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QUESTION NOTES > SMALL BOWEL > Flashcards

SMALL BOWEL Flashcards

1
Q

Mgmt appendiceal carcinoid >2cm or involves base

A

right hemicolectomy

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2
Q

When do right hemicolectomy for appendiceal carcinoid? (6 reasons)

A 
>/= 2cm
involves base
mucosal cellular origin
associated w/mucin production
lymphovascular invasion
involves LN @mesoappendix
pos margins
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3
Q

Most common SB primary CA

A

NET

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4
Q

Most common to mets to SB

A

melanoma

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5
Q

FRIENDS-H

A

prevent fistula closure

  • foreign body
  • radiation
  • infection
  • epithelization of tract
  • neoplasia
  • distal obstruction
  • short fistula tract (<2cm)
  • high output
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6
Q

Mgmt distal obstruction causing SBO, open or laparoscopic?

A

open

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7
Q

Modified Alvarado Score

A

+2: RLQ pain, WBC >10
+1: fever, rebound, migration to RLQ, anorexia, N/V, left shift

r/o appendicitis if <3
CT if score 4-6
OR if 7+

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8
Q

What is an appendicolith

A

calcified deposit within appendix (incidental)

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9
Q

Pneumatosis intestinalis most common in what GI location?

A

jejunum > ileocecal > colon

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10
Q

Demographics associated with perf appendicitis

A
  • male
  • increasing age
  • lack of insurance
  • 3+ comorbid conditions
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11
Q

Parastomal hernia more likely to develop in loop vs. end ileostomy?

A

loop - bc skin incision required for loop is larger (accommodate two pieces of bowel)

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12
Q

Three approaches to repair of parastomal hernia

A

(surgical repair usually disappointing; mgmt non-op)

  1. local
  2. repair with prosthetic mesh
  3. stoma relocation
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13
Q

Nutrition supply by SB

A

glutamine

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14
Q

MC Cx following reversal of loop ileostomy (#1 and #2)

A 
#1 = SBO (7%)
#2 = surgical site infection
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15
Q

Incidence of carcinoid tumors by location? Incidence of metastatic carcinoid tumors by location?

A

appendix > ileum > rectum; ileal carcinoids more likely to mets (35%) than appendix (3%)

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16
Q

Mgmt J-tube dislodgement

A

replacement at bedside; if difficult:
+ <10d -> emergent exploration for replacement to avoid perionteal contamination
+ >10d -> elective replacement in OR or w/ fluoro by IR

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17
Q

ChemoRx for small bowel adenoCA

A

folfox: leucourvin + 5FU + oxaliplatin

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18
Q

CT w/ evidence of “small bowel mass with concentric rings” … think?

A

intussusception

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19
Q

Intestinal hamartomas, think?

A

Peutz-Jeghers syndrome (high % will develop SBO 2/2 intussusception)

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20
Q

Radiation injury to small bowel appears as…? Cx?

A

grey/opaque lesions. vasculitis and fibrosis -> chronic, recurrent partial SBO (may be asymp for as long as 10yrs)

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21
Q

Surgery for tumors in terminal ileum

A

right colectomy bc ileocolic vessels will need to be sacrificed to resect nodal disease along this vascular pedicle

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22
Q

Factors of poor prognosis GIST

A
  • > 10cm
  • high mitotic rate
  • arises from small bowel
  • not favorable mutation (ie. not c-kit, not responsive to imatinib)
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23
Q

Small bowel vs. colonic distention on KUB

A

small -> valvulae conniventes (transverses small bowel) = Kerckring folds = plicae circulares
colonic -> haustra (does not transverse)

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24
Q

Small bowel lymphomas MC found where?

A

ileum (greatest concentration of gut-associated lymphoid tissue)

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25
Q

F/u elderly pt with acute appendicitis

A

colonoscopy 2-mo after discharge bc 5% risk colon CA

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26
Q

Carcinoid cancer arise from…?

A

enterochromaffin-like cells (AKA Kulchitsky cells)

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27
Q

How does competent ileocecal valve aid in prevention of short bowel syndrome?

A

reduces speed of small bowel transit -> aids in reabsorption of water, electrolytes, and nutrients

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28
Q

What is: Gambee suture?

A

interrupted single layer suture that causes inversion of mucosa during small bowel anastomosis

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29
Q

MC location for small bowel adenocarcinoma

A

duodenum

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30
Q

MCC idiopathic (no pathological lead point) intussusception in children?

A

hypertrophied Peyer patches (MC distal ileum)

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31
Q

Mgmt pt with appendicitis + inflammatory phlegmon

A

IV Abx (high morbidity rate for immediate surgery)

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32
Q

MCC malignancy related small bowel obstruction

A

carcinoid tumor

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33
Q

CT finding in carcinoid tumor

A

fibrosis in mesentery

34
Q

Tx for carcinoid crisis

A

octreotide

35
Q

Sxs of carcinoid crisis

A
  • facial flushing
  • diarrhea
  • tachycardia
  • arrhythmias
  • hypotension
  • mental status change due to release of serotonin
36
Q

Suspect SMA syndrome when…

A

young person s/p rapid weight loss, presenting abd pain, N/V

37
Q

Dx imaging characteristics for SMA syndrome

A

aortomesenteric angle <25 degrees (nl 38-65)

38
Q

Mgmt SMA syndrome

A

medical. if fail, then dudoenojejunostomy.

39
Q

For any obstructing NET (ie. carcinoid), should always have what kind of procedure in addition to tumor excision?

A

cholecystectomy bc high likelihood to use octreotide -> biliary stasis and cholecystitis

40
Q

What is the Spigelman scoring system?

