Small bowel duplication

Brief introduction of small intestine repeat deformity Duplication of smallintestine (duplicationofsmallintestine) refers to a circular or tubular structure of the hollow organ that appears on the proximal mesangial side of the small intestine. The adjacent small intestine has the same tissue structure, and its blood supply is also very close. It occurs in any part of the small intestine, but it is most common in the ileum. basic knowledge The proportion of illness: 0.004%-0.007% Susceptible people: young children Mode of infection: non-infectious Complications: volvulus, mediastinal tumor, intussusception, peritonitis

Small intestine repeat malformation

Dwelling-like outer bag theory (20%):

At 8 to 9 weeks of embryos, the epithelial cells covered by connective tissue in the distal part of the small intestine bulge out to form a temporary suffocation-like outer bag, which gradually disappears. If left, the original diverticulum-like outer bag can develop into Cyst-type small intestine repeat deformity.

Notochord - primary intestinal separation disorder (15%):

At 3 weeks of embryonic, there is a notochord between the inner and outer ectoderm. At this time, there is abnormal adhesion between the ectoderm. The notochord is divided into two parts in the left and right parts, wherein the notochord and the vertebral body pass through the ectoderm and the digestive tract. When the endoderm is developed into a bowel tube, when the endoderm develops into a bowel, the intestine tube part which is pulled by the strip-like adhesion forms a diverticular bulge to the dorsal side, and the part can develop into a repeat deformity later, since the adhesion occurs in the original The dorsal side of the intestine, so the repeated deformity is also located on the mesenteric side, the adhesion of the cable can affect the development of the vertebral body, so this repeated deformity, often accompanied by vertebral body developmental malformations, such as semi-vertebral body, butterfly vertebra, etc., Li Long, etc. The intestinal duplication was divided into 2 types, and the mesenteric repeated malformation intestine was located between the two mesangial membranes, which was 91.6%, combined with thoracic deformity, and this type was caused by the separation of the notochord and the original intestine.

Intestinal ischemic necrosis theory In recent years, many scholars have studied that after the development of the primitive gut, due to the ischemic necrosis of the gut, there are changes in intestinal atresia, stenosis and short intestine. The supply of blood vessels can develop into repeated deformities, so some small intestines with repeated malformations can be accompanied by intestinal atresia, stenosis and short bowel deformities.

Pathogenesis (20%):

Small intestinal repeat deformity has a normal development of the digestive tract tissue structure. Most of the deformities are combined with the attached main intestine to form a common muscle wall, sharing a common serosa, mesentery and blood supply, but with separate, separate or transported mucosa. Cavity, a few malformations have separate mesangial and vascular branches, small intestine repeats deformed cavity with multiple intestinal lining of intestinal mucosa, 20% to 35% of ectopic gastrointestinal mucosa or respiratory mucosa, ectopic mucosa with gastric mucosa See, occasionally, there are more than 2 kinds of ectopic mucosa at the same time, 80% of the repetitive mucosal cavity and the main intestine are not in communication with each other, and the mucous secretion is accumulated in the cavity to form a round or oval cyst, and the deformity is mostly single, a few There may be more than two repeat deformities in the digestive tract of the case. Repeated deformity is a benign disease in children, but it can be cancerous in adulthood. The pathological morphology of small intestinal repeat deformity can take many forms.

1. According to the clinical appearance classification

(1) Extra-intestinal cyst-type repeat deformity: the most common type of repeat deformity, which is a cystic mass that is circular or oval and does not communicate with the small intestine, and is closely attached to the two leaves of the small intestine mesentery. Very inconsistent, the small one is only 1cm in diameter, the larger one can occupy most of the abdominal cavity, the cyst is filled with colorless or pale yellow mucous secretion, the cyst grows to a certain extent, it can compress the main intestine or induce intestinal torsion, and the inner wall of the cyst is different. In patients with gastric mucosa or pancreatic tissue, peptic ulcer occurs due to the corrosive action of gastric acid or pancreatic enzyme, causing intracapsular hemorrhage or perforation to cause peritonitis.

