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Toronto Notes 2019 SMALL INTESTINE Complications of Gastric Surgery
• mostresolvewithin1yr
Alkaline Reflux Gastritis
• duodenalcontents(bilious)refluxintostomachcausinggastritis±esophagitis • treatment
■ medical: H2-blocker, metoclopramide, cholestyramine (bile acid sequestrant) ■ surgical: conversion of Billroth I or II to Roux-en-Y
Afferent Loop Syndrome
• accumulationofbileandpancreaticsecretionscausesintermittentmechanicalobstructionand distention of afferent limb
• clinicalfeatures
■ early postprandial distention, RUQ pain, nausea, bilious vomiting, anemia
• treatment:surgery(conversiontoRoux-en-Yincreasesafferentloopdrainage)
Dumping Syndrome
• early:15-30minpost-prandial ■ etiology
◆ rapid emptying of hyperosmotic chyme leads to jejunal distention, stimulating release of vasoactive hormones
■ clinical features
◆ post-prandial epigastric cramping, bloating, emesis, nausea, and vasomotor symptoms
(dizziness, palpitations, tachycardia, diaphoresis) ■ treatment
◆ frequent small meals high in fibre and protein, low in carbohydrates; avoidance of liquids with meals
◆ last resort is interposition of antiperistaltic jejunal loop between stomach and small bowel to delay gastric emptying
• late:3hpost-prandial
■ etiology: hypoglycemia following postprandial insulin peak ■ treatment: small snack 2 h after meals
Blind-Loop Syndrome
• bacterialovergrowthofcolonicGram-negativebacteriainafferentlimb • clinicalfeatures
■ anemia/weakness, diarrhea, malnutrition, abdominal pain, and hypocalcemia
• treatment: broad-spectrum antibiotics, and surgery (conversion to Billroth I)
Postvagotomy Diarrhea
• up to 25%
• bilesaltsincoloninhibitwaterresorption
• treatment:medical(cholestyramine),andsurgical(reversedinterpositionjejunalsegment)
SMALL INTESTINE
Small Bowel Obstruction
Mechanical Small Bowel Obstruction
Pathophysiology
• obstruction→gasandfluid(swallowedorGIsecretions)accumulateproximaltositeofobstruction and distal decompression → intestinal activity increases to overcome obstruction → colicky pain and diarrhea (initially)
• bowelwalledemaanddisruptionofnormalbowelabsorptivefunctioncanleadtoincreased intraluminal fluid and transudative fluid loss into peritoneal cavity, electrolyte disturbances
• increaseintramuralpressurecanleadtoimpairedmicrovascularperfusionleadingtointestinal ischemia and necrosis (strangulated bowel obstruction)
General Surgery and Thoracic Surgery GS21 Liver
Stomach
Gallbladder
Pancreas
Bile juice
A. Alkaline Reflux Gastritis
Liver Stomach
Gallbladder Pancreas
Obstruction
B. Afferent Loop Syndrome
Liver Stomach Food Flow
Gallbladder
Pancreas
Small Intestine
C. Dumping Syndrome
Liver Food Flow Stomach
Gallbladder Pancreas Chyme Bacteria
D. Blind Loop Syndrome
Liver
Cut CN X Stomach
Gallblader Pancreas
H2O
Colon
E. Postvagotomy Diarrhea
© Wensi Sheng 2010
Figure 10. Complications of gastric surgery