compression ▪ Increased wall enhancement
→ ischemia → appendix wall necrosis ▪ Severe
→ bacterial invasion (wall) → appendix ▫ Visible abscess, pus spillage
rupture → bacterial invasion (peritoneum)
→ peritonitis Ultrasound (pregnancy, children)
▪ Periappendiceal abscess, subphrenic ▪ Visible, noncompressible, dilated appendix
abscess, pylephlebitis, portal venous ▪ ↑ blood flow in appendix wall
thrombosis, sepsis ▪ Visible appendicolith
▪ Right iliac fossa fluid collection

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LAB RESULTS
▪ Neutrophilic leukocytosis
▫ ↑ with progression
▪ Mildly elevated serum bilirubin
▫ Perforation marker

TREATMENT
MEDICATIONS
▪ Antibiotics
▪ IV fluids, no food/water orally (NPO)
Figure 34.1 Camera view of a laparoscopic
SURGERY appendicectomy being performed. The
appendicectomy has been performed and
▪ Removal (appendectomy)
the stump is visible on the right of the image,
▪ Abscess drainage with the severed appendix reflected laterally.

DIVERTICULITIS
osms.it/diverticulitis

PATHOLOGY & CAUSES SIGNS & SYMPTOMS

▪ Inflamed diverticula; microperforation of ▪ Left lower-quadrant pain (often sigmoid
diverticulum colon); palpable abdominal mass; diarrhea/
constipation; nausea; vomiting; fever;
urinary urgency/frequency/dysuria (inflamed
CAUSES sigmoid colon → bladder irritation)
▪ Increased intraluminal pressure → erosion
→ inflammation, focal necrosis → micro/
macro perforation DIAGNOSIS
RISK FACTORS DIAGNOSTIC IMAGING
▪ Diverticula present
CT scan with contrast
▪ Inflammation → hyperdense tissue
COMPLICATIONS
▪ Stricture, intestinal obstruction Abdominal X-ray
▪ Diverticulum perforation ▪ Bowel obstruction
▫ Abscess, peritonitis ▪ Bowel perforation
▪ Fistula formation ▫ Free air
▫ Bladder communication
▫ Other organ communication (vagina, LAB RESULTS
skin, other parts of bowel) ▪ Leukocytosis
▫ Vesicoenteric fistula: pneumaturia (air in
urine), fecaluria (stool in urine)

OSMOSIS.ORG 265
 TREATMENT
MEDICATIONS
▪ Uncomplicated
▫ Antibiotics, fluids, no food/water orally
(NPO)

SURGERY
▪ Resection
▫ Severe case/recurrence/complication
Figure 34.2 Gross pathology of sigmoid
diverticulosis. Notice how the diverticula
OTHER INTERVENTIONS appear either side of the longitudinal muscle.
▪ High-fiber diet
▫ Prevents recurrence

DIVERTICULOSIS
osms.it/diverticulosis
(some areas) → mucosa/submucosa
PATHOLOGY & CAUSES herniation predisposed → diverticulum
formation
▪ Diverticulum (plural diverticula): ▫ Sigmoid colon: smallest diameter →
outpouching of hollow anatomical structure highest pressure (Laplace’s Law:
wall P∝1/D), most common location
▫ Most frequent in large intestine ▪ Outpouching: tend to form where intestinal
(particularly sigmoid colon) wall-supplying blood vessels (i.e. vasa
▪ Diverticulosis: multiple diverticula present recta) traverse muscle layer

TYPES RISK FACTORS

True diverticulum ▪ Lifestyle: low-fiber diet, constipation; fatty
food, red meat-rich diet; inactivity; smoking
▪ All organ wall layers included (e.g. Meckel’s
diverticulum) ▪ ↑ age ↑ risk
▪ Biologically-male
False (pseudo-) diverticulum ▪ Family history
▪ Only mucosa, submucosa layers included ▪ Obesity
▫ Most common ▪ Connective tissue disorders
▫ Colonic diverticula ▫ Marfan syndrome
▫ Ehlers–Danlos syndrome
CAUSES ▫ Autosomal dominant polycystic kidney
▪ Multifactorial pathogenesis from abnormal disease
colonic motility
▪ Abnormal/exaggerated smooth muscle
contractions → unequal intraluminal
pressure distribution → high pressure

