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7: Digestive System > Chapter 92 Small Intestine > Flashcards

Chapter 92 Small Intestine Flashcards

1
Q

where does the root of the mesentery attach?

Using same anatomic resference, at what level does cranial mesenteric artery originate?

A

Root of mesentery ventral to L2

Cranial mesenteric artery ventral to L1

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2
Q

Label the diagram:

A
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3
Q

Name two vessels that the cranial mesenteric artery anastomoses with

A
  • Caudal pancreaticoduodenal artery (from cranial mesenteric a.) anastomoses with cranial pancreaticoduodenal atery (from celiac a.)
  • Middle colic (from cranial mesenteric a.) anastomoses with left colic artery (from caudal mesenteric a.)
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4
Q

Label the diagram:

A
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5
Q

Where is the cranial mesenteric ganglion located?

A

On the sides of and caudal to cranial mesenteric artery

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6
Q

How much do the villi increase SI area in dogs?

And in cats?

A

Dogs x8 surface area

Cats x15 surface area

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7
Q

What are the two types of cell in Si mucosa?

A
  • Epithelial cells
  • Goblet cells
  • (c.f. in colon 3rd cell type is enterochromaffin cell)
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8
Q

How long does it take for total villous epithelail replacement?

A

2-6 days

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9
Q

What are the Si lymphoid aggregates called

A

Peyer’s patches

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10
Q

What are the two types of motility in normal SI?

Define each

A

Segmentation: Random contraction of small area

Peristalsis: Organized wave of contraction

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11
Q

What 2 compounds are absorbed in the ilium?

A
  • Cobalamin (B12)
  • Bile salts

(Folate absorbed in jejunum)

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12
Q

How do enterocytes change as they migrate from base of crypt to tip of villus?

A
  • At base they are dividing, undifferentiated epithelial cells, primarilty for fluid secretion
  • Differentiate into immature enterocytes and function to digest and absorb
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13
Q

What proportion of ‘fluid presented’ does jejunum absorb?

And ilium

A

Jejunum 50%

Ileum 75%

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14
Q

What hormone is responsible for pancreatic digestive enzyme and bile secretion?

What hormone causes bicarb release (from pancreas)?

A
  • Cholecystekinin (produced in duodenal mucosal cells) in response to nutrients
  • Secretin
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15
Q

Name the enzyme(s) responsible for breakdown of the following:

Proteins

Carbs

Lipid

A

Proteins:

  • Trypsin
  • Chymotrypsin
  • Carboxypeptidases
  • Aminopeptidase

Carbs:

  • Amylase (carbs –> oligosaccharides)
  • Sucrase (sucrose –> glucose + fructose)
  • Lactase (lactose –> glucose + galactose)
  • Maltase (maltose –> glucose)

Lipid:

  • Lipase
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16
Q

How do bile acids work to enhance lipid breakdown/absorbtion?

A
  • Digestive enzymes not fat soluble.
  • Bile acids have hydrophilic + hydrophobic parts. Hydrophobic parts embed in lipid –> lipid breakdown into smaller parts.
  • Increase surface area of oil-water interface –> improved access for pancreatic lipase
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17
Q

How are absorbed fatty acids/glycerides packaged within enterocytes?

A

As chylomicrons

(then into lymph (not portal vein!) into cava)

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18
Q

What blood gas/electrolyes combo is usually seen with upper gi obstruction?

A

Hypochloraemic, hypokalaemic metabolic alkalosis

(V –> loss of gastric fluid i..e high concentration of HCl, K and Na in gastric fluid)

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19
Q

List 6 ways to assess intestinal viability

A
  1. Bleeding/vessel pulsation
  2. Colour
  3. Thickness
  4. Peristalsis
  5. Surface oximetry
  6. IV fluoroscein + UV light
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20
Q

What dose of fluoroscein is given to asses Si integrity?

What finding is consistent with non-viability?

A

10-15 ml/kg iv.

