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Appendix > Small Bowel 2 > Flashcards

Small Bowel 2 Flashcards

1
Q

What is the most common malignant neoplasm of small bowel?

A

CARCINOID

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2
Q

What are the top 4 malignant neoplasms of small bowel?

A
  1. CARCINOId
  2. Adenocarcinoma
  3. Lymphoma
  4. GISTs
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3
Q

Most common symptoms of malignant small bowel neoplasms?

A

pain + weight loss

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4
Q

These small bowel neoplasms arise from the enterochromaffin cells (Kulchitsky cells) in the crypts of Lieberkuhn;

A

carcinoids

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5
Q

Carcinoid of small bowel arise form what cells?

A

enterochromaffin cells (Kulchitsky cells) in the crypts of Lieberkuhn

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6
Q

The GI tract is the most common site for carcinoid tumors, the small intestine is the 2nd most common site, what’s first?

A

APPY

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7
Q

In the small intestine, carcinoids almost always occur where?

A

within last 2 feet of ileum

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8
Q

What do carcinoids secrete?

A

serotonin + substance P

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9
Q

What symptoms characterize carcinoid syndrome?

A

cutaneous flushing
bronchospasm
diarrhea
vasomotor collapse

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10
Q

What are the top 3 locations we see carcinoids in the GI tract?

A

appendix–> 45% (only 3% will mets)
ileum–> 28% (35% will metastasize)
rectum –> 16%

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11
Q

Small bowel carcinoids tend be multi-centric, in what % of pts?

A

20-30%

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12
Q

What % of pts with carcinoids develop carcinoid syndrome?

A

10%

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13
Q

What do we need to develop carcinoid syndrome?

A

you need hepatic mets or extra-abdominal disease due to first pass metabolism of vasoactive peptides

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14
Q

Common signs and symptoms of carcinoid syndrome?

A 
flushing 
diarrhea
hepatomegaly
cardiac lesions (right heart valve dx)
asthma
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15
Q

What causes diarrhea in carcinoid syndrome?

A

increased serotonin levels circulating

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16
Q

How do we diagnose carcinoid syndrome??

A

carcinoids make serotonin–> metabolized by liver/lung into 5-HIAA

    • measure urine levels of 5-HIAA over 24 hrs
  • *measure plasma levels of chromogranin A (seen in 80% of pts with carcinoid tumors)
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17
Q

Surgical management of carcinoids of small bowel?

A

tumors < 1 cm, without LN involvement–> segmental intestinal resection

tumors > 1 cm, LN involved, multiple tumors–> wide excision of bowel + mesentery

lesion of terminal ileum–> R-Hemi

small duodenal tumors–> local excision
more extensive duodenal tumors–> pancreaticoduodenectomy

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18
Q

Connection between carcinoid tumors and anesthesia?

A

anesthesia can precipitate a carcinoid crisis;

hypotension, bronchospasm, flushing

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19
Q

How do we treat carcinoid crisis precipitated by anesthesia?

A

IV bolus of 50-100 micro-grams of octreotide

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20
Q

What is the role of surgery in pts with carcinoid tumors an widespread metastatic disease?

A

surgical debulking still done to provide relief of sxs

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21
Q

Medication used to tx symptoms of carcinoid syndrome?

A

somatostatin analogues like ocreotide

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22
Q

Why is there limited success with chemotherapy for carcinoids?

A

they’re slow growing

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23
Q

Role of chemo for carcinoids?

A

limited to pts non-responsive to anything else

pts who have a high proliferation rate

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24
Q

5 yr survival rates in pts with carcinoids?

A

resection of carcinoid tumor localized to primary site–> 100%

pts with regional disease–> 65%
pts with distant mets–> 25-35%

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25
Q

Peak incidence of adenocarcinoma of small bowel?

A

7th decade

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26
Q

Where do we find most adenocarcinomas?

A

duodenum + prox. jejunum

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27
Q

Treatment for duodenal adenocarcinoma?

A

pancreaticoduodenectomy unless found in 3rd or 4th part of duodenum

jejunal + ileal adeno–> segmental resection + mesentery

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28
Q

Where do we find small bowel lymphomas?

