lower gastro-intestinal ANOMALIES. power point

lower GI anomalies

1. CONGENITAL ANOMALIES OF LOWER GIT NDANSAW JOSEPH NDIFELAYE

2. OUTLINE INTRODUCTION ANOMALY CAUSES COMPLICATION INVESTIGATION SUMMARY CONCLUSION

3. The gastrointestinal (GI), or digestive, tract extends from mouth to anus. The division of the GI tract into upper and lower is a matter of some confusion and debate. On embryologic grounds, the GI tract is divided into; Upper: mouth to major papilla in the duodenum Middle: duodenal papilla to mid-transverse colon Lower: mid-transverse colon to anus These derivation of 3 areas are from the foregut, midgut, and hindgut, respectively. INTRODUCTION 3

4. INTRODUCTION CONTD Another classification is based on the ligament of Treizt or the suspensory ligament of the duodenum. With division of upper and lower GI above and below this ligament respectively. In this presentation, we will be using the latter division. 4

5. DIAGRAM OF THE GIT 5 Jejunum accounting for upper 2/5 while ileum accounting for lower 3/5. The ascending and transverse colon can be seen.

6. LOWER GIT ANOMALIES Lower GIT structural/ functional anomalies during embryonic development presents at birth. These are from the duodenum to the anus. They are caused by genetic and environmental factors. At birth may be asymptomatic. Nausea, vomiting, difficulty passing stool to life incompatibility. Prenatal USS, MRI, CT and radiographs. Conservative or surgical management.

7. GASTROSCHITIS This is extrasomatic protrusion of the intestine through a defect in the abdominal wall near the umbilicus. Week 4, lateral folds fail to fuse leading to a defect in the abdominal wall causing protrusion of intestine. Most common on the right side. Usually small intestine. Stomach and liver may also protrude.

8. causes Genetic and environmental Young mother, alcohol, tobacco.

9. complications Intestinal inflammation Malabsorption Infarction Infection

10. diagnosis Intrauterine USS, MRI CT, Xray

11. INTESTINAL ATRESIA Congenital malformation resulting in closed or absent part of the intestine. In contrast to stenosis in which the passage way exist and is just narrowed. Can involve any part of the intestine. Duodenal and non duodenal. Trisomy 21

12. complications Stomach and duodenal distension Polyhydramnios Perforation Pneumoperitoneum Meconium peritonitis

13. diagnosis Prenatal USS Duodenal atresia – Dilated fluid filled stomach adjacent to dilated duodenum. Non duodenal – Dilated flid filled bowel loops and polyhydramnios. Plain X-ray – Duodenal - Double bubble sign. Non duodenal- dilated bowel with air fluid level.

14. INTESTINAL MALROTATION Improper rotation of midgut during embryogenesis. Rapid midgut growth in restricted space. Herniation into the umbilical coelum . 270 rotation around SMA. Error occurs leading to final anomaly.

15. INTESTINAL MALROTATION Small intestine lodges into the left abdominal cavity. Cecum in lower right quadrant. First 2/3 lodge into right side over small intestine. Small intestine in the right side. Cecum in the epigastrium. Appendix follow cecum.

16. COMPLICATION Ileus Ischaemia Malnutration Hernia

17. MECKEL’S DIVERTICULUM Abnormal pouch on antimesenteric sides of the ileum. True diverticulum. Early fetal life: nutrients received from York sac into ileum via omphalomesenteric duct until it obliterates (5-6 weeks of pregnancy). Improper obliteration will lead to Meckel’s diverticulum. May contains ectopic epithelia cell: omphalomesenteric duct lined with pluripotent cells.

18. COMPLICATIONS Diverticulitis Ulcers Perforation Food impaction Lithiasis Peritonitis Peritoneal adhesion Intussusception Vulvulus Neoplasms

19. MECKEL’ RULE’S of 2s 2yrs 2% 2 feet from ileocecal valve 2 inches in size 2 types of ectopic mucosa

20. DIAGNOSIS Abdominal USS CT scan Technetium-99

21. OMPHALOCELE Persistent pathological herniation of intestine into umbilical cord Midgut herniate through umbilicus Pulls layer of peritoneum into the umbilical cord due to insufficient space in the abdominal cavity. Midgut does not return leading to omphalocele. High mortality rate.

22. CAUSES Genetics Environmental factors Trisomy 13 Trisomy 18 Trisomy 21 Beckwith-Wiedemann syndrome

23. DIAGNOSIS Intrauterine USS MRI

24. COMPLICATION Abdominal cavity malformation Volvulus Ischemic bowel

25. GASTROSCHISIS VS OMPHALOCELE GASTROSCHISIS OMPHALOCELE Herniated organs exposed to air Herniated organs covered by peritoneum Organs protrude through lateral opening in abdominal wall. Organs protrude through umbilicus Small defect in abdominal wall Large defect in abdominal wall.

26. ANORETAL MALFORMATIONS Anorectal malformations (ARMs) are a complex group of congenital anomalies involving the distal anus and rectum, as well as the urinary and genital tracts in a significant number of cases. Most ARMs result from abnormal development of the anorectal septum in early fetal life. In most cases, the anus is not perforated and the distal enteric component ends blindly (atresia) or as a fistula into the urinary tract, genital tract, or perineum.

27. ANORETAL MALFORMATIONS  ARMs are also present in a great number of syndromes and associations of congenital anomalies. The classification of ARMs is mainly based on the position of the rectal pouch relative to the puborectal sling, the presence or absence of fistulas, and the types and locations of the fistulas. All of this information is crucial in determining the most appropriate surgical approach for each case. Imaging studies play a key role in the evaluation and classification of ARMs.

28. PLAIN RADIOGRAPH can be variable depending on the site of atresia (i.e. high or low), level of meconium impaction and physiological effects such as straining may show multiple dilated bowel loops with an absence of rectal gas air within the urinary bladder suggests high type  6 calcified meconium in the bowel loops would suggest high type (meconium calcifies due to urine exposure) ,

29. INVERTOGRAM A coin/metal piece is placed over the expected anus and the baby is turned upside down (for a minimum of 3 minutes). The distance of the gas bubble in the rectum from the metal piece is noted: >2 cm denotes high type <2 cm denotes low type False-positives may occur if the image is taken in the first 24 hours of life or if there is impacted meconium within the distal rectum 

30. FLUOROSCOPY The fistula is considered low (below the levator ani plane) if it is below the  pubococcygeal line  and high if above it

31. ULTRASOUND SCAN the anus may be seen as an echogenic spot at the level of the perineum and in anal atresia, this echogenic spot may be absent  4 may show bowel dilatation an infracoccygeal or transperineal approach may allow differentiation between high and low subtypes  4 kidneys should be assessed in such patients  6 spinal US can reveal spinal cord lesions like tethering of cord

32. MRI Can be used pre/post-operatively to study pelvic floor, renal, and spinal abnormalities 

33. CONCLUSION High index of suspicion

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