Small bowel Flashcards
Steps to Witzel Jejunostomy
Midline incision
Loop of jejunum 20 distal to ligament of treitz
Pursestring suture
enterotomy
feeding tube place and purse string suture is tied
create 4-6cm serosal tunnel
3-0 silk interrupted Lembert sutures
Jejunum sutured to peritoneum
tube brought out through stab incision in abdominal wall
tube sutures in place midline is closed
MC primary source of metastatic disease to small bowel
Melanoma of Skin
MC cancer of small bowel
metastatic disease
MC primary cancer of small bowel
carcinoid
2nd MC primary cancer of small bowel
adenocarcinoma
Broad vs narrow base Meckel diverticulum
Narrow: <2cm -> diverticulectomy
Broad: >2cm -> segmental resection
Older male, Hx of CRC, 1cm sessile polyp in 1st portion of duo, Bx shows finger-like projections and dysplastic epithelium, what is Dx?
Small intestinal villous adenoma
Small intestinal villous adenoma
sessile polyp fingerlike projections & dysplastic epithelium on Bx highest malignant potential (35-55%) assoc w/ FAP can be large (>5cm)
Brunner gland polyps
hyperplastic proliferation of Brunner gland ducts and stroma, in prox duodenum
no risk of malignant transformation
mimin PUD
Small bowel polyp biopsy findings concerning for malignancy
ulceration
severe dysplasia
pancreatic/CBD dilation
MC location of villous adenomas
duodenum
MC location of small bowel adenoma
ileum
MC extranodal site for NHL
GI tract
(stomach > SB > LB)
Lugano Staging System for GI Lymphoma
Stage I-E1: confined to mucosa or submucosa
Stage I-E2: Confined to muscularis propria or serosa
Stage II-E1: involvement of local nodes (para-gastric, para-intestinal)
Stage II-E2: Involvement of distal nodes (para-aortic, mesenteric)
Stage IV: disseminated extranodal involvement, supra-diaphragmatic nodal involvement
Carcinoid syndrome
intense facial flushing
severe diarrhea
primary small bowel tumor (carcinoid) with liver lesion (mets)
release of serotonin -> urinary 5-HIAA
Metabolic test of choice to dx carcinoid syndrome
urinary 5-HIAA
>25mg/d is diagnostic
chromogranin A (CgA) >95% sensitive for well-differentiated metastatic neuroendocrine tumors (can be falsely elevated w. PPI use)
Imaging findings for SB neuroendocrine tumors
hyperenhancing small bowel mass, desmoplastic mesenteric reaction, tethering of adjacent small bowel, bulky adenopathy
liver mets: isodense with central necrosis
Carcinoid syndrome treatment
Octreotide or Lanreotide (somatostatin analogs)
GI Neuroendocrine tumors location
Appendix, distal ileum, colon, and rectum
Cell origin of GI neuroendocrine tumors
enterochromaffin cells (aka: Kulchitsky cells)
Pt w/ chronic abd pain, bloating, diarrhea, weight loss (think IBD/IBS), noted w/ small bowel mass.
Path: villous atrophy of adjacent jejunal mucosa
what is diagnosis?
enteropathy-associated T-cell lymphoma (EATL)
Enteropathy-associated T-cell lymphoma
MC affects prox jejunum
Histo: circumferentially associated ulcers, assoc w/ perf. tumor cells invade the intestine wall, monotonous anaplastic clonal cells, express T-cell markers/recs, pale-staining cytoplasm, prominent nucleoli
Adjacent mucosa shows signs of celiac disease (villous atrophy, crypt hyperplasia, increased LCs and plasma cells in lamina propria)
Dx: bx for type and grade and to guide tx
tx: cyclophosphamide, doxorubicin, vincristine, prednisone; aggressive -> stem cell transplant; surgery for complications - perf, obstruction
MC histo subtype of SB lymphomas
B-cell NHL (MALT, Diffuse large B-cell)
MC site of Diffuse large B-cell lymphoma
terminal ileum (peyer’s patches - LN basins)
Diffuse large b-cell lymphoma
Aggressive, large tumors
Responsive to chemo
Small bowel hemangiomas
Rare benign tumors of SB
Present with occult GIB, IDA (but not a common cause of GIB due to rarity of diagnosis)
Operative management to control sxs -> endoscopic management is usually successful and first-line