A

ileum–> greatest concentration of gut-associated lymphoid tissue

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29
Q

What is neoadjuvant therapy for malignant GIST?

A

imatinib

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30
Q

What is imatinib?

A

tyrosine kinase inhibitor that blocks c-kot in malignant GISTs, inhibits BCR-ABL

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31
Q

What is the most common acquired diverticulum of small bowel and what is the most common congenital diverticulum of small bowel?

A

acquired–> duodenal diverticulum

congenital–> Meckel’s

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32
Q

These represents 2nd most common cause of diverticula after colon:

A

duodenal diverticula

commonly seen peri-ampullary around D2

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33
Q

Tx for duodenal diverticula?

A

most are asymptomatic, when found should be left alone

symptomatic diverticula–> diverticulectomy with Kocher maneuver

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34
Q

Most commonly encountered congenital anomaly of the small intestine occurring in 2% of the population:

A

Meckel’s diverticulum

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35
Q

Is Meckel’s diverticulum a true diverticulum?

A

YES

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36
Q

What is a Meckel’s diverticulum?

A

failure or incomplete closure of the omphalomesenteric/vitelline duct

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37
Q

Where do we commonly see a Meckel’s diverticulum?

A

2ft proximal to ileocecal valve

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38
Q

Why is not uncommon to find different tissues within a Meckel’s?

A

the cells of the vitelline duct are pluripotent

can see gastric mucosa (50% of time)
can see pancreatic mucosa (5% of time)

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39
Q

Do we see Meckel’s in the mesenteric or anti-mesenteric border of the bowel?

A

ANTI-mesenteric border

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40
Q

Most common clinical presentation of a Meckel’s?

A

bleeding (seen in 25-50% of pts)

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41
Q

What causes the bleeding encountered in Meckels?

A

chronic acid producing gastric mucosa adjacent to ileum

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42
Q

Are Meckel’s malignant vs benign?

A

majority benign

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43
Q

How does a Meckel’s cause SB obstruction?

A

SB volvulizes around the fibrotic Meckel’s band attached to abdominal wall

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44
Q

What is a Littre’s hernia?

A

inguinal hernia containing Meckel’s diverticulum

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45
Q

How does a Meckel’s cause intussussception?

A

the diverticulum, if broad, can invaginate into the SB lumen and be carried forward by peristalsis

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46
Q

How do we try and treat intussussception caused by a Meckel’s?

A

usually barium enema

will ultimately need diverticular resection to prevent recurrence

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47
Q

This should be on the differential alongside appendicitis in someone with RLQ:

A

Meckel’s diverticulitis

if operating for suspected appendicitis and the appendix is normal, check the distal ileum for an inflamed Meckel’s

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48
Q

Best test for Meckel’s?

A

Pertechnetate scan –> which is taken up preferentially by gastric mucosa cells and ectopic gastric tissue in the diverticulum

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49
Q

What do you do for asymptomatic Meckel’s diverticula found in child vs adults?

A

children–> remove

adults–> controversial

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50
Q

What is pneumatosis intestinalis?

A

multiple gas-filled cysts found in the GI tract

cysts seen in subserosa, submucosa, rarely muscle

most common in jejunum

spontaneous rupture of cysts give rise to pneumoperitoneum

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51
Q

WHat causes pneumoperitoneum in pneumatosis intestinalis?

A

rupture of thin walled gas-filled cysts found in subserosa, submucosa of intestinal wall

peritonitis is unusual

** pneumatosis intestinalis represents one of few cases of sterile pneumoperitoneum

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52
Q

In pts with free abdominal air but no signs of peritonitis, we can consider this on differential;

A

pneumatosis intestinalsis

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53
Q

Most cases of pneumatosis intestinalis assc with what?

A

COPD

immunocompromised states

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54
Q

Pneumatosis intestinalis in neonates usually assc with what?

A

necrotizing enterocolitis

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55
Q

What is the tx for pneumatosis intestinalis?

A

no tx unless rare complications occur;

volvulus
tension pneumo
rectal bleeding

56
Q

What is vascular compession of the duodenum called by the SMA?

A

SMA syndrome, AKA Wilkie’s syndrome

57
Q

What is Wilkie’s syndrome?

A

compression of duodenum by SMA

58
Q

What portion of duodenum compressed by SMA resulting in Wilkie’s syndrome?

