SMALL BOWEL Flashcards
Mgmt appendiceal carcinoid >2cm or involves base
right hemicolectomy
When do right hemicolectomy for appendiceal carcinoid? (6 reasons)
>/= 2cm involves base mucosal cellular origin associated w/mucin production lymphovascular invasion involves LN @mesoappendix pos margins
Most common SB primary CA
NET
Most common to mets to SB
melanoma
FRIENDS-H
prevent fistula closure
- foreign body
- radiation
- infection
- epithelization of tract
- neoplasia
- distal obstruction
- short fistula tract (<2cm)
- high output
Mgmt distal obstruction causing SBO, open or laparoscopic?
open
Modified Alvarado Score
+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+
What is an appendicolith
calcified deposit within appendix (incidental)
Pneumatosis intestinalis most common in what GI location?
jejunum > ileocecal > colon
Demographics associated with perf appendicitis
- male
- increasing age
- lack of insurance
- 3+ comorbid conditions
Parastomal hernia more likely to develop in loop vs. end ileostomy?
loop - bc skin incision required for loop is larger (accommodate two pieces of bowel)
Three approaches to repair of parastomal hernia
(surgical repair usually disappointing; mgmt non-op)
- local
- repair with prosthetic mesh
- stoma relocation
Nutrition supply by SB
glutamine
MC Cx following reversal of loop ileostomy (#1 and #2)
#1 = SBO (7%) #2 = surgical site infection
Incidence of carcinoid tumors by location? Incidence of metastatic carcinoid tumors by location?
appendix > ileum > rectum; ileal carcinoids more likely to mets (35%) than appendix (3%)
Mgmt J-tube dislodgement
replacement at bedside; if difficult:
+ <10d -> emergent exploration for replacement to avoid perionteal contamination
+ >10d -> elective replacement in OR or w/ fluoro by IR
ChemoRx for small bowel adenoCA
folfox: leucourvin + 5FU + oxaliplatin
CT w/ evidence of “small bowel mass with concentric rings” … think?
intussusception
Intestinal hamartomas, think?
Peutz-Jeghers syndrome (high % will develop SBO 2/2 intussusception)
Radiation injury to small bowel appears as…? Cx?
grey/opaque lesions. vasculitis and fibrosis -> chronic, recurrent partial SBO (may be asymp for as long as 10yrs)
Surgery for tumors in terminal ileum
right colectomy bc ileocolic vessels will need to be sacrificed to resect nodal disease along this vascular pedicle
Factors of poor prognosis GIST
- > 10cm
- high mitotic rate
- arises from small bowel
- not favorable mutation (ie. not c-kit, not responsive to imatinib)
Small bowel vs. colonic distention on KUB
small -> valvulae conniventes (transverses small bowel) = Kerckring folds = plicae circulares
colonic -> haustra (does not transverse)
Small bowel lymphomas MC found where?
ileum (greatest concentration of gut-associated lymphoid tissue)
F/u elderly pt with acute appendicitis
colonoscopy 2-mo after discharge bc 5% risk colon CA
Carcinoid cancer arise from…?
enterochromaffin-like cells (AKA Kulchitsky cells)
How does competent ileocecal valve aid in prevention of short bowel syndrome?
reduces speed of small bowel transit -> aids in reabsorption of water, electrolytes, and nutrients
What is: Gambee suture?
interrupted single layer suture that causes inversion of mucosa during small bowel anastomosis
MC location for small bowel adenocarcinoma
duodenum
MCC idiopathic (no pathological lead point) intussusception in children?
hypertrophied Peyer patches (MC distal ileum)
Mgmt pt with appendicitis + inflammatory phlegmon
IV Abx (high morbidity rate for immediate surgery)
MCC malignancy related small bowel obstruction
carcinoid tumor
CT finding in carcinoid tumor
fibrosis in mesentery
Tx for carcinoid crisis
octreotide
Sxs of carcinoid crisis
- facial flushing
- diarrhea
- tachycardia
- arrhythmias
- hypotension
- mental status change due to release of serotonin
Suspect SMA syndrome when…
young person s/p rapid weight loss, presenting abd pain, N/V
Dx imaging characteristics for SMA syndrome
aortomesenteric angle <25 degrees (nl 38-65)
Mgmt SMA syndrome
medical. if fail, then dudoenojejunostomy.