(2) Cystic swelling in the intestinal wall: cysts occur in the empty, ileal muscle layer or submucosal, and do not communicate with the small intestine and intestine, this type occurs mostly in the terminal ileum or ileocecal area, Zhao Li et al reported 13 cases of intestine Intramural cyst malformation, 11 cases (84.6%) were located in the terminal ileum within 5 cm from the ileocecal valve. This type of cyst was slightly enlarged and protruded into the intestine. Early obstruction of the intestinal lumen caused obstruction or induced intussusception. The cysts are less than 4 cm in diameter.

(3) Tubular repeat deformity: There are two forms of tubular repeat deformity.

1 long tubular deformity: deformed into a long tubular shape, attached to the side of the mesentery, juxtaposed with the main intestine tube, the deformed wall has a completely normal intestinal structure, often with the main intestine, the mesenteric and blood vessels supply, the length of the deformity is different, the length of the small is long Cm, a wide range of up to 50 ~ 70cm, even spread to the small intestine, most of the malformed intestine proximal blind blind, distal opening and the main intestine; the wall is lined with gastric mucosa or pancreatic tissue, more common than cystic, and deformed It is not connected with the main intestine; or the distal end of the deformity is blindly closed, and the proximal end is open to the main intestine. The deformed cavity is filled with a large number of mucosal secretions, which are large tubular cysts, which cause intestinal obstruction by pushing or pressing the main intestine.

2 ventricular dysplasia: malformation in the shape of a diverticulum, extending from the main mesenteric mesenteric to any part of the abdominal cavity, the end of which is free, adheres to the intestinal tube or organ that is in contact; the proximal segment of the proximal end of the intestine opens to the main intestine Such malformations can have their own independent mesangial and vascular supply, and can be completely removed during surgery.

(4) Thoracic and abdominal cavity repeat deformity: the thoracic and abdominal cavity repeat deformity accounts for 2% to 6% of the digestive tract repeat, which can originate from any part of the abdominal gastrointestinal tract. The chest and abdomen repeat of the small intestine originates from the jejunum, and the deformity is long tubular. The mesenteric side of the main intestine is emitted, and enters the posterior mediastinum through an abnormal hole or esophageal hiatus of the diaphragm. The deformed end can extend to the apex of the pleura and attach to the cervical vertebra or upper thoracic vertebra. The thoracic and abdominal cavity is deformed and has spinal deformity, such as half. Vertebral body, vertebral body fusion, anterior spine or spinal canal of the spinal canal.

Repeated thoracic and abdominal deformities can also exist in the thoracic cavity and abdominal cavity respectively. There is no connection between them. Although these cases are rare, they are easily misdiagnosed or missed clinically. Therefore, if there is any abnormality in the diagnosis of any part of the repeated deformity, check whether there is a second deformity. .

2. Classification according to mesangial blood transport relationship In recent years, Li Long and others have classified the relationship between the small intestine and the main intestine mesenteric blood supply, and divided it into a juxtaposition type and a mesenteric type.

(1) Parallel type (type I): The mesenteric artery is separated from the aorta by the two intestines. The two vessels are from the peritoneal side of the two pages to the supplied intestine, and the blood vessels of the main intestine are not passed through the repeating intestine. The blood supply from the repeated intestinal tubes did not affect the blood supply of the main intestine. This type accounted for 75.3% of the repetitive malformations, mostly cysts, and only 6.2% with thoracic deformities.

(2) Mesangial type (II): The repeated intestine is located in the two peritoneum of the mesentery. The arterial tube crosses the repeated intestinal tube to the main intestine from both sides, and the short branch that breaks into the repeated intestinal tube does not affect the blood supply of the main intestine. The type accounted for 24.7% of the repetitive malformations, mostly in the tubular type, and the combined thoracic deformity was as high as 91.6%.

Small bowel repeat deformity prevention

1. Smoking banned alcohol: It is the primary measure to prevent throat cancer. The smoke is the hottest leader. The wine is the hottest and hottest. Smoking and drinking are extremely harmful to the pharynx.

Second, light diet: Where the ginger pepper mustard and all the spicy hot things will hurt the mucous membrane of the throat, should avoid eating these spicy and fried foods, eat more fruits and vegetables containing vitamin C.

