Small Bowel Disorders Flashcards by Meg Dolohanty

what does the mesentery of the small bowel contain?

blood supply

lymphatics of the bowel

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what is the most common cause of small bowel obstructions?

postoperative adhesions then neoplasms and hernias

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what does Intusussception look like on CT?

target, bullseye

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what do you call not passing gas or stool

obstipation

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passing gas but not stool

constipation

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time where someone has a SBO but no distention

if it is really proximal

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SBO presentation

HPOTN, tachy, fever (septic)
sunken eyes, skin tenting, dry oral mucosa
abdominal distention
hernias, altered bowel sounds

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what will bowel sounds be like with an early SBO?

hyperactive

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what will bowel sounds be like with a late SBO?

hypoactive

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what do peritoneal signs w/ a SBO indicate?

strangulation (need emergency surgery)

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what does occult blood on a rectal w/ SBO suggect?

late strangulation or malignancy

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mass on rectal exam w/ SBO suggests what?

obturator hernia

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for a SBO what type imaging do you want?

three way of the abdomen

upright chest w/ supine and upright abdomen

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on CTabd/ pelvis (IV oral and contrast) what represents an SBO

Obstruction is present if the small-bowel loop is greater than 2.5 cm in diameter dilated proximal to a distinct transition zone of collapsed bowel less than 1 cm in diameter

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what indicates strangulation on a CT abd/ pelvis

bowel wall thickening
portal venous gas
pneumatosis

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air within the bowel wall

pneumoatisis

indicates some necrosis may be going on

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what Factors indicating higher risk of strangulation

Localized abdominal tenderness
Peritoneal signs
Fever or leukocytosis

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what are signs of complete obstruction

no stool or flatus for 12 hours

no air in rectum on imaging

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Tx for SBO

NGT placement for decompression and suction to decrease risk of aspiration
agressive fluid and electrolytes

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tx for adhesive SBO

most resolve w/o surgery (more surgery means more scar tissue)
NPO, NGT, IVF
serial exams, ask about passing gas

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Surgical for tx of adhesive SBO

lysis of adhesions

resect non-viable areas

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Tx of hernias

Reduce hernia then send them home and repair electively

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if a patient has a SBO and doesn’t have intrabdominal surgery or hernias what do you do?

exploratory laparoscopy/ laparotomy

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Results as a persistent remnant of the vitelline duct.

Meckel’s Diverticulum

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the rules of 2's w/ Meckel's diverticulum

Occurs in 2% of individuals, becomes symptomatic in 2% of cases, has 2 types of mucosa, and is found within 2 feet of the ileocecal valve, occurs 2x more often in males

imaging for Meckel's Diverticulum

upper GI, small bowel follow through

most common presentation of Meckel's Diverticulum in pediatrics

GI bleeding in pediatric patients | bleeding from ulceration of tissue adjacent due to gastric mucosa

second most common presentaiton of Meckel's diverticulum

diverticulus

presentation of meckel's diverticulum in adults

Obstruction most common presentation in adults secondary to herniation, intusussception, or torsion around a persistent omphalomesenteric band

how are most cases of meckel's diverticulum found?

incidentally at laparotomy for other indications

what is used to diagnose bleeding from a Meckel's diverticulum in a patient w/ GI bleeding and no upper or lower source

Tech-99 petechnetate scan

Tx for meckel's diverticulum

surgical resection if symptomatic or if reoperation would be challenging (adhesions)

Occlusion of the mesenteric vessels secondary to arterial thrombosis (1/3) emboli (1/3), nonocclusive etiology (NOMI) (1/3)- low flow states

Mesenteric ischemia

presentation w/ acute mesenteric ischemia

present suddenly, pain out of proportion of PE usually >60 and a long term smoker Hx of PVD, CAD or A-fib HPOTN, tachy

diagnostic for acute mesenteric ischemic (labs)

metabolic acidosis, lactic acid (late finding) | hemoconcentration

what may you see on an EKG w/ acute mesenteric ischemia

a-fib or signs of recent MI

what should you look for on echo w/ acute mesenteric ischemia

mural thrombus

gold standard for diagnosis of acute mesenteric ischemia

angiography

what will CT show w/ acute mesenteric ischemia

thrombus mesenteric venous gas pneumatosis intestinalis bowel wall thickening, dilation

what is the test of choice for mesenteric venous thrombosis?

