Chapter 11, part 2 Flashcards by Deborah Karp

What is the most common true diverticulum of the GI tract?

Meckel’s diverticulum

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Approximately 50% of symptomatic Meckel’s diverticulum contain ______

Ectopic gastric mucosal cells

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What is the most common presenting symptom in adults of Meckel’s diverticulum?

Obstruction

Acute inflammation is also common and can mimic appendicitis

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What is necessary in the pt with Meckel’s diverticulum who presents with GI bleeding? Why?

Segmental ileal resection

To eliminate the base of the diverticulum where ectopic gastric mucosa may be found and the adjacent small bowel

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Rule of 2s in Meckel’s diverticulum

~2% are asymptomatic
2 types of mucosa possible (small intestine and gastric)
Located within 2 feet of the ileocecal valve
2x more common in males
Commonly presents within the first 2 yrs of life

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What is the most common acquired or false diverticula of the small bowel?

Duodenal diverticula

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Where are >60% of duodenal diverticula found?

In the periampullary region projecting from the medial wall

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Clinical manifestations of duodenal diverticula

Obstruction
Perforation
Bleeding into the small bowel

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Tx of duodenal diverticula- if pancreatic and biliary structures not involved

The most common and effective tx is diverticulectomy
Kocher maneuver (dissecting the lateral peritoneal attachments of the duodenum to allow access to the pancreas, duodenum, and other retroperitoneal structures) is performed, and a duodenectomy is made

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Tx of duodenal diverticula- if pancreatic and biliary structures are involved

A choledochoduodenostomy or a choledochojejunostomy to a Roux-en-Y limb may be indicated

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Jejunoilial diverticula

Acquired pulsion pseudodiverticula associated with increasing age
Marker for underlying dysmotility syndrome
Most are located where blood vessels perforate the muscularis propria

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Dx of jejunoilial diverticula

Enterocylsis is the study of choice

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Complications of enterocylsis for jejunoilial diverticula

Diverticulitis
Obstruction
Perforation

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What does jejunoilial diverticula have an associated increased risk with?

Lymphoma

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What can acute mesenteric ischemia result from?

SMA embolization
SMA thrombosis
Nonocclusive mesenteric ischemia
Acute mesenteric venous thrombosis

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RFs of acute mesenteric ischemia

Atrial fibrillation
CHF
Atherosclerotic coronary, carotid, or PVD
Hx of hypercoagulability

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Labs for acute mesenteric ischemia

Leukocytosis
Hyperkalemia
Metabolic acidosis
Elevated levels of:
Lactate
LDH
ALT
AST
CPK

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Dx of acute mesenteric ischemia

CT:
Bowel dilation
Wall thickening
Intestinal pneumatosis
Portal venous gas
Mesenteric stranding

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Tx of acute mesenteric ischemia

Correction of metabolic derangements and acidosis is a goal of initial therapy + cardiac monitoring + Foley catheter

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Tx of acute mesenteric ischemia when SMA embolus suspected

Surgical laparotomy and embolectomy

Alternative: local infusion of thrombolytic therapy if there is no evidence of bowel infarction

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Tx of acute mesenteric ischemia when SMA thrombus suspected

Bypass graft or endovascular stent is often needed to reestablish flow to the affected bowel in conjunction with thrombectomy

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After the intial tx of acute mesenteric ischemia, what is indicateds?

Anticoagulation with warfarin for at least 6 mos

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What may be used as an adjunct during arteriography for acute mesenteric ischemia?

Vasodilating agents, such as papverine and tolazoline

What is chronic mesenteric ischemia caused by?

Atherosclerotic dz of the celiac axis, SMA, or IMA

What are the common collateral circuits in chronic mesenteric ischemia?

The celiac artery and the gastroduodenal artery The SMA and pancreatic branches The SMA and IMA through the meandering mesenteric artery and the marginal artery of Drummond The left colic and middle colic arteries

What is present only in occlusive disease?

The meandering mesenteric artery

Gold standard of dx of chronic mesenteric ischemia

Arteriography, which detects occlusion or stenosis of the celiac axis, the SMA, and the presence of collateral vessels

Tx of chronic mesenteric ischemia

Surgical reconstruction or percutaneous transluminal angioplasty with or without a stent

When is surgery used for chronic mesenteric ischemia?

Often used in younger pts with fewer comorbidities, while endovascular approaches may be preferred for the elderly and infirm

Contraindications to surgery for chronic mesenteric ischemia

Extrinsic compression of the celiac axis by the median arcuate ligament because it has a high failure rate

Frequently described techniques of surgical reconstruction for chronic mesenteric ischemia

Bypass grafting Endarterectomy Reimplantation

Small bowel neoplasms

The rapid transit of material through the samll bowel and low intraluminal pH may protect the mucosa from contact with carcinogens + highly evolved immune system

What is the most common type of benign neoplasm?

Adenoma

What are the three types of adenomas?

Tubular Vilious Brunner's gland

Where are vilious adenomas most commonly found?

Duodenum

What is considered a large vilious adenoma?

>5 cm | Significant malignant potential

Brunner's gland adenoma

Found in the duodenum and are caused by hyperplastic proliferation of nl submucosal exocrine glands No malignant potential Resection reserved for sx

Tx for benign neoplasms

Surgical intervention is indicated bc of the possibility of CA and the risks of mechanical complications Operation usually consists of segmental resection and primary anastomosis, though small lesions may simply be excised

What are the most common symptomatic benign tumor of the small bowel?

Leiomyomas

Where are leiomyomas most commonly located?

Jejunum

What is the most common indication for operative management of leiomyomas?

Bleeding

Where are lipomas most commonly located?

Most often intramural and located in the ileum

Hamartoma

Commonly occur as part of Peutz-Jegher's syndrome, an autosomal dominant-inherited syndrome characterized by mucocutaneous melanotic pigmentation and GI polyps Increased risk for the development of malignancies

Where are hemartomas usually located?

Jejunum and ileum

Presentation of hemartomas

Pts have small, 1-2 mm brown-black spots on the circumoral region of the face, buccal mucosa, palms and soles, lips, digits, and perianal area

Where are hemangiomas most commonly found?

Jejunum

Presentation of hemangiomas

Onset of bleeding may be the only presenting symptom

Diagnostic test for hemangiomas

Angiography and Tc-labeled RBC scanning

Tx for hemangiomas

If the lesion can be localized, conservative resection is recommended If the lesion cannot be localized, intraoperative or localization via intra-operative enteroscopy may be helpful

What are the most common malignant neoplasms of the small bowel?

Adenocarcinoma Sarcoma Lymphoma Carcinoid tumors

Presentation of malignant neoplasms

Weight loss Diarrhea Obstructive sx

Tx options for malignant neoplasms

Wilde surgical resection with regional lymph node bx Palliative resection Intestinal bypass to relieve sx or prevent complications

Where are adenocarcinomas more common?

Duodenum and jejunum

~50% of adenocarcinomas involve what?

Ampulla of Vater

RFs for adenocarcinomas

Adenomatous polyps Polyposis syndromes Crohn's dz FHx of hereditary nonpolyposis colorectal cancer