Small Bowel Flashcards by Brian Boyarsky

Nutrient vs. Water absorption small vs. large bowel

Small bowel: Nutrient and water

Large: Water

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The 4 portions of the duodenum

Bulb – 90% ulcers
Descending – ampulla/dcuts
Transverse – 3
Ascending – 4

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Which portions of the duodenum are the acute angle between the aorta and SMA

3 and 4

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Vascular supply of duodenum

GDA (Superior (A/P superior))/Pancreaticoduodenal (IMA)

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Jejunum – T/F Maximum site of all absorption

100 cm long; long vasa recta, circular muscle folds. True

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B12 is absorbed in…

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Bile acids are absorbed in …

Ileum, TI (conjugated)

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Fe is absorbed in the …

Duodenum

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Folate is absorbed in the …

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Does the ileum have long or short vasa recta

Short

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95% of NaCl and 90% of water absorbed in the jujunum or ileum

Jejunum

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Which is longer the jejunum or ileum

Ileum (150 vs 100 cm)

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Name the different cell types in the small intestine

Absorptive
Goblet: mucin
Paneth: secretory granules
Enterochromaffin (carcinoid)
Brunners; Peyers; M cells

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Most important hormone in the migrating motor complex (which phase of gut motility?)

Motilin --
I - rest
II - acceleration and GB contraction
III - peristalsis
IV - decel

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95% of bile salts are re-absorbed

50% active resorption in TI (Na/K ATPase)

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Why do gallstones form after TI resection

Malabsorption of bile salts

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How is short gut diagnosed?

Symptoms, not length of bowel

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Symptoms of short gut

Weight loss, steatorrhea, nutritional deficinency

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How do you check for fecal fat?

Sudan red stain

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What test do you use for B12 absorption

Schilling test

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How much bowel do you need to survive off TPN / vs. with a competent ileocecal valve?

75cm to survive off TPN, 50cm with competent ileoceal valve

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Treatment of short gut

Restrict fat, PPI, Lomotil

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Causes of statorrhea

Gastric hypersecretion of acid, increased intestinal motility; interrpution of bile sale resorption (TI resection); decreased panc enzymes; weight loss / ADEK essential fatty acids

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Causes of non-healing fistula

FRIENDS

Foreign body, radiation, IBD, epithelialization, neoplasm, distal obstruction, sepsis/infection

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High output fistulas

More likely with proximal bowel (duodenum, proximal jejunum); less likely to close with conservative management

Which fistulas are more likely to close: colon or small bowel

Colon

Patients with a fistula and persistent fever

Abscess: fistulogram, CT, UGI with SBFT

Most fistulas are iatrogenic and treated conservatively first with...

NPO, TPN, stoma appliance, octreotide

Surgical options for fistula

Resect bowel segment containing fistula and perform primary anastamosis

MCC SBO in virgin/non-virgin abdomen

Virgin: SBO/Hernia, LBO/Cancer | Non-virgin: SBO/Adhesions, LBO/Cancer

Why do you see air with SBO

Swallowed nitrogen

What percentage of partial vs full SBO are cured by conservative management

80% vs 40%

Surgical indication for SBO

Progressive pain, peritonitis, fever, leukocytosis, failure to resolve

A gallstone ileus is caused by...

Fistula between gallbladder and duodenum second part

Meckel's diverticulum is caused by...

Failure of closure of omphalomesenteric duct to close

50% of painless lower GI bleeds in children < 2 years old

Meckel's

Most common tissue found in Meckel's

Pancreatic; however gastric can cause symptoms

Management of duodenal diverticula

Rule out gallbladder-duodenal fistula; observe unless perforated, bleeding, obstructive, symptomatic (D>J>I)

Extra-intestinal manifestations of Crohn's

Arthritis, arthralgia, pyoderma, ocular, growth failure, megaloblastic anemia B12/folate

Rectal sparing in Crohn's

True

Most commonly involved bowel segment in Crohn's

Crohn's vs. UC

Transmural inflammation, skip lesions, cobblestoning, deep ulcers, creeping fat

Meds for Crohn's

Remicade (infliximab) Sulfasalazine, loperamide, steroids; Flagyl; TPN

What percentage of Crohn's patients evenutally need an operation

90%

Do you perform lateral sphincteroplasty in patients with Crohn's disease?

Can you do a pouch or ilio-anal anastamosis for patients with Crohn's disease?

Serotonin is produced by...

Kulchitsky cells -- enterochromaffin cell or argentaffin cell 5-HIAA is a breakdown product of serotonin

Carcinoid syndrome

Liver mets: flushing, diarrhea Asthma-like, R heart valve lesions (Liver usually clears serotonin(

Octreotide scan

Used for carcinoid

Most common site for carcinoid

Appendix

Appendiceal carcinoid treatment

< 2 cm: appy | > 2 cm: R hemi

CTX for carcinoid

Strptozocin, 50FU | Octreotide; palliation

Treatment for salmonella enteritis

Bactrim | * RLQ, diarrhea, fever, HA, mac pap rash, leukopenia, bleeding/perf

In a child -- * RLQ, diarrhea, fever, HA, mac pap rash, leukopenia, bleeding/perf rare

Salmonella typhoid enteritis

MCC electrolyte abnormality a/w ileus

MCC death in appendix mucocele

Malignant small bowel obstruction

T/F Regional ileitis can mimic appendicitis

True; 10% go on to develop Crohn's

Should you open for an appendix mucocele?

Yes; rupture --> pseudomyxoma peritonei

MCC acute abdominal pain in 1st trimester

Appendicitis

What trimester is acute appendicitis most likely?

Second

When is acute appendicitis most likely to perforate in pregnancy?

Third trimester

Is the appendix displaced cephalad during pregnancy?

Yes

What percentage of fetal death with ruptured appendicitis in pregnancy?

35%

Women with suspected appendicitis should always have...

b-HCG and abdominal ultrasound to r/o pregnancy

What is the general sequence of symptoms a/w acute appendicitis

1st: Anorexia 2nd: Peri-umb abdominal pain 3rd: Vomiting

What does a CT scan show in acute appendicitis?

Diameter > 7 mm; Wall thickness > 2mm; no contrast in lumen

Most likely location of perforation of appendicitis

Midpoint of anti-meseneric border

Most common cause of acute appendicitis in children

Lymphoid hyperplasia; can follow a viral illness

Most common cause of acute appendicitis in adults

Fecalith

What is the pathophysiology of ruptured appendicitis?

Luminal obstruction, distension of appendix, venous congestion and thrombosis, ischemia, gangrene, rupture

Treatment of ruptured appendicitis

Perc drainage and interval appendectomy -- need to r/o perforated cecal cancer

Do you need to repair a parastomal hernia?

No -- unless symptomatic

Most common stomal infection

Candida

What is diversion colitis?

Secondary to lack of SCFA's -- treatment is SCFA enemas

Most common cause of stoma stenosis

Ischemia; dilate if mild

Most common cause of fistula near stoma site

Crohn's

Are gallstones more common in patients with ileostomy

Yes -- loss of bile salts

Are uric acid stones more likely in patients with ileostomy?

Yes; loss of bicarb

Where are most small bowel adenomas found?

Duodenum; can p/w bleeding, obstruction; need resection when identified

Is Peutz-Jeghers syndrome AD or AR?

AD: hamartomas throughout GT tract (small and large bowel); mucocutaneous melanotic skin pigmentation; patients have increased extra-intestinal malignancies,; MC -- breast cancer, small risk of Gi malignancies

Do patients with Peutz-Jeghers get prophylactic colectomy?