CT abd/pelvis w/ 3D imaging

if not peritonitis w/ acute mesenteric ischemia what do you do?

anticoagulate

if peritionitis present w/ acute mesenteric ischemia what should you do?

Surgery, embolectomy or vascular reconstruction evaluate viability and resect as necessary 2nd look laparotomy 24-48 hours later to visually inspect anastomosis and remaining bowel for progressive ischemia

usually results from long-standing atherosclerotic disease of 2 or more mesenteric vessels

Chronic mesenteric ischemia (CMI)

pain after eating and fear of food

mesenteric angina

tx for chronic mesenteric ischemia

angioplasty +/- stent or bypass

are tumors of the small bowel common?

No, usually benign and found incidentally

cause of a small bowel bleeding, associated w/ Osler-Weber-Rendu syndrome

hemangiomas

Rare AD disorder characterized by mucocutaneous melanotic pigmentation and multiple gastrointestinal polyps The polyps are hamartomas and occur mostly in the jejunum and ileum May cause bowel obstruction and to a lesser extent, GI bleed increased chance of adenocarcinoma

Peutz-Jeghers Syndrome

what is the most common malignant tumor of the small bowel

adenoscarincomas

``` Slow growing neuroendocrine tumor Can be benign or malignant Appendix most common site Small intestine 2nd most common site May present with obstruction, pain, bleeding or carcinoid syndrome ```

carcinoid tumors

what is carcinoid syndrome

cutaneous flushing diarrhea bonrchoconstriction and right sided cardiac valvular dz

what will be elevated with carcinoid tumors?

elevated urinary 5-HIAA (serotonin)

tx for carcinoid tumors

surgical resection and debulking | octreotide (somatostatin)

Can be benign or malignant Can occur anywhere in the GI tract large ones are associated w/ complications such as GI hemorrhage, obstruction, bowel perf

Gastrointestinal Stromal Tumors (GISTs)

Tx for GISTs?

imatinib mesylate | radical and complete resection for best chance

10 – 15% malignant small bowel neoplasms Fatigue, malaise, weight loss and abdominal pain 25% present with perforation, obstruction intussusception or hemorrhage

lymphomas

tx for lymphomas of small bowel

surgery for diagnosis, staging, relief of obstruction and resection or debulking if mild obstruction- chemo

Chronic transmural inflammation | Can involve any area of the bowel – mouth to anus, most likely to involve the ileocecal region

Crohn's Disease

Age distribution of Crohn's Disease

bimodal most showing up 15=5 second peak 55-65

presentation of crohn's

``` diarrhea and abdominal pain N/V w/ obstruction pain is vague, aggrevated by eating periana disease- abscesses, fissues, fistulae RLQ tenderness/ mass ```

where are extraintestinal findings w/ Crohn's Dz

Skin, joints, mouth, eyes, liver, and bile ducts

routine labs for crohn's

CBC ESR CRP

what 2 tests are avaliable to attempt to differentiatie UC from Crohn's

p-ANCA- ulcerative colitis | ASCA- Crohn dz

diagnostics for Crohn's

CT, BE, small bowel follow through Enteroclysis (weight through nose to get dye in) upper and lower endoscopy capsulography

Tx for Crohn's

Medical antidiarrhea cholestyramine with terminal ileum involvement immune supression and modulation

who is surgery reserved for w/ someone w/ Crohn's

reserved for complications due to chronic nature of the disease and risk of short gut syndrome if too much small bowel resected over time

indications for surgery w/ Crohn's

``` Intractable disease Obstruction – fairly common due to fibrosis and stricture formation Fistula Abscess Perforation Hemorrhage ```