Small Bowel Flashcards by Fatema Arastu

How does small bowel get its blood supply

From superior mesenteric artery

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Drainage of small bowel

superior mesenteric vein, which drains into portal vein, into liver

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Lymph drainage of small intestine

Goes through regional lymphatics to the cisterna chyli

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Small intestine innervation

Parasympathetic nerves from right vagus, sympathetic nerves from greater and lesser splanchnics (visceral pain)

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Layers of small intestine from lumen outwards

Mucosa, submucosa, muscularis, serosa

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What does mucosa layer of small intestine contain

plicae circulares, villi, microvilli, crypts of lieberkuhn

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which layer of small intestine contains the nerves and blood vessels? Is also the strongest layer

submucosa

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Muscularis layer of small intestine contains…

both longitudinal and circular muscles

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As you go from jejunum to ileum, what changes occur?

vascular arcades become more complex, lumen narrows, and circular mucosal folds become shorter and fewer

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IBD major divisions

Crohn’s dz and ulcerative colitis

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What are independent risk factors for crohn’s disease

smoking and high sugar

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Which site is most frequently affected in Crohn’s disease

terminal ileum

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Skip lesions seen in Crohn’s or UC?

Unique to Crohn’s

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Creeping fat sign unique to…

Crohn’s disease

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Patient presents wtih diarrhea, recurrent acute abdominal pain, anorectal lesions, anemia, malnutrition. Abdomen pain releived by defecation. Thickened bowel wall, stricture formation, “creeping fat,” in mucosa- pinpoint hemorrhages, cobblestoning, aphthous ulcers. Malaise, weight loss, fever. Systemic manifestations include pyoderma gangrenosum, uveitis, bone and joint lesions, pericarditis, Dx?

Chrohn’s

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Signs and symptoms in Crohn’s

MACARDS- malnutrition, anemia, constitutional symptoms, anorectal lesions, recurrent and acute abdominal pain, diarrhea, and systemic manifestations

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diarrhea in Crohn’s

continuous or intermittent. If non-bloody, SB involved. If bloody, think colon.

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abdominal pain in crohn’s

chronic pain- mild, following meals, in low mid abdomen, relieved by defecation. acute pain- RLQ- TI involved usually

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Acute RLQ pain in crohn’s mimics..

appendicitis

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constitutional effects in crohn’s

lassitude, malaise, weight loss, fever

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anorectal lesions in crohn’s

chronic anal fissures, large ulcers, edematous skin tags, complex fistulas, and recurrent peri-rectal abscesses

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anemia in crohn’s

iron deficiency anemia, macrocytic anemia, vitamin B12 or folate deficiency. May see angular cheilitis

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signs of malnutrition in crohn’s

steatorrhea, chronic partial obstruction, decreased oral intake (hurts when eating), vitamin D and zinc deficiency common, protein-losing enteropathy, growth retardation in children

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Labs in Crohn’s

Prometheus test for IBD. tests for antibodies include ASCA, I2, ompC, CBir1 which will be elevated in Crohn’s. pANCA higher in UC

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Xray signs of Crohn's

String sign- stricture through segment of small bowel. and cecal narrowing

Medical tx in crohn's

aminosalicylates, anti-TNF alpha, antibiotics, immunosuppressives, steroids

Key guideline when performing surgery in crohn's

preserve intestinal length- only take out what is absolutely necessary. If take too much out, patient will be on TPN (total parenteral nutrition) forever

Crohn's has no surgical or medical cure. T or F?

TRUE!

Acute form of colonic distension in which colon dilates and perforates

Toxic megacolon

What other anatomical part of GI tract is also involved in UC besides colon?

Rectum usually involved

Backwash ileitis may be observed in...