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COMPLICATIONS
▪ Blood vessel surrounding weakened
TREATMENT
outpouching ruptures → large intestine
blood loss → bloody stool
SURGERY
▪ Resection (if complications develop)
▪ Inflammation (diverticulitis)
▪ Segmental colitis
OTHER INTERVENTIONS
▪ Lifestyle changes
SIGNS & SYMPTOMS ▫ Diet (↑ fiber intake), avoid constipation, ↑
physical activity, smoking cessation
▪ Often asymptomatic
▪ Vague abdominal pain, tenderness, bloating
▪ Occasional cramping
▪ Altered bowel habit (diarrhea/constipation)
▪ Rectal bleeding (hematochezia—fresh
blood in stool)

DIAGNOSIS
▪ Often found incidentally

DIAGNOSTIC IMAGING
X-ray with barium enema
▪ Lower gastrointestinal series
▪ Directly shows pouches

CT scan Figure 34.3 Barium study demonstrating

▪ Visualization of colonic diverticula, multiple diverticula.
thickening of the bowel wall thickening (>
4mm), an increase in soft tissue density
within pericolonic

OTHER DIAGNOSTICS
Colonoscopy, sigmoidoscopy
▪ Visible outpouching

OSMOSIS.ORG 267
 FEMORAL HERNIA
osms.it/femoral-hernia
▪ Abdominal contents enter hernia → may
PATHOLOGY & CAUSES precipitate intestinal obstruction
▫ Most common cause worldwide
▪ Intestinal projection across femoral canal
associated with femoral artery, vein; below ▫ Incarcerated/strangulated; severe
inguinal ligament, lateral to pubic tubercle abdominal pain, tenderness, erythema,
fever, nausea, vomiting

CAUSES
▪ Congenital, acquired DIAGNOSIS
▪ Weakness/abnormal fascial opening in
abdominal wall DIAGNOSTIC IMAGING
▪ Usually includes properitoneal fat/omentum
Ultrasound
edge/small bowel loop
▪ Variable echogenicity of tissue; movement
of intra-abdominal structures in an inferior
RISK FACTORS direction through the femoral canal
▪ Biologically-female, congenital disorder
(embryological development → processus CT scan
vaginalis obliteration failure), hernia (family ▪ Visualization of characteristic funnel-
history), obesity, pregnancy, frequent heavy shaped neck; protrusion through femoral
lifting ring

COMPLICATIONS TREATMENT
▪ Narrow femoral canal
▫ ↑ incarceration/strangulation risk SURGERY
▪ Compression of femoral vein ▪ Repair
▪ Bowel obstruction ▫ Open/laparoscopic (case-dependent)
▪ Early/elective repair
▫ Uncomplicated, asymptomatic hernia
SIGNS & SYMPTOMS
▪ Urgent repair
▪ Asymptomatic (commonly) ▫ Complicated hernia (may require bowel
resection)
▪ Can manifest intestinal obstruction
symptoms
▫ Bulging mass, pain, discomfort
▫ Supine: may resolve
▫ Valsalva maneuver (coughing/straining):
worsens