Third, pay attention to oral hygiene: pay attention to personal hygiene, wash hands frequently. In the morning and evening, you can use a light salt water to rinse your mouth. After you rinse your mouth, you can drink a cup of light salt water to clean and moisten the throat, improve the throat environment and prevent bacterial infection.

Fourth, strengthen exercise: usually participate in physical exercise is also one of the measures to prevent throat cancer, enhance the body's defense capabilities, because the body's immunity and throat resistance is the most likely to cause repeated attacks of throat disease.

Fifth, keep the indoor air fresh: In the air-conditioning environment, always open the window to ventilate, put the basin water indoors, increase the humidity. At the same time, avoid inhaling dust, smoke, and irritating gases. If working in a dusty environment, wear a mask for protection.

Small bowel repeat malformation complications Complications, volvulus, mediastinal tumor, intussusception, peritonitis

1. Respiratory symptoms Symptoms of thoracic and abdominal cavity repeats In addition to abdominal symptoms, symptoms of respiratory or mediastinal compression may occur at the same time, sometimes manifested as pleural symptoms, sick children with breathing difficulties, asthma, cyanosis, mediastinal shift, easily misdiagnosed as Pneumonia or mediastinal tumor.

2. Intestinal torsion due to the repeated gravity of the intestine and the elongated mesenteric torsion, acute, complete, strangulated intestinal obstruction symptoms and signs, mostly in newborns and infants, acute onset, severe symptoms, vomiting Abdominal pain is severe, and the abdomen often touches the torsion mass.

3. Intussusception in the distal ileum and ileocecal intestinal cystic repeat deformity is easy to induce intussusception, the author reported that intestine repeat deformity in 17 cases (26%) intussusception, and under 1 year of age 15 For example, accounting for 88.2%, all have typical clinical manifestations of acute intussusception. Intussusception caused by repeated malformation can not cause the head to be reset regardless of the pressure or water pressure enema. Occasionally, after the successful enema reduction, the abdomen still has a package. Block, still see cystic mass under B-ultrasound.

4. Peritonitis is caused by the corrosive effect of the fascinating gastric mucosa and pancreatic tissue on the intestinal wall. It has been reported that there are ectopic gastric mucosa in the perforation site, and ulcers have formed, and the perforation is located at the bottom of the ulcer. The clinical is acute peritonitis. Symptoms and signs may not be obvious in the signs of infants and young children. It is not easy to distinguish from perforation of acute appendicitis. It requires patience and careful examination.

Symptoms of repeated intestinal malformations Common symptoms Abdominal pain Intussusception tarmac Peritonitis Abdominal muscles Bloody ileocecal tuberculosis Intestinal atresia ileum Repeated deformity Hairpin

Small intestinal repeat deformity due to pathological anatomical features, location, pathological morphology, range of size, whether it is connected with the intestine, complications or other complex factors, clinical symptoms vary greatly, symptoms can occur at any age, 60% to 83% Within 2 years of age, many cases have symptoms within 1 month of birth, and a few cases are asymptomatic. They are only found during laparotomy in other diseases.

1. Intestinal obstruction is often a clinical manifestation of cystic repeat deformity that does not communicate with the main intestine, especially cysts in the intestinal wall. The cyst protrudes into the intestinal lumen, and the intestinal lumen is blocked to cause different degrees of intestinal obstruction. The cyst is easy to become a nesting point to induce the intestine The stack is characterized by sudden vomiting, abdominal pain, jam-like bloody stools and other symptoms of acute intestinal obstruction. The age of onset of these cases is small. Zhao Li et al reported that 13 cases were infants under 2 years old, and 5 to 9 months accounted for 61.5. %, when the extraintestinal cyst gradually increases, it will cause obstruction due to compression of the intestine. It can also induce intestinal torsion due to gravity, leading to severe abdominal cramps, vomiting, stopping defecation and venting, and even bloody stools, fever, and fine veins. , shock and other symptoms of poisoning.