Use UV lamp. Areas of non-fluorescence >3mm (n.b. more liekly asesses mucosal integrity, not full thickness SI)

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21
Q

Why is two layer Si closure not recommended/

A

Results in avascular necrosis of inverted tissue –> prolonged lag phase of healing and increased intraluminal protrusion of tisue i.e more prone to obstruction

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22
Q

What 3 suture patterns are suitable for SI closure

A

Simple interrupted, simple continuous, modified Gambee

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23
Q

List 2 methods to re-inforce SI suture line

A
  • Omental wrap (angiogenic, immunogenic and adhesive properties)
  • Serosal patch
  • (Gall bladder serosal patch reported experimentally)
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24
Q

What volume of saline is instilled to assess 10cm length of bowel?

A

Approx 15 ml

(slightly more with digital occlusion vs slightly less w Doyen occlusion)

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25
Q

List 5 techniques to deal with luminal disparity

A
  1. Side-to-side stapling (GIA)
  2. Slightly divergent sutures from smaller to larger lumen side
  3. Slanted cut along smaller side
  4. Spatulate
  5. Partially close larger lumen
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26
Q

list 4 stapling techniques for SI anastomisis

A
  1. Side to side GIA
  2. EEA stapler
  3. Triangulating (everting) end-to-end anastomisis using x3 TA30 staple cartriges
  4. Skin staples (place a stay at each 120º, tension between two stays while staples applied)
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27
Q

List 2 techniques to reduce risk of leakage from transverse (TA) staple line of anastomosis

A
  • Offset longitudinal staple lines
  • Oversew
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28
Q

What is closed height of 3.5mm staple (blue)?

And 4.8mm (green)?

A
  1. 5 mm –> 1.5 mm
  2. 8 mm –> 2 mm

(TAV3 = 2.5 mm –> 1 mm and three rather than two staple rows)

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29
Q

What surgical step is employed to prevent tension + separation of ‘inner corner’ of GIA staple line?

A

Crotch suture (ensure to engage submucosa)

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30
Q

Where do side-to-side stapled anastomoses leak from?

A

TA staple line!

(particularly where GIA and TA staples overlap)

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31
Q

How did anastomosis with skin staples compare with hand-sutures simple interrupted sutures?

A
  • Same bursting strength
  • Same lumen diameter
  • Significantly faster
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32
Q

What is risk of 360º omental wrap?

A

Intestinal obstruction

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33
Q

What skin biopsy punch size for GI biopsies?

A

6mm

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34
Q

Why is enteroplication not typically recommended?

A

rate of complication due to enteroplication > rate of intussusception recurrence

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35
Q

List 5 potential complications of enteroplication

A
  1. Obstruction
  2. Ileus
  3. Strangulation
  4. Perforation
  5. Segmental volvulus
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36
Q

In what 4 instances can enteroplication be considered

A
  1. Recurrent intussusception
  2. Not possible to remedy underlying cause for intussusception
  3. Pre-disposing cause not identified
  4. Generalised hypermotility/enteritis
37
Q

Where do recurrent intussusceptions usually occur?

A

Orad to previous intussusception

38
Q

List 4 potential complications after SI surgery

A
  1. Septic peritionitis
  2. Adhesions
  3. Short bowel syndrome
  4. Ileus
39
Q

What is dehisence rate of enterotomy/enterectomy?

And of biopsy?

A

<15%

11% for biopsy

40
Q

List 5 factors that have been associated with higer risk of dehisence

A
  1. Pre-op septic peritonitis (40% vs 6%!)
  2. Hypoalbuminaemia
  3. Intra-op hypotension
  4. Use of blood products
  5. Delayed enteral nutrition
41
Q

What is risk for breakdown with presence of pre-op septic peritonitis?

A

40%

42
Q

What heamatology change can be seen with septic peritonitis?

A

Increased band neutrophils

43
Q

List 3 techniques for post septic peritonitis abdo drainage

A
  1. Closed suction drain
  2. Open drain
  3. Vacuum assisted peritoneal drainage
44
Q

List 4 benefits of vacuum assisted peritoneal drainage over open peritoneal drainage

A
  1. Quantification of fluid
  2. Lower risk of nosocomial infection and evisceration
  3. Reduced frequency of dressing changes
  4. Faster time to closure
45
Q

What % BW fluid can the peritoneal membrane + omentum absorb?