A

D3

59
Q

This medication has been shown to significantly decrease severity of nausea/vomiting in pts with malignant bowel obstruction?

A

ocreotide

60
Q

The two most common types of ectopic tissue seen in a Meckel’s are?

A

gastric

pancreatic

61
Q

Nodal and distant mets are common with carcinoids 1-2 cm in size, with nodal spread seen in what % and liver spread in what %?

A

nodal spread in 60-80%

liver mets 20%

62
Q

Carcinoid syndrome results from what ?

A

circulating vasoactive products; serotonin, histamine, kallikrein, bradykinin, prostaglandins

normally these products deactivated by monoamine oxidase in liver

for carcinoid syndrome to occur these products must be released in the systemic circulation through primary bronchial carcinoid, retroperitoneal mets or another source that does not drain thru portal circulation or have haptic mets that overwhelm liver’s MAO

63
Q

How do we treat liver mets in carcinoid syndrome?

A

usually removed, helps provide symptomatic relief in pts who don’t respond to the somatostatin analogues

64
Q

SB adenocarcinoma is relatively rare, found mostly where?

A

duodenum + jejunum –>80%

***+ surgical margin assc. with poor prognosis

65
Q

In pts with Peutz-Jeghers syndrome, 90% of pts have what small bowel lesions?

A

hamartomatous polyps, mostly in jejunum

66
Q

69% of pts with Peutz-Jeghers syndrome, that have hamartomatous polyps in the small bowel, develop what?

A

intussussception

67
Q

Complication rates of stricturoplasties vs segmental resections for strictures in Crohn’s?

A

stricturoplasties have higher complications rates; post-op bleeding from suture line

thus stricturoplasties for Crohn’s are used to preserved substantial bowel length, they’re not used to small strictures that can be segmentally resected due to higher risk of complications

68
Q

Gold standard to diagnose intussussception, showing characteristic ‘bull’s eye sign”;

A

CT with IV/PO contrast

69
Q

In adults that present with intussussception, the lead point is ususally?

A

a small bowel tumor 80% of the time

thus a segmental resection of affected area, don’t reduce the intussussception, lymphadenectomy, anastomosis

70
Q

Why don’t we reduce intussussception in adults?

A

tumor cells can be shed or tumor can be disrupted given inflamed nature of the bowel

71
Q

Most common xray findings in intussussception and most pathognomonic xray finding in intussussception:

A

most common–> non-specific air fluid levels, no gas in colon

pathognomonic–> sausage shaped soft tissue density, outlined by two strips of air

72
Q

Best test to diagnose Crohn’s?

A

c-scope with bx

73
Q

What are the two forms of pneumatosis intestinalis?

A

cystic—> seen in submucosa as cysts

linear–> seen in subserosa, muscualris as a thin linear gas pattern

74
Q

Mortality rate from enterocutaneous fistulas?

A

15-20%

75
Q

Majority of enterocutaneous fistulas are caused by?

A

iatrogenic 85%
predisposing conditions; Crohn’s diverticulitis, malignancy, trauma (20%)

anastomotic leaks, bowel injury, erosion by suction catheters, lacs to bowel by mesh or retention sutures

76
Q

Differences in proximal vs distal fistulas?

A

proximal fistulas–> higher output, more fluid & electrolyte loss

distal fistulas–> lower output, tend to close spontaneously

77
Q

What is a high output fistula?

A

> 500 cc/day

78
Q

What are some factors that prevent spontaneous fistula closure?

A 
high output
radiation enteritis
cancer 
active IBD
distal obstruction
undrained abscess
foreign body in fistula tract
epithelialization of fistula tract
fistula tract < 2.5 cm long
79
Q

MC cause of death in pts with fistulas?

A

historically was malnutrition and dehydration

now it’s sepsis

80
Q

How do we manage fistulas surgically?

A

source control, nutritional optimization

conservative course for 4-6 weeks, if it hasn’t closed, then surgery should be considered

ideally you want to wait 3-6 months

81
Q

Role of ocretide in fistula management?

A

shown to reduce fistula outputs

not provided an improvement in fistula closure rates

82
Q

Preferred operation for fistulas?