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GALLSTONE ILEUS
osms.it/gallstone-ileus
Effect on intestinal wall
PATHOLOGY & CAUSES
▪ Simple: no blood supply impairment
▪ Gastrointestinal motility (peristalsis) ▪ Strangulated: blood supply cut off to bowel
disruption → impaired bowel content section
propulsion ▪ Closed loop: obstruction occurs at each end
▪ Blockage → progressive intestine dilation of bowel section
blockage-proximal, decompression Type of factor
blockage-distal
▪ Mechanical: obstruction caused by
▪ Gas accumulation (swallowed air, bacterial gallstone, neoplasm, adhesion, stricture,
fermentation) → ↑ bowel distention hematoma, meconium (in cystic fibrosis),
▪ Bowel wall edema → ↓ bowel content medical device migration (PEG tube)
absorption → luminal fluid sequestration ▪ Functional: intestinal musculature
▪ ↑ capillary permeability → transudative fluid paralysis caused by trauma (surgery, blunt
loss from intestinal lumen into peritoneal abdominal trauma), peritonitis, medication
cavity (opiates, anticholinergics)
▪ Emesis → fluid, electrolyte (Na, K, H, Cl)
loss → metabolic alkalosis, hypovolemia
RISK FACTORS
▪ Bowel dilation continues → ↓ intestinal
▪ Surgery; bowel manipulation, anesthesia,
wall tissue perfusion → ischemia, necrosis,
postoperative opioids
bowel perforation
▪ Hernia, neoplasm history, abdominal/pelvic
irradiation, chronic inflammation, abdominal
TYPES trauma
Onset
▪ Acute: factors such as torsion, COMPLICATIONS
intussusception → sudden onset ▪ Fluid/electrolyte/acid-base imbalance;
▪ Chronic: factors such as tumor growth → bowel strangulation, necrosis; perforation;
prolonged onset sepsis
▪ Recurrent: often caused by adhesions →
intermittent obstructions
SIGNS & SYMPTOMS
Extent
▪ Partial: some of intestinal lumen remains ▪ Abdominal distension, cramping pain,
open constipation, nausea, vomiting
▪ Complete: total lumen obstruction ▪ Dehydration: tachycardia, dry mucous
membranes, ↓ urine output
Location ▪ Bowel sounds
▪ Intrinsic: obstruction within bowel ▫ High-pitched “tinkling” sound
wall—e.g. inflammatory stricture, edema, auscultated: acute mechanical bowel
hemorrhage, foreign body (ingested, obstruction
parasite accumulation, large biliary calculus) ▫ Muffled, hypoactive bowel sounds:
▪ Extrinsic: obstruction outside bowel wall— significant bowel distention association
e.g. torsion, compression (hernia) ▪ Abdominal percussion: hyperresonance/
tympany

OSMOSIS.ORG 269
 DIAGNOSIS
DIAGNOSTIC IMAGING
X-ray
▪ Small intestine, colon distension

TREATMENT
SURGERY
▪ Surgical intervention: e.g. release
adhesions, complete obstructions, repair
bowel

OTHER INTERVENTIONS
Figure 34.4 A CT scan of the abdomen and
▪ No food/water orally (NPO)
pelvis in the coronal plane demonstrating
▪ Fluid, electrolyte replacement a gallstone in the terminal ileum. If so large
▪ Parenteral feeding → nasogastric that it is unable to pass through the ileocecal
decompression valve, the gallstone will cause small bowel
obstruction.

GASTROENTERITIS
osms.it/viral-gastroenteritis
▪ Viral contact
PATHOLOGY & CAUSES ▫ E.g. daycare center, cruise ship, closed
community outbreak; contaminated
▪ Gastrointestinal tract viral infection (lasts food/water
12 hours–3 days)
▪ Primary transmission
▫ Oral–fecal route
COMPLICATIONS
▪ Severe dehydration → altered mental
▪ Viruses → epithelium damage → osmotic
status, weight loss
diarrhea (> three stools daily), vomiting

CAUSES SIGNS & SYMPTOMS

▪ Children: rotavirus (most common)
▪ Adult: norovirus (most common), astrovirus, ▪ Watery diarrhea; nausea; vomiting;
adenoviruses abdominal cramps, pain; fever; malaise;
dehydration (dry lips, skin turgor,
tachycardia)
RISK FACTORS
▪ ↑ morbidity
▫ Children, elderly, immunocompromised
individuals

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DIAGNOSIS
LAB RESULTS
▪ Stool sample
▫ Excludes bacterial/parasitic etiology
▪ ↑ C-reactive protein (CRP), ↑ leukocytes
▪ Polymerase chain reaction (PCR)
▫ Stool, vomit: enzyme-linked
immunosorbent assay (ELISA)
performed for rotavirus

TREATMENT
Figure 34.5 A scanning electron micrograph
of a cluster of Norwalk virus capsids. OTHER INTERVENTIONS
▪ Fluid replacement