A

3-5% bodyweight per hour!

46
Q

List 4 factors known to encourage adhesion formation

List 3 techniques to minimise adhesion formation

Name a preventative measure

A

Factors leading to adhesion:

  1. Ischaemia
  2. Haemorrhage
  3. FB
  4. Infection

To minimise adhesion:

  • Atraumatic tissue handling
  • Moisten tissues
  • Aseptic technique

Perioneal lavage with dialysis solution or tissue plasminogen activator reduced adhesions experimentally.

47
Q

Is proximal or distal SI excision better tolerated?

A

Proximal better tolerated as preserves ileum.

Removal of ileum –> steatorrhea

48
Q

What % bowel excision can –> short bowel syndrome.

A

50%

(but some dogs tolerate 85% resection without any need for special management so v variable)

49
Q

List 4 pathophysiological effect that –> short bowel syndrome

A
  • Reduced mucosal surface area
  • Reduced intestinal transit time
  • Bacterial overgrowth
  • Gastric + intestinal hypersecretion
50
Q

What are the 2 most consistent signs of short bowel syndrome?

A

Persistent diarrhoea

Weight loss

51
Q

What are typical radiographic signs of intestinal obstruction?

A
  • Multiple, gas-dilated loops
  • Dual SI population
  • Turgid, stacked loops
52
Q

In patients with short bowel syndrome, how long did it take for orally administered contrast to reach colon

A

10 minutes

53
Q

List 5 steps in medical management of short bowel syndrome

What surgical options have been reported in humans

A
  1. IV electrolye supplementation
  2. Small, frequent, highly digestible meals (monomeric containing soluble fibre + glutamine. Some fat to slow gastric emptying and –> enterocyte growth)
  3. Injectable fat soluble vitamins
  4. Anti-diarrhoea drugs if persistent diarrhoea (loperamide (=Imodium) 0.08 mg/kg tid)
  5. Abx if bacterial overgrowth

Surgical options reported (but high mornbidity! Not reported in small animals))

  • Intestinal valve construction
  • Reversed SI segment interposition
  • Reversed colonic segment interposition
  • Reversed electrical intestinal pacing
54
Q

What is outcome in animals with short bowel syndrome

A

Dependent on a lot of individual patient factor factors, but 80% owners felt ‘good’ outcome

55
Q

List 4 steps in managing post-op ileus

A
  1. Correct underlying disorders
  2. Early, frequent ambulation
  3. Early feeding
  4. Prokinetics
    • Cisapride
    • Metoclopramide
    • Mirtazepine
    • Erythromycin
  5. (reverse opioids if possible)
56
Q

What dose of erythromycin is used to stimulate gastric emptying?

A

0.5 - 1.0 mg/kg po or iv tid

Similar effects to hormone motilin

57
Q

What measurement is typically used to assess for Si dilation in dogs?

And cats?

What value is suggestive of obstruction?

A

Dogs: Intestinal diameter vs height of L5 body

Cats: Intestinal diameter vs height of cranial endplate of L2

Obstruction likely if ratio >2 in dogs, >3 in cats

58
Q

What three values combined resulted in >95% sensitivity for presence of intestinal obstruction?

And what three values for >95% specificty?

A

N.B the sens values are wrong- should be LESS THAN

59
Q

List 3 radiographic signs compatible with linear FB

A
  • SI bunched in cranial-mid ventral bdomen
  • Plication
  • Gas in small eccentrically located bubbles
60
Q

What is preferred modality for GI Fb detection

A

US

61
Q

List an alternative methdon to multiple enterotomies for linear FB removal (described in cats only)

A

Single enterotomy catheter technique (tubing attaced to proximal linear FB via enterotomy then tubing milked distally)

(conservative management also reported in cats presented stable, successful in 50% but of others, 40% developed peritonitis - surgery recommended)

62
Q

What is a management option if intestinal viability is equivocal

A

Repeat coeliotomy 24 hours later

63
Q

What dimension of skin staples are used for enterotomy/enterectomy?