For any obstructing NET (ie. carcinoid), should always have what kind of procedure in addition to tumor excision?
cholecystectomy bc high likelihood to use octreotide -> biliary stasis and cholecystitis
What is the Spigelman scoring system?
stage 0-4 for staging of duodenal polyps in pts wtih FPA (based on # polyps, polyp size, histological type, and severity of dysplasia)
Mgmt for Spigelman score 0-IV
0-1: q5yr EGD
2: q3yr
3: q1-2yr
4: Whipple (pancreas-sparing duodenectomy not effective)
Tx small bowel adenoCA
surgical resection of primary tumor + regional LN is only curative option. chemorad only for unresectable disease.
Operative Tx obstructing neuroendocrine tumor of small bowel (ie. carcinoid)
en-block resection with involved mesentery - bc 40-80% spread to mesenteric LN
Mgmt B-cell lymphoma (non-MALT) vs. T-cell lymphoma
B: if asymp, then chemoradiation (resect if symp)
T: always resection (chemoresistant and likely to progress to obstruction -> perf/bleed)
Breakdown of Spigelman score
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
MC congenital abnormality of the GI tract
Meckel diverticulum
MC symptom of Meckel diverticulum if symptomatic
majority asymptomatic
- children: painless GI bleeding
- adult: obstruction (#1), diverticulitis (#2)
Imaging CT: tubular distended cystic mass w/ wall calcification in RLQ adjacent to cecum
appendiceal mucocele
Why do appendiceal mucoceles need to be resected?
may harbor a cystadenocarcinoma
When do right hemicolectomy for appendiceal mucocele? (3)
- suspicion of nodal spread
- involvement of terminal ileum or cecum
- positive margins
MC primary surgical disease of the small bowel
Crohn’s
Can present as small bowel perf… what kind of mass?
small bowel lymphoma
Mgmt MALT in small bowel vs. stomach
stomach: tx H.pylori + resection
small bowel: resection only
Second MC site of diverticula formation in intestinal tract
duodenum
Duodenal diverticula are classified as either… or…? Difference in layers involved?
congenital (true - all layer involved) or acquired (pulsion - mucosa, submucosa, and muscularis mucosa through weakness in duodenal wall)
MC location duodenal diverticula in second portion
ampulla of Vatar (weakness in duodenal wall)
Mgmt contained duodenal perf in stable pt
nonop - NGT decompression + Abx + bowel rest w/ or wo endoscopically placed drains or stents
MC location of duodenal diverticulum
2nd portion of duodenum - most located near ampulla
Presentation of symptomatic duodenal diverticulum
Abdominal pain with pancreatitis and diverticula discovered on imaging/ERCP
Mgmt pancreatitis 2/2 duodenal diverticula
Open diverticulectomy and primary primary closure, after resolution of pancreatitis
Breakdown of how much fluid each GI section makes in one day (saliva, stomach, small bowel, biliary, pancreatic)
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)
Mgmt Crohn’s strictures at duodenum
gastrojejunostomy
MC malignant tumor of appendix
adenocarcinoma (MC overall tumor of appendix is carcinoid)
When should operative intervention be considered for EC fistula?
if persist after 6-weeks from formation
Metabolic derangement for pts with proximal EC fistula
acidosis (bc proximal fistula tend to be high in bicarb)
Obturator sign of acute appendicitis indicates…
(pain with internal rotation of thigh) pelvic appendix
Iliopsoas sign of acute appendicitis indicates…
(pain extension of thigh) retrocecal appendix
Pelvic appendicitis tends to have what hx and exam findings?
urinary symptoms and diarrhea (bladder and rectal irritation) + Obturator sign
Where in small bowel does protein absorption mostly occur?
jejunum
Cx early appendectomy for perforated appendicitis
increase risk bowel obstruction, wound infection, reoperation
Interval appendectomy should occur when?
6-8 weeks after insult
What Rx has shown results that it may aid in closure of fistulas in Crohn’s?
infliximab
What layer of intestinal wall is most important for strength in hand-sewn anastomosis?
submucosa - highest content of collagen fibers (tensile strength determined by collagen cross linking)
Appendicitis is MC in what trimester?
2nd
MC epithelial tumor of appendix
pseudomyxoma peritonei
MC presenting sxs of pseudomyxoma perionei (#1, #2)
#1: increasing abdominal girth #2: ovarian mass on pelvic exam (females); inguinal hernia +/- mucoid fluid (men)
Which IBD has rectal sparing?
Crohn’s
Mgmt mesenteric cyst
cyst enucleation
Mesenteric cyst thought to be 2/2…? Cyst contents?
2/2 structural abnormality of mesenteric lymphatic system - straw-colored (milky, if following fat ingestion), and proteinaceous contents
MC location mesenteric cyst
small bowel mesentery (TI is most common)