2. Gastrointestinal hemorrhage The mucosal cavity is lined with ectopic gastric mucosa or repeated deformity of pancreatic tissue and main intestine. The ulceration causes gastrointestinal bleeding, Holcomb collects 101 cases of digestive tract duplication, and 21 cases have ectopic gastric mucosa. Among them, 11 cases (52%) appeared in the ileal repeat deformity. He believed that blood in the stool is often the first symptom of ileal tubular repeat deformity. It is common for children over 1 year old. The clinical manifestation is recurrent middle-volume blood in the stool. The color of bloody stool depends on the color. The location of bleeding and the amount of bleeding, the location of high bleeding is less tar, the position is low or the bleeding is dark red or bright red blood, infants and young children often show acute lower gastrointestinal bleeding, while older children with intermittent bloody stools With abdominal pain as the main complaint, bleeding can stop on its own, but easy to repeat bleeding caused by anemia, occasionally sustained a large number of blood in the stool caused by shock.

3. Abdominal mass and abdominal pain about 2/3 cases in the abdomen touch the mass, cystic deformity is round or oval, smooth surface with sac sexy, without tenderness, the boundary of the tumor is very clear, there is a certain degree of activity, Tube-shaped malformation is connected to the main intestine, and the endocrine fluid is excreted, so there is less chance of touching the tumor. If the outlet drainage is not smooth, the volume of the malformed intestinal fluid can be stored in the abdomen to touch the cord, once the outlet is drained. Unobstructed, the tumor shrinks, and the faster cysts increase abdominal pain due to increased wall tension. When trauma or infection causes cystic hemorrhage or inflammatory exudation, the tumor rapidly increases, abdominal pain is aggravated, and abdominal muscle tension and tenderness are accompanied. Once the cyst is ruptured or perforated, it causes peritonitis.

4. Respiratory symptoms Symptoms of thoracic and abdominal cavity repeats In addition to abdominal symptoms, symptoms of respiratory or mediastinal compression may occur at the same time, sometimes manifesting as chest symptoms, sick children with breathing difficulties, asthma, cyanosis, mediastinal shift, easily misdiagnosed as Pneumonia or mediastinal tumor.

5. Coexisting malformed small intestine repeated deformity can coexist with small intestine atresia, poor intestinal rotation, umbilical bulging, and sometimes repeated deformity due to coexisting malformation. Emergency thoracoabdominal recurrence is often accompanied by neck, thoracic vertebral body or fusion malformation. There are few patients with intestinal block deformity in the abdominal mass. Children with malnutrition are more likely to touch the active mass due to weak abdominal wall.

Small bowel repeat deformity examination

1. X-ray examination of the abdominal plain film can show the displacement of the intestinal tube, in the case of incomplete intestinal obstruction, the gastrointestinal fluoroscopy sees the intestine has a curved impression, and the barium meal can be seen in a group of small intestine tincture filling defects or pressure, especially pay attention to the end Images of the vicinity of the ileum and ileocecal valve, if you can see the tubular or sacral sputum filling outside the small intestine, and have an important diagnostic value when peristalsis occurs.

Spinal X-ray findings of vertebral body abnormalities should be further performed by spinal canal angiography, magnetic resonance or CT examination to determine the presence or absence of intraspinal neural tube cysts.

2. Ultrasound examination Ultrasound examination of the abdomen shows that the abdominal mass is cystic, and its position and size are judged, which is conducive to diagnosis and differential diagnosis.

3. Radionuclide examination When the ectopic gastric mucosa is repeated in the intestine, the abdominal scan after intravenous injection of 99mTc often shows the radioactive concentration zone of the repeated intestinal tube, but it needs to be distinguished from the Merkel diverticulum. Note that a negative result cannot be denied a diagnosis.

4. Laparoscopy, if conditionally laparoscopic, can accurately determine the location and type of lesion.

Diagnosis and differential diagnosis of small intestine

Preoperative diagnosis is not easy. It is often diagnosed by emergency laparotomy because of complications. The preoperative diagnosis rate in the literature is only 15.3%~45.7%. The smaller the deformity cyst is, the lower the preoperative diagnosis rate is. Therefore, if the patient encounters 2 years old or younger Pediatric patients with unexplained abdominal pain, blood in the stool, incomplete or complete intestinal obstruction, especially in the abdominal cavity to cystic mass should consider the small intestine repeat deformity, abdominal X-ray film shows uniform density of cyst shadow, or small intestine tincture filling Defective, compressed, tubular or diverticulous sputum filling outside the small intestine, and spinal deformity have diagnostic value.

The disease needs to be identified with the Merkel diverticulum.

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