Prevention
▪ Hygiene practices, rotavirus vaccine

INGUINAL HERNIAS
osms.it/inguinal-hernias
▫ Testicular descent path: covered
PATHOLOGY & CAUSES by three layers of spermatic fascia
(three layers); external spermatic
Direct inguinal hernia fascia (external oblique muscle fascia
▪ Peritoneal sac; projects directly through continuation); cremasteric muscle
inguinal triangle (AKA Hesselbach’s fascia; internal spermatic fascia (internal
triangle) oblique muscle fascia continuation)
▪ Projects medially to inferior epigastric
vessels, lateral to rectus abdominis, pierces CAUSES
parietal peritoneum
▪ Hesselbach’s triangle composition: inguinal Indirect inguinal hernia
ligament (AKA Poupart’s ligament), rectus ▪ Processus vaginalis closure failure (i.e.
abdominis muscle (lateral border), inferior internal inguinal ring and processus
epigastric vessels vaginalis obliteration failure)
▪ Covered by external spermatic fascia

Indirect inguinal hernia RISK FACTORS

▪ Most common hernia Direct inguinal hernia
▪ Intestinal projection through internal ▪ Acquired, affects transversalis fascia
inguinal ring
▫ Chronic intra-abdominal pressure ↑ (e.g.
▫ Location: spermatic cord (biologically- obesity, chronic cough, constipation,
male), round ligament (biologically- heavy lifting—occupational/recreational)
female) exit the abdomen
▪ Abdominal wall musculature atrophy

OSMOSIS.ORG 271
 (aging)
▪ Older, biologically-male individuals
DIAGNOSIS
Indirect inguinal hernia DIAGNOSTIC IMAGING
▪ Biologically-male individuals > biologically- Ultrasound
female individuals
▪ Direct inguinal hernia
▫ Biologically male: late right testicle
▫ Variable echogenicity of tissue;
descent
movement of intra-abdominal structures
▫ Biologically female: asymmetric pelvis in an anterior direction through the
Hesselbach triangle
COMPLICATIONS ▪ Indirect inguinal hernia
▫ Visualization through abdominal wall in
Direct inguinal hernia
biologically-female individuals
▪ Incarceration/strangulation potential
CT scan
Indirect inguinal hernia
▪ Direct inguinal hernia
▪ Can form hydrocele
▫ Visualization of a protrusion with
▪ May precipitate intestinal obstruction compressing inguinal canal contents;
▪ Most common cause worldwide inguinal canal pushed into a semicircle
of tissue that resembles a moon
crescent
SIGNS & SYMPTOMS ▪ Indirect inguinal hernia
▫ Identifies occult hernia/complications;
▪ May be asymptomatic hernia neck visualized superolateral to
▪ Bulging mass (indirect inguinal hernia, the inferior epigastric vessels
mass in groin), pain, discomfort
▫ Valsalva maneuver cessation/prone: may
resolve
OTHER DIAGNOSTICS
▪ Indirect inguinal hernia
▪ Valsalva maneuver: worsens projection
▫ History, clinical exam; sufficient for
▫ Coughing/straining
majority of suspected inguinal hernias
Direct inguinal hernia
▪ May precipitate intestinal obstruction
▫ Most common cause worldwide
▫ Incarcerated/strangulated: severe
abdominal pain, tenderness, erythema,
fever, nausea, vomiting

Indirect inguinal hernia

▪ Visible bulge
▫ May be unapparent in biologically-
female individuals
▪ Incarcerated/strangulated
▫ Severe abdominal pain, tenderness,
erythema, fever, nausea, vomiting

Figure 34.6 Intraperitoneal view of an

inguinal hernia during a laparoscopic hernia
repair. The peritoneal cavity extends into the
inginal canal, lateral to the epigastric vessels,
making this an indirect hernia.

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TREATMENT
SURGERY
Repair
▪ Open/laparoscopic (case-dependent)
▪ Elective repair
▫ Symptomatic hernias
▪ Direct inguinal hernia (asymptomatic)
▫ Monitor, surgical repair preferred

Figure 34.8 A CT scan in the coronal plane

Figure 34.7 Clinical appearance of a hernia demonstrating an indirect inguinal hernia.
in the groin. It is often not possible to The proximal bowel is dilated, indicating a
distinguish between a direct and indirect strangulated hernia causing obstruction.
hernia on clinical examination alone.