A

fistula tract excision
segmental resection of the involved segment of intestine
reanastomose

83
Q

This is a rare condition manifested by diarrhea, stetatorrhea, megaloblastic anemia, weight loss, abd pain and malabsorption of fat soluble vitamins (ADEK):

A

blind loop syndrome

84
Q

What causes blind loop syndrome?

A

bacterial overgrowth in a stagnant area of small bowel

usually due to stricture, stenosis, fistula, diverticula

85
Q

What causes megaloblastic anemia in blind loop syndrome?

A

bacterial overgrowth due to stagnant area of bowel

these bacteria compete for B12

86
Q

How do we treat megaloblastic anemia caused by bacterial overgrowth in blind loop syndrome?

A

course of broad spectrum abx, adding IF does not help

87
Q

How can we confirm blind loop syndrome?

A

can get cultures from an intestinal tube

C-xylose breath test

Schilling test–> C-labeled Vit B12 is absorbed, and excretion in urine is noted (usually 0-6% in blind loop syndrome, normal is 7-25%)

88
Q

Tx for blind loop syndrome?

A

IV B12

broad spectrum abx–> augmentin, kefflex + flagyl

89
Q

For radiation enteritis, what’s the dose that can cause damage to the intestine?

A

dosages > 5000 cGy

90
Q

Various drugs have been used to help with radiation enteritis, what’s the most promising?

A

amifostine

sulhydryl compound that is converted intra-cellularly to an active metabolite –> binds to free radicals and prevents cell damage

91
Q

What is short bowel syndrome?

A

total SB length that is inadequate to support nutrition

92
Q

Of cases of short bowel syndrome, 75% are due to massive intestinal resections from what?

A

mesenteric occlusion
volvulus
trauma to superior mesenteric vessels

93
Q

MC cause of short bowel syndrome in neonates is?

A

necrotizing enterocolitis

94
Q

Clinical hallmarks of short bowel syndrome?

A

diarrhea, malnutrition, fluid + electrolyte deficiency

95
Q

Why do we see an increase in gallstones and kidney stones with short bowel syndrome?

A

decrease in enterohepatic circulation

hyperoxaluria causes kidney stones

96
Q

What are some common causes of Wilkie’s syndrome?

A

vascular compression of duodenum usually due to weight loss, supine immobilization, scoliosis, body cast

97
Q

Operative treatment for duodenal vascular compression by SMA?

A

duodeno-jejunostomy

98
Q

Characterize fistulas and their outputs:

A

low output–> less than 200 cc/day
moderate–> 200-500
high output –> greater than 500 cc/day

99
Q

IF a fistula remains open after 6-8 weeks, spontaneous closure is?

A

unlikely

100
Q

In pts with carcinoid syndrome, they can become hypotensive unresponsive to fluids and pressors, what do we give?

A

ocreotide (somatostatin analogue)

101
Q

Strongest risk factor for developing sxs with a Meckel’s?

A

ectopic gastric tissue

102
Q

What are some risk factors assc with developing sxs due to a Meckels?

A

male sex
age less than 50
diverticulum > 2 cm
ectopic tissue

103
Q

For a pt with an acute flare up for Crohn’s dx, initial management includes?

A

oral steroids–> then taper

infliximab usually reserved for pts who have not responded to other therapies

104
Q

This is a potent vasodilator that does not increase intestinal O2 uptake:

A

papaverine

105
Q

What is MALT?

A

mucosal associated lymphoid tissue–> seen in stomach, asscs with h.pylori –> once h pylori treated, MATL regresses

when found in small bowel and isolated, resection takes care of it, nothing else to do

106
Q

ALmost 80% of these small bowel tumors arise in duodenum and proximal jejunum and may assc. ulcers;

A

adenocarcinomas

frequently cause obstruction

107
Q

Most appropriate antibiotics for small bowel intestinal overgrowth?

A

rifaximin (inhibits DNA dependent RNA polymerase)

usually for 14 days

108
Q

Why do we need screening in pts with FAP if they’ve had a total procto-colectomy with ileo-anal anastomosis?

A

polyps typically seen throughout colon and rectum

but also seen in stomach, duodenum thus screening w/anoscopy and EGD recommended post-op regularly

109
Q

Fistulization between gallbladder and duodenum?

