Intestinal Failure and other Small Bowel Problems

Question 1

What is intestinal failure?

Answer 1

Where the gut is no longer able to supply the hydration and nutritional needs of the body

Question 2

What is acute intestinal failure?

Answer 2

Short term (2 weeks) 
Type I and II intestinal failure
e.g. mucositis post chemo

Question 3

What is chronic intestinal failure?

Answer 3

Long term
Type III intestinal failure
e.g. short gut syndrome

Question 4

What is Type I intestinal failure?

Answer 4

Self limiting, short term

Post operative or paralytic ileus

Question 5

What is Type II intestinal failure?

Answer 5

Prolonged
Accosted with sepsis or metabolic complications
Often related to abdo surgery with complications

Question 6

What is Type III intestinal failure?

Answer 6

Long term but stable

Home parenteral neutron often indicated

Question 7

How is Type I intestinal failure managed?

Answer 7

Fluid replacement, correct electrolytes
Parenteral nutrition if unable tolerate food/fluids after a week
Acid suppression: PPIs
Octreotide
Mg preservation (a hydroxycholecalciferol)
Allow some enteral feeding if poss

Question 8

Which veins are generally used for parenteral nutrition?

Answer 8

Large veins, especially in the neck

Question 9

What are the complications of parenteral nutrition?

Answer 9

Pneumothorax 
Arterial puncture 
Misplacement 
Sepsis 
SVC thrombosis 
Line fracture/leakage/migration 
Metabolic bone disease 
Nutrient toxicity/insufficiency 
Liver disease 
Metabolic disturbance 
Psycho-social 
Inappropriate usage

Question 10

What are the feeding options for Type II intestinal failure?

Answer 10

Parenteral +/- some enteral feeding

Question 11

What are the two current options for management of Type III intestinal failure?

Answer 11

Home parenteral nutrition

Intestinal transplantation

Question 12

What conditions could result in Type III intestinal failure and require HPN?

Answer 12

Short gut syndrome 
Crohn's disease 
Neoplasia (not an indication in the UK) 
Vascular 
Mechanical 
Radiation enteritis 
Dysmotility

Question 13

What is short bowel syndrome?

Answer 13

A bowel of less than 200cm

Insufficient length to meet nutritional needs without artificial nutrimental support

Question 14

At what length must the small bowel be in order to indicated HPN?

Answer 14

Less than 50cm + all of colon

Less than 100cm + no colon

Question 15

What are the main indications for small bowel transplantation?

Answer 15

Loss of venous access for HPN or liver disease

usually combined with liver transplant

Question 16

Where is the blood supply for the small bowel derived from?

Answer 16

Superior mesenteric artery

Question 17

What are the causes of small bowel ischaemia?

Answer 17

Mesenteric arterial occlusion =
Mesenteric artery atherosclerosis
Thromboembolism from heart

Non occlusive perfusion insufficiency = 
Shock 
Strangulation obstructing venous return 
Drugs 
Hyperviscosity

Question 18

How is acute ischaemia of the small bowel classified?

Answer 18

By degree of infarction caused (mucosal, mural or transmural)
The longer the period of hypoxia, the more severe the ischameia

Question 19

What are the complications of small bowel ischaemia?

Answer 19

Resolution
Fibrosis, stricture, chronic ischaemia, “mesenteric angina and obstruction
Gangrene, perforation, peritonitis, sepsis and death

Question 20

What causes Meckel’s Diverticulum?

Answer 20

Incomplete regression of the vitello-intestinal duct

Question 21

What are the complications of Meckel’s Diverticulum?

Answer 21

Often asymptomatic

May cause bleeding, perforation or diverticulitis which mimics appendicitis

Question 22

Which types of tumours are more common in the small bowel?

Answer 22

Primary are rare

Metastases from ovary, colon and stomach are more common

Question 23

What are some primary tumours of the small bowel?

Answer 23

Lymphomas
Carcinoid tumours
Carcinomas

Question 24

What types of lymphoma occur in the small bowel, and what is their treatment?

Answer 24

All non-Hodgkins in type
Maltomas (b-cell) derived
Enteropathy associated with T-cell lymphomas (associated with coeliacs)

Surgery and chemotherapy

Question 25

What is the most common site for carcinoid tumours of the small bowel?

Answer 25

Appendix

Question 26

What are carcinoid tumour of the small bowel like?

Answer 26

Small, yellow, slow growing Locally invasive Produce hormone like substances

Question 27

What are the complications of carcinoid tumours of the small bowel?

Answer 27

Can cause intussusception, obstruction | If metastases to the liver, a carcinoid syndrome occurs, producing flushing and diarrhoea

Question 28

What is the pathology of acute appendicitis?

Answer 28

Aute inflammation (neutrophils), which MUST involve the muscle coat Mucosal ulceration Serosal congestion, exudate Pus in lumen

Question 29

What are the complications of appendicitis?

Answer 29

``` Peritonitis Rupture Abscess Fistula Sepsis and liver abscess ```

Question 30

What is coeliac disease?

Answer 30

An abnormal reaction to gluten which damaged enterocytes and reduces absorptive capacity

Question 31

What does coeliac disease have a strong association with?

Answer 31

HLA-B8 Dermatitis herpetiformis Childhood diabetes

Question 32

What is the aetiology of coeliac disease?

Answer 32

Glaidin (component of gluten) is the suspected toxin Tissue injury may be a bystander effect of abnormal autoimmune reaction to Glaidin Mediated by T-cell lymphocytes which exist within the small intestinal epithelium

Question 33

What does the surface epithelium of the small bowel look like in coeliac disease?

Answer 33

Loss of villous structures due to loss of enterocytes from IEL mediated damage

Question 34

What is the result of the loss of villi in coeliac disease?

Answer 34

Loss of surface area Reduction in absorption Flat duodenal muscle

Question 35

What are the metabolic effects of coeliac disease?

Answer 35

Malabsorption of fats, sugars, amino acids, water and electrolytes Steatorrhoea Reduced intestinal hormone production, so reduced pancreatic secretion and bile flow, causing gallstones

Question 36

What are the effects of malabsorption in coeliac disease?

Answer 36

``` Unexplained weight loss Anaemia (Fe, Vit B12, Folate) Abdominal bloating Failure to thrive Vitamin deficiencies ```

Question 37

Other than malabsorption, what are the complications of coeliac disease?

Answer 37

T cell lymphomas of GI tract Increased rose of small bowel carcinoma Galls stones Ulcerative-jejenoilleitis