INTESTINAL ADHESIONS
osms.it/intestinal-adhesions
▪ Injury prevents enzyme secretion →
PATHOLOGY & CAUSES macrophages, fibroblasts deposit collagen
into adhesion → permanent
▪ Fibrous tissue bands form physical
attachment between intestines → ↓
intestinal motility CAUSES
▪ Formed from scarred, post-trauma tissue ▪ Surgery (most common), inflammation
(cholecystitis, pancreatitis, peritonitis),
▪ Tissue injury → inflammation → fibrin
endometriosis, pelvic inflammatory disease
deposits → fibrin connects parts left (similar
to reconstructive “glue”)
▪ Adhesions extend between tissue if both COMPLICATIONS
parts have been injured, close proximity ▪ Bowel obstruction, intestinal wall volvulus/
▪ Initial fibrous adhesions dissolved by ischemia
fibrinolytic enzymes

OSMOSIS.ORG 273
 SIGNS & SYMPTOMS
▪ Abdominal pain, vomiting, bloating,
constipation

DIAGNOSIS
DIAGNOSTIC IMAGING
X-ray
▪ Detect obstruction; small intestine dilation

CT scan, ultrasound Figure 34.9 Intraoperative view of abdominal

▪ Exclude other obstructive causes adhesions.

TREATMENT
SURGERY
▪ Surgical/laparoscopic adhesion excision

INTUSSUSCEPTION
osms.it/intussusception
RISK FACTORS
PATHOLOGY & CAUSES ▪ Most common < 24 months old,
intestinal malrotation history, previous
▪ Condition that occurs when part of intussusception, intussusception in sibling,
intestine folds into adjacent section → biologically male
obstruction
▪ Ileocecal region most commonly affected
▪ May be idiopathic/caused by abnormal
COMPLICATIONS
structure (causes pathological lead point) ▪ Peritonitis, sepsis
→ peristalsis causes one part of bowel
to move ahead of adjacent section →
bowel telescoping → ↑ pressure, impaired SIGNS & SYMPTOMS
venous return → bleeding, bowel ischemia,
infarction ▪ Intermittent abdominal pain (worsens with
peristalsis)
▪ Guarding
CAUSES
▪ Straining efforts, draw knees toward chest
▪ Adults: abnormal growth (e.g. polyp, tumor)
▪ Vomiting
▪ Infants: post-infection lymphoid hyperplasia
(Peyer’s patches), Meckel’s diverticulum ▪ Sausage-like abdominal mass
▪ “Red currant jelly” stool (blood, mucus)

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DIAGNOSIS TREATMENT
DIAGNOSTIC IMAGING SURGERY
▪ Free telescoped intestine portion → clear
Ultrasound, X-ray, CT scan
obstruction → remove necrotic tissue
▪ Telescoped intestine: visualized as classic
bull’s-eye image
▪ Intestinal obstruction signs OTHER INTERVENTIONS
▪ Reduction by air/hydrostatic contrast
material enema (e.g. saline, barium)
OTHER DIAGNOSTICS
▪ May be felt during digital rectal examination
(children)

IRRITABLE BOWEL SYNDROME

(IBS)
osms.it/IBS
previous gastroenteritis, stress
PATHOLOGY & CAUSES
▪ Chronic functional gastrointestinal system SIGNS & SYMPTOMS
disorder; recurrent abdominal pain,
impaired bowel motility ▪ Impaired bowel motility → diarrhea/
▫ No microscopic, macroscopic constipation
irregularities ▪ Recurrent abdominal pain
▫ Constipation/diarrhea ▫ Bowel movement → improvement
▪ Bloating, nausea, mucus in stool
CAUSES
▪ Pathology not completely understood; likely
multifactorial DIAGNOSIS
▫ Visceral hypersensitivity: altered stimuli
response OTHER DIAGNOSTICS
▫ Fecal flora alterations; bacterial ▪ Based on predominant consistency of stool
overgrowth ▫ Diarrhea predominant, constipation
▫ Food sensitivity: short-chain predominant, mixed stool pattern,
carbohydrates; ↑ water in bowel → unclassified
smooth muscle spasm, diarrhea; ▪ Organic disease exclusion
metabolized by bacteria → gas →
bloating, spasm, pain “Rome IV” diagnostic criteria
▫ Psychosocial influence ▪ Abdominal pain ≥ one day weekly in last
three months, associated with two/more of
▫ Genetic factor
following
▫ Defecation → lessened pain
RISK FACTORS ▫ Change in stool frequency
▪ Biologically-female (region-dependent), ▫ Change in stool consistency