A

Regular size (4.8 x 3.4mm)

64
Q

How does prognosis differ in dogs vs cats with linear FB

A

Prognosis better in cats

In dogs, 30% of dogs have septic peritonitis at surgery and >40% need R+A

65
Q

What diagnosis is made if ileus is unreponsive to medical management and ex-lap negative (+ taken biopsies!)?

A

Intestinal pseudo-obstruction

66
Q

What is the prognosis for intestinal pseudo-obstruction?

A

Grave

usually because of progressive emaciation

67
Q

What is ideal diagnositc test for mesenteric infarction?

What is most commonly performed

A

Mesenteric angiography.

Sequential US over 48 hrs reveals dramatic changes suggestive of thrombus:

  • Focal bowel dilation
  • Initially normal bowel layering –> complete loss of normal layering within 24 hours
68
Q

Which part is intussusceptum and which is intussuscipiens?

A

Intussusceptum = invaginated, inner portion

Intussuscipiens = outer portion

69
Q

How does presentation of iliocolic intussusception differ from more proximal one.

A

Iliocolic intussusception more likely to present with tenesmus and haematochezia rather than vomiting

70
Q

Aside from US name a method to diagnose iliocolic intussusception (not CT)

A

Barium enema

71
Q

What is US appearance of intussusception?

A
  • Concentric SI rings in transverse
  • Parallel lines in longitudinal
72
Q

What US finding is suggestive of an intussusception that is able to be reduced (and therefor ?at risk of spontaneous reduction?)

What additional step should be performed in these cases?

A

Absence fo vascular collapse in intussusceptum

Repeat US after GA, before sx (incase spontaneously reduced)

73
Q

What is reported recurrence rate of intussusception

Within what timeframe does it usually occur?

A

5-25%

Usually within 3 days (up to 3 weeks)

74
Q

What conditions has mesenteric volulus been associated with?

A
  • EPI
  • Enteritis
  • Ileocolic carcinoma
  • GI FB
  • GI surgery
  • Abdo trauma
  • GDV
75
Q

What are 2 most frequent presenting signs of mesenteric volvulus

A
  • Haematochezia
  • Abdominal distention
76
Q

What features distinguish mesenteric volvulus from mechanical obstruction or GDV

A
  • Uniform and extensive SI distension
  • Normal position of stomach
77
Q

List 2 surgical option sfor mesenteric volvulus

A

De-rotation

R+A without de-rotation (duodenoilial anastomosis reported)

78
Q

What technique can be used to ‘close’ duodenal defects when R+A ideally avoided

A

Serosal patching

Vascularised jejunal patch graft also reported

79
Q

How are feline alimentary lymphomas classified?

A

Large cell: intermediate/high grade, often focal lesion

Small cell: low grade, usually diffuse

80
Q

List 4 non-neoplastic differential for Si mass

A
  • Haematoma
  • Granuloma
  • Abcess
  • Sclerosis (FGESF)
  • (cyst)
  • (intestinal (duodenal) duplication or diverticulum)
81
Q

What paraneoplastic syndrome has been reported with canine and feline T-cell lymphoma?

A

Hypereosinophilia

82
Q

What paraneoplastic syndrome has been reported with smooth muscle tumours

A
  • Hypoglycaemia
  • Nephrogenic diabetes insipidus
83
Q

What are minimum recommeded margins for SI neoplasia?

A

3 cm

84
Q

What is typical chemo protocol for feline large cell lymphoma?

And small cell?

A

Large cell = CHOP

Small cell = pred + chlorambucil

CHOP: Cyclophosphamide, Hydroxydaunomycin [doxorubicin], Oncovin [vincristine],and Prednisolone)

85
Q

What is another name for c-kit.

In what tumours is c-kit expressed?

A

C-kit = CD 117

GIST

86
Q

What is MST for small cell intestinal lymphoma?

And large cell

A

Small cell 2 years

Large cell 6 months

87
Q

What % of FGESF cases had intralesional bacteria?

What is treatment

A

Bacteria in 70%

Tx = pred +- surgery

88
Q

Name two congenital malformations of the SI

Name a life threatening presentation

Tx?

A

Intestinal duplication and diverticulum

Can present with profuse GI haemorrhage

Tx: R+A

7: Digestive System (12 decks)

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