A

stage 0-4 for staging of duodenal polyps in pts wtih FPA (based on # polyps, polyp size, histological type, and severity of dysplasia)

41
Q

Mgmt for Spigelman score 0-IV

A

0-1: q5yr EGD

2: q3yr
3: q1-2yr
4: Whipple (pancreas-sparing duodenectomy not effective)

42
Q

Tx small bowel adenoCA

A

surgical resection of primary tumor + regional LN is only curative option. chemorad only for unresectable disease.

43
Q

Operative Tx obstructing neuroendocrine tumor of small bowel (ie. carcinoid)

A

en-block resection with involved mesentery - bc 40-80% spread to mesenteric LN

44
Q

Mgmt B-cell lymphoma (non-MALT) vs. T-cell lymphoma

A

B: if asymp, then chemoradiation (resect if symp)
T: always resection (chemoresistant and likely to progress to obstruction -> perf/bleed)

45
Q

Breakdown of Spigelman score

A

Stage 1 = 1-4
Stage 2 = 5-6
Stage 3 = 7-8
Stage 4 = 9-12

Number of points 1 // 2 // 3
# polyps 1-4 // 5-20 // >20
mm size 1-4 // 5-10 // >10
histology tubulous // tubulovillous // villous
dysplasia mild // moderate // severe
46
Q

MC congenital abnormality of the GI tract

A

Meckel diverticulum

47
Q

MC symptom of Meckel diverticulum if symptomatic

A

majority asymptomatic

  • children: painless GI bleeding
  • adult: obstruction (#1), diverticulitis (#2)
48
Q

Imaging CT: tubular distended cystic mass w/ wall calcification in RLQ adjacent to cecum

A

appendiceal mucocele

49
Q

Why do appendiceal mucoceles need to be resected?

A

may harbor a cystadenocarcinoma

50
Q

When do right hemicolectomy for appendiceal mucocele? (3)

A
  • suspicion of nodal spread
  • involvement of terminal ileum or cecum
  • positive margins
51
Q

MC primary surgical disease of the small bowel

A

Crohn’s

52
Q

Can present as small bowel perf… what kind of mass?

A

small bowel lymphoma

53
Q

Mgmt MALT in small bowel vs. stomach

A

stomach: tx H.pylori + resection

small bowel: resection only

54
Q

Second MC site of diverticula formation in intestinal tract

A

duodenum

55
Q

Duodenal diverticula are classified as either… or…? Difference in layers involved?

A

congenital (true - all layer involved) or acquired (pulsion - mucosa, submucosa, and muscularis mucosa through weakness in duodenal wall)

56
Q

MC location duodenal diverticula in second portion

A

ampulla of Vatar (weakness in duodenal wall)

57
Q

Mgmt contained duodenal perf in stable pt

A

nonop - NGT decompression + Abx + bowel rest w/ or wo endoscopically placed drains or stents

58
Q

MC location of duodenal diverticulum

A

2nd portion of duodenum - most located near ampulla

59
Q

Presentation of symptomatic duodenal diverticulum

A

Abdominal pain with pancreatitis and diverticula discovered on imaging/ERCP

60
Q

Mgmt pancreatitis 2/2 duodenal diverticula

A

Open diverticulectomy and primary primary closure, after resolution of pancreatitis

61
Q

Breakdown of how much fluid each GI section makes in one day (saliva, stomach, small bowel, biliary, pancreatic)

A 
Saliva = 1.5 L
Stomach = 1-2 L
Small bowel = 1.5 L
Biliary = 500cc
Pancreatic = 1.5-3 L
(But most are absorbed back by small [8.5 L] and large [400cc] bowels)
62
Q

Mgmt Crohn’s strictures at duodenum

A

gastrojejunostomy

63
Q

MC malignant tumor of appendix

A

adenocarcinoma (MC overall tumor of appendix is carcinoid)

64
Q

When should operative intervention be considered for EC fistula?

A

if persist after 6-weeks from formation

65
Q

Metabolic derangement for pts with proximal EC fistula

A

acidosis (bc proximal fistula tend to be high in bicarb)

66
Q

Obturator sign of acute appendicitis indicates…

A

(pain with internal rotation of thigh) pelvic appendix

67
Q

Iliopsoas sign of acute appendicitis indicates…

A

(pain extension of thigh) retrocecal appendix

68
Q

Pelvic appendicitis tends to have what hx and exam findings?

A

urinary symptoms and diarrhea (bladder and rectal irritation) + Obturator sign

69
Q

Where in small bowel does protein absorption mostly occur?

A

jejunum

70
Q

Cx early appendectomy for perforated appendicitis

A

increase risk bowel obstruction, wound infection, reoperation

71
Q

Interval appendectomy should occur when?

A

6-8 weeks after insult

72
Q

What Rx has shown results that it may aid in closure of fistulas in Crohn’s?

A

infliximab

73
Q

What layer of intestinal wall is most important for strength in hand-sewn anastomosis?

A

submucosa - highest content of collagen fibers (tensile strength determined by collagen cross linking)

74
Q

Appendicitis is MC in what trimester?

A

2nd

75
Q

MC epithelial tumor of appendix

A

pseudomyxoma peritonei

76
Q

MC presenting sxs of pseudomyxoma perionei (#1, #2)

A 
#1: increasing abdominal girth
#2: ovarian mass on pelvic exam (females); inguinal hernia +/- mucoid fluid (men)
77
Q

Which IBD has rectal sparing?

A

Crohn’s

78
Q

Mgmt mesenteric cyst

A

cyst enucleation

79
Q

Mesenteric cyst thought to be 2/2…? Cyst contents?

A

2/2 structural abnormality of mesenteric lymphatic system - straw-colored (milky, if following fat ingestion), and proteinaceous contents

80
Q

MC location mesenteric cyst

A

small bowel mesentery (TI is most common)

QUESTION NOTES (28 decks)

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