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 OTHER INTERVENTIONS
TREATMENT ▪ Stress management
▪ Diet modification
▪ No definitive cure
▫ Low fermentable oligo-, di-,
monosaccharides/polyols diet (low
MEDICATIONS FODMAPs diet)
▪ Symptom-guided therapy ▫ Avoid gas-producing food (caffeine,
▫ Diarrhea predominant: drugs (e.g. alcohol)
loperamide) ▫ Probiotics
▫ Constipation predominant: fiber ▫ Physical activity
supplementation, adequate fluid intake,
osmotic laxatives
▫ Spasm, pain: antispasmodics

ISCHEMIC COLITIS
osms.it/ischemic-colitis
▫ Hypercoagulable states (e.g. factor V
PATHOLOGY & CAUSES Leiden)
▫ Biologically-female individuals
▪ Inflammatory, ischemic condition; ▫ Impaired perfusion (e.g. aortic surgery,
affects colon, most often splenic flexure, myocardial infarction, hemodialysis)
rectosigmoid junction
▫ Vasculopathy
▪ Sudden blood flow ↓ → insufficient
▫ Certain drugs (e.g. vasopressors)
perfusion, oxygen/nutrient delivery to
bowel → compromised cellular metabolism
→ ischemia, inflammation, infarction, COMPLICATIONS
necrosis → possible perforation ▪ Gangrenous bowel, stricture, pancolitis,
▪ Damaged, gangrenous mucosa promotes colonic perforation, peritonitis, sepsis,
fluid/electrolyte loss → dehydration, shock, shock, metabolic acidosis, multisystem
metabolic acidosis organ failure, reperfusion injury, potentially
fatal
CAUSES
▪ Ischemia causes may be occlusive (embolic, SIGNS & SYMPTOMS
thrombotic)/nonocclusive (↓ mesenteric
circulation → severe hypotension,
▪ Symptomatology may be self-limiting
vasospasm)
▪ Localized abdominal cramping, tenderness
▫ Usually acute, may be chronic disorder
(usually left side)
for marathon runners
▪ Loose, bloody stools, hematochezia
▪ ↓ bowel sounds
RISK FACTORS ▪ Guarding, rebound tenderness
▪ Any cause of ↓ perfusion/mesenteric arterial
▪ Fever
embolism, thrombosis/vasoconstriction
▪ May develop shock signs (e.g. hypotension)
▫ Risk ↑ with age/comorbidities

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▪ Stool culture
DIAGNOSIS ▪ Identifies infectious etiology
DIAGNOSTIC IMAGING
X-ray/CT scan TREATMENT
▪ Abdominal; visualizes obstruction,
perforation, pneumonitis MEDICATIONS
▫ Thumbprinting: segmented bowel ▪ Antibiotics
edema/thickening pattern ▫ Perforation/infection
▫ Double-halo pattern: mucosa,
muscularis hyperdensity SURGERY
▫ Pneumatosis coli, pneumoperitoneum ▪ Bowel resection
indicates perforation ▫ Necrotic tissue
Colonoscopy
▪ Visualizes ischemia: edema, erythema,
friable mucosa
▪ Single-stripe sign: linear ulcer seen along
longitudinal axis
▪ Submucosal hemorrhage: bluish nodules
▪ Biopsy: transmural fibrosis, mucosal
atrophy

LAB RESULTS
▪ Leukocytosis, thrombocytopenia, ↓
hemoglobin
▪ ↑ serum lactate, lactate dehydrogenase Figure 34.10 The endoscopic appearance of
(LDH), creatine phosphokinase (CPK), the colon in a case of ischemic colitis. There is
amylase indicates tissue damage mucosal edema and patchy erythema.

OSMOSIS.ORG 277
 OTHER INTERVENTIONS
▪ Circulatory support
▫ IV fluids, electrolytes
▪ Supplemental oxygen
▪ Bowel rest

Figure 34.11 Histological appearance of the

colon in an individual with ischemic colitis.
There is mucosal necrosis, a sign that the
condition is in its early stages at the time of
biopsy.