A

produces gallstone ileus

110
Q

What’s Bouveret’s syndrome?

A

GOO caused by gallstone in duodenum

111
Q

Extrinsic compression of CBD by gallstone?

A

Mirizzi syndrome

112
Q

Treatment for high risk GISTs?

A

prolonged adjuvant therapy usually with imatinib if ckit positive for 3 yrs or more

113
Q

In pts with blind loop syndrome this test can aid in the diagnosis;

A

d-xylose test (carb breath test)

bacteria in blind loop break down carbs to hydrogen and methane which is detected in the breath

114
Q

Bile salts and vit B12 are absorbed where?

A

terminal ileum

if terminal ileum resected, bile salts are not re-absorbed, introduced to colon, interfere with colonic absorption of fluids and electrolytes

pts experience diarrhea

Tx–> oral cholestyramine

115
Q

What medications are known to be protective against radiation enteritis?

A

ACEi

statins

116
Q

This syndrome characterized by severe post-prandial epigastric abdominal pain and nonbilious emesis, usually in pts w/gastric bypass surgery;

A

afferent loop syndrome

117
Q

This medication indicated in pts with short bowel syndrome who can’t be weaned off TPN;

A

teduglutide
glucagon-like-peptide 2 analog

(ocreotide usually used short-term in pts with short gut syndrome)

118
Q

Blind loop syndrome is most commonly associated with what procedure?

A

antecolic biliroth II with a long >30 cm afferent limb

(retrocolic loop gastroenterostomy is preferred)

Tx–> convert to a biliroth I or a Roux-en-Y

119
Q

The vitelline duct connects the yolk sac to the midgut of the embryo, and self-involutes during 9th week of development, failure to involute leads to a?

A

Meckel’s

120
Q

Crohn’s disease can have a 10-12 fold increased risk of what small bowel cancer?

A

adenocarcinoma

usually in the terminal ileum

121
Q

Duodenal Crohn’s dx is unusual, tx of choice for Crohn’s involving the 1st and 2nd portions of the duodenum include?

A

gastrojejujonostomy and vagotomy (vagotomy done to prevent marginal ulcers)

duodenojejunostomy indicated for refractory strictures of 3rd/4th part of duodenum

***pancreaticoduodenectomy is not performed for duodenal Crohn’s

122
Q

Most common complication following reversal of a loop ileostomy?

A

SBO - 7%

followed by SSI

123
Q

Lymphomas of small bowel tend to be found where?

A

ileum
tend to be large when found
perforation occurs in 25% of pts

124
Q

Different types of small bowel stricturoplasties:

A

single short segment 5-7 stricture; H-Mickulicz
medium segment 10-15 cm; Finney
>15 cm segment; Michelassi

large bowel does not respond well to stricturoplasties,
in large bowel strictures need resection, 7% chance of having cancer

125
Q

Small bowel lymphomas are more commonly of B cell or T cell origin?

A

B cell

126
Q

What part of small bowel do most small bowel lymphomas originate?

A

ileum—> has Peyer’s patches

127
Q

Pts with a hx of this disease are more likely to develop T-cell lymphoma of small bowel;

A

celiac dx

128
Q

Who is at higher risk of developing T cell lymphoma of small bowel?

A

pts w/celiac dx

immunocompromised pts

129
Q

Most common small bowel location for lymphoma?

A

ileum

130
Q

In what part of small intestine is most protein absorption taking place?

A

jejunum

131
Q

How is protein digested?

A

begins in stomach, gastric acid denatures protein

small intestine, protein comes in contact with pancreatic proteases

trypsinogen gets activated by brush border enterokinase in duodenum

activated trypsin activates other enzymes

132
Q

Approx. 80-90% of protein digestion and absorption occurs in the?

A

jejunum

133
Q

A Heineke-Mickulicz stricturoplasty is indicated for strictures what size?

A

5-7 cm long

134
Q

How to perform a Heineke-Mickulicz stricturoplasty?

A

make a longitudinal incision across the stricture

place two stay sutures on either end

close in a tranverse fashion with simple interrupted silk sutures

135
Q

FInney stricturoplasties are best suited for what length strictures?

A

10-15 cm long

Appendix (39 decks)

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