Diagnosis of UC by

Endoscopy- loss of vascular pattern, granularity, friability, hyperemia, ulceration. no patches of normal mucosa. Barium enema can help diagnose- "lead pipe" - loss of haustral markings, pseudopolyps, fine serrations

apple core lesion -

stricturing in UC should raise suspicion of cancer

Truelove and Witt classification

classifies UC severity

How many stools per day are mild, severe, vs. fulminant

Less than 4 stools/day= mild UC. More than 6/day, severe diarrhea. More than 10 day, fulminant diarrhea

Medical tx of UC

Avoid NSAIDS, lactose. Sulfasalazine, steroids.

Indications for Surgical tx of UC

acute severe disease that doesn't respond to medical tx, emergently in perforation, urgently in toxic megacolon, hemorrhage, refractory fulminant colitis

What are Ladd's bands

Congenital bands often discovered during infancy. Occur with malrotation causing obstruction of small bowel

Most common surgical disorder of the small intestine due to

obstruction

Mechanical obstruction of small bowel

Simple obstruction, strangulation, and closed loop obstruction

Causes of small bowel obstruction

A New FIV Hurray Voila!- volvulus, cystic fibrosis, adhesions, neoplasm, stricture, foreign bodies, Gallstone ileus, Hernia, hematoma, IBD, intussusception

Most common cause of small bowel obstruction

adhesion- caused by inflammation of the abdomen or by surgery

"Target sign" on CT indicative of

intussusception in adults

intussusception more common in which population

children.

Tx of intussusception in children

Barium enema- diagnostic and tx

Most common site of foreign body small bowel obstruction is...

ileocecal valve

Patient presents with vomiting, abdominal pain, and obstipation. She has high pitched bowel sounds, peristaltic rushes, gurgles, tympanitic percussion, and distension. Tachycardia, dehydration. Xray shows air fluid levels and stair stepping. Amylase elevated, hemoconcentration, electrolyte abnormalities, leukocytosis. Dx?

smal bowel obstruction

proximal vs. distal SBO differences in vomiting, obstipation, and abdominal pain

vomiting in Proximal SBO occurs early and is profuse, obstipation late. distal SBO- vomiting late and feculent, obstipation early

SBO tx

NGT, IVF, NPO, pain control. complete SBO- surgery. partial SBO- bowel rest.

Patient presents with severe continous pain, hematamesis, peritoneal signs on exam, leukocytosis, lactic acidosis. Bowel blocked in 2 places. Dx

Closed loop obstruction

Patient with sudden severe diffuse abdominal pain but physical exam is normal. CT also negative. could be..

acute mesenteric ischemia

Gastroenteritis tx

Viral- so NO ABX. stool studies, hydration, replace electrolytes, avoid anti-diarrheal medication

Most common small bowel benign tumors

adenomas

Most often found benign small bowel tumors (most symptomatic)

GIST (like leiomyomas and leiomyosarcomas)

Most common primary malignant small bowel tumor

adenocarcinoma

What predisposes someone to primary SB lymphoma in proximal jejunum?

celiac disease

Small bowel malignant neoplasms

primary malignant tumors, metastatic malignant tumors, and carcinoid tumors

carcinoid small bowel neoplasms arise from... and associated wtih....

arise from enterochromafin cells. associated with MEN type 1 and 2

what is most common site in carcinoid small bowel neoplasms

appendix

10% of patients with carcinoid tumor have "carcinoid synrdrome" which includes

bronchoconstriction, diarrhea, flushing, and R sided heart valve disease from collagen deposition

Which carcinoid tumors would you more likely see carcinoid syndrome in?

Ovarian, bronchail carcinoids, and hepatic metastases more than intestinal carcinoids- circulation related

How to test for lactose intolerance

Lactose breath test OR give 100g oral lactose, check blood glucose every 30 min x 2 hours to see if it rises more than 20mg/dl over that time

Tx of lactose intolerance

lactose free diet, supplementation of vitamin D, calcium, and riboflavin

tx for celiac disease

gluten free diet

diagnosis of celiac disease

igA endomysial antibodies, igA tTG antibodies

What part of GI tract does celiac disease damage?

Diffuse damage to proximal SB