NECROTIZING ENTEROCOLITIS
(NEC)
osms.it/necrotizing-enterocolitis
RISK FACTORS
PATHOLOGY & CAUSES ▪ Gestational age < 32 weeks
▪ Low birth weight < 2kg/4.41lbs
▪ Severe intestinal disorder: inflammation,
ischemic necrosis ▪ Dysbiosis-contributing interventions
▫ Terminal ileum, colon (most often ▫ Antibiotics, acid-reducing agents,
affected) feeding bovine milk formula
▪ Multifactorial pathology ▪ Human milk promotes commensal bacteria
growth, supports mucosal integrity
▪ Preterm infants
▪ Infections, gas-forming organism presence
▫ Immature gastrointestinal tract
characterized by ↓ intercellular junction ▪ Underlying conditions
integrity + ↓ mucosal barrier → ▫ Term infants (e.g. fetal growth
triggering event → normal intestinal restriction, perinatal hypoxia, congenital
microbiome dysbiosis → ↑ pathogenic heart disease, gastrointestinal disorders,
bacterial growth → exaggerated sepsis)
immune system response → release of
host cytokines, chemokines → tissue COMPLICATIONS
injury → necrosis
▪ Bowel perforation, ileus, septic shock,
▪ Term infants metabolic acidosis, coagulopathy,
▫ Usually underlying condition adversely respiratory failure
affecting intestinal perfusion ▪ Surgical complications

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▫ Strictures, short bowel syndrome OTHER DIAGNOSTICS

▪ ↑ impaired neurodevelopmental
Surgery
development risk
▪ Through surgical/postmortem specimens
▪ High mortality rate
▫ Gross examination: gangrenous
necrosis, hemorrhage, subserosal gas
SIGNS & SYMPTOMS collection
▫ Histological examination: edema,
▪ Abrupt feeding tolerance change hemorrhage, transmural necrosis,
▪ Abdominal distension, tenderness bacterial infiltration
▪ Erythema, crepitus, induration may also be
present
TREATMENT
▪ ↑ gastric residuals
▪ Vomiting (often bilious), bilious drainage MEDICATIONS
from enteral feeding tubes ▪ Empirical antimicrobial therapy
▪ Hematochezia
▪ Nonspecific findings
SURGERY
▫ Temperature instability, lethargy, apnea
▪ Exploratory laparotomy, bowel resection
▪ Primary peritoneal drainage (PPD) → ↓
intra-abdominal pressure

OTHER INTERVENTIONS
▪ Address complications (e.g. metabolic
correction/hematologic abnormalities)
▪ Bowel rest with nasogastric intubation
decompression
▪ Supplemental oxygen/mechanical
ventilation
▪ Fluid replacement
▪ Inotropic support
Figure 34.12 Gross pathology of necrotizing ▪ Total parenteral nutrition (TPN)
enterocolitis.

DIAGNOSIS
DIAGNOSTIC IMAGING
Abdominal radiography, ultrasound
▪ Pneumatosis intestinalis,
pneumoperitoneum/hepatobiliary gas

LAB RESULTS
▪ Positive blood culture, ↓ platelets, ↓ red
blood cells, disseminated intravascular
coagulopathy evidence, ↑ serum lactate

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 SMALL BOWEL ISCHEMIA &
INFARCTION
osms.it/ischemia-and-infarction

cardiopulmonary bypass surgery,

PATHOLOGY & CAUSES hemodialysis → ↓ intestinal perfusion)
▪ Coagulative disorders
▪ Serious small bowel condition; reduced
▪ Atherosclerotic occlusive disease
blood flow, subsequent infarction; AKA
mesenteric ischemia ▪ Hypovolemia (e.g. dehydration,
hemorrhage)
▫ Collateral circulation network →
small bowel especially vulnerable to ▪ Bowel strangulation (e.g. volvulus,
widespread ischemic injury incarcerated hernia)
▫ Hypoxia, subsequent reperfusion → ▪ Vasoconstriction medications
tissue injury
▪ ↓ blood flow may be acute/chronic COMPLICATIONS
▫ Acute: sudden ↓ small intestine ▪ Ileus, shock, metabolic acidosis,
perfusion multisystem organ failure, high mortality
▫ Chronic: episodic ↓ digestion
perfusion (often related to mesenteric
atherosclerosis) SIGNS & SYMPTOMS
▪ Insufficient perfusion, oxygen/nutrient
delivery to bowel → compromised cellular ▪ Severe abdominal pain (often postprandial);
metabolism → ischemia, inflammation, nausea, vomiting; distended abdomen;
transmural infarction, necrosis → bacterial guarding, rebound tenderness (develops
transmigration + possible perforation later); ↓ bowel sounds; fever; feculent
▪ Damaged, gangrenous mucosa promotes breath odor; rectal bleeding; may exhibit
fluid/electrolyte loss → dehydration, shock, shock signs (e.g. hypotension)
metabolic acidosis
DIAGNOSIS
CAUSES
▪ Ischemia causes DIAGNOSTIC IMAGING
▫ Occlusive (arterial/venous): embolic,
thrombotic, tumor, volvulus, CT/magnetic resonance (MR) angiography
intussusception, hernia, atherosclerosis ▪ Detects acute mesenteric ischemia
▫ Nonocclusive: severe hypotension, Abdominal X-ray/CT scan
vasospasm → ↓ mesenteric circulation
▪ Dilated bowel loops, bowel wall thickening,
thumbprinting, intestinal pneumatosis, free
RISK FACTORS intraperitoneal air
▪ Any cause of ↓ perfusion/mesenteric arterial
embolism, thrombosis/vasoconstriction LAB RESULTS
▪ Cardiac disorders (e.g. arrhythmia, valvular ▪ Leukocytosis with left shift, ↑ hematocrit
disease → arterial emboli formation (dehydration, hemoconcentration)
from heart; ↓ cardiac output, peripheral
▪ ↑ serum lactate, amylase, alkaline
hypoperfusion)
phosphatase
▪ Procedures (e.g. cardiac catheterization,

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 Chapter 34 Intestinal Diseases

OTHER DIAGNOSTICS SURGERY

▪ Laparotomy ▪ Resection
▫ Abdominal exploration
OTHER INTERVENTIONS
TREATMENT ▪ Pain management
▪ Bowel rest with decompression
MEDICATIONS
▪ Antibiotics
▪ Circulatory support
▫ IV fluids, electrolytes, inotropic
medications

VOLVULUS
osms.it/volvulus

PATHOLOGY & CAUSES SIGNS & SYMPTOMS

▪ Intestinal obstruction ▪ Abdominal tenderness, pain, distension,
▫ Intestinal twisting/looping bilious vomiting, constipation, fever,
auscultation (abnormal bowel sounds,
often decreased), percussion (tympany),
TYPES hematochezia (may indicate bowel
▪ Classified by location ischemia, necrosis)
Sigmoid volvulus (most common)
▪ Usually middle-aged/elderly individuals DIAGNOSIS
▪ Causes include pregnancy, chronic
constipation (e.g. Hirschsprung’s disease), DIAGNOSTIC IMAGING
intestinal adhesions
X-ray
Cecal volvulus ▪ Asses volvulus shape
▪ Causes include impaired abdominal ▫ Bent inner tube sign (“coffee bean” sign)
mesentery development, pregnancy,
chronic constipation Barium enema
▪ May show “bird’s beak” shape (point of
Midgut volvulus
twisted bowel)
▪ Usually infants/young children
▪ Perforation suspected → barium contrast
▪ Caused by anomalous intestinal contraindicated
development (e.g. intestinal malrotation)
CT scan
COMPLICATIONS ▪ Twisted mesentery (“whirlpool” sign)
▪ Mesenteric artery compression → intestinal
wall ischemia, infarction
▪ Intestinal wall perforation, infection (e.g.
diffuse peritonitis)

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 TREATMENT
SURGERY
▪ In case of midgut volvulus/ischemia/
necrosis; surgical resection if necessary

OTHER INTERVENTIONS
▪ IV fluid replacement
▪ Bowel decompression
▫ Sigmoid volvulus: sigmoidoscopy
▫ Cecal volvulus: colonoscopy

Figure 34.13 Abdominal radiograph

demonstrating a massively dilated sigmoid
colon in a case of sigmoid volvulus.

Figure 34.14 3D CT virtual colonoscopy

demonstrating sigmoid volvulus.

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