Small bowel pathology

Question 1

What is the toxic agent released from gluten?

Answer 1

Gliadin

Question 2

What are some of the symptoms of coeliacs disease?

Answer 2

General malaise/tiredness (?iron deficiency anaemia)
Diarrhoea 
Nausea 
Vomiting 
Bloating
Angular stomatitis 
Weight loss 
Oral ulceration
Osteomalacia

Question 3

What is coeliacs disease?

Answer 3

A T-cell mediated autoimmune disease in which the body has an adverse reaction to the breakdown products of gluten (gliadins)

Question 4

Which antibodies in coeliacs disease are produced in response to gliadins?

Answer 4

Anti-gliadin

Anti-endomysial

Question 5

What is the autoimmune antibody produced in coeliacs disease and what does it do?

Answer 5

Anti-endomysial antibody

Attacks the tissue transglutaminase resulting in the abnormal breakdown of gluten

Question 6

What changes in the small bowel wall occur in coeliacs?

Answer 6

Hypertrophy of crypts

Atrophy of villi

Question 7

Why does malabsorption occur in coeliacs disease?

Answer 7

There is atrophy of villi, therefore the surface area for absorption is greatly reduced

Question 8

What investigations should be done if a diagnosis of coeliacs is suspected?

Answer 8

Anti-endomysial antibody / anti-tTg antibody

Endoscopy and duodenal biopsy

Question 9

Why is the proximal small bowel most affected in coeliacs disease?

Answer 9

The concentration of gluten is highest here

Question 10

What are some of the common causes of abdominal artery ischaemia/occlusion?

Answer 10

Atherosclerosis
Embolism
Dissection
External compression by mass legions
Fibromuscular dysplasia

Question 11

What are some of the common sites of occlusion in abdominal artery ischaemia/occlusion?

Answer 11

Superior mesenteric
Celiac arteries
Bifurcation of the aorta

Question 12

What are some of the signs and symptoms of acute abdominal artery occlusion?

Answer 12

Severe, diffuse abdominal pain

In renal artery: sudden onset flank pain and haematuria

Question 13

What are some of the signs and symptoms of chronic bowel ischaemia?

Answer 13

Often asymptomatic - unless both superior mesenteric and celiac arteries occluded 
Intestinal angina
Abdominal bruit
Nausea 
Vomiting
Constipation
Dark stools

Question 14

In which condition might sublingual GTN be useful?

Answer 14

Bowel ischaemia for “intestinal angina”

Question 15

How is the diagnosis of chronic abdominary artery ischaemia made?

Answer 15

Based mainly on clinical findings

Angiography

Question 16

What are some causes of small bowel obstruction?

Answer 16

Adhesions
Hernaie
Tumours
Crohn's 
Volvulus
Gallstone ileus
Intersusception
Ischaemia
TB
Hair ball

Question 17

What types of hernia are there?

Answer 17

Inguinal
Femoral
Umbilical/paraumbilical
Epigastric
Incisional

Question 18

How might a small bowel obstruction present?

Answer 18

Colicky abdominal pain (often felt around umbilicus)
Vomiting - often provides pain relief
Abdominal distension
High pitched “tinking” bowel sounds

Question 19

What signs may be present in strangulation (complete bowel obstruction)?

Answer 19

Shock
Oliguria (low urine output)
No flatulence
Tender abdomen

Question 20

What investigations should be done if diagnosis of small bowel obstruction suspected?

Answer 20

History
Examination
Plain AXR

Question 21

Which sign on a supine AXR is the sign of a gallstone ileus?

Answer 21

Gas in biliary tree

Question 22

How might you differentiate between loops of small and large bowel on AXR?

Answer 22

Small bowel loops are the width of the lumen

Large bowel are not complete width

Question 23

How would you manage a small bowel obstruction?

Answer 23

NG tube for aspiration
Nil by mouth
Hydration
Electrolyte restoration
If unsettled - laparotamy

Question 24

In which patients might Meckel’s diverticulum present symptomatically?

Answer 24

Children

Question 25

What are some of the symptoms of Meckel’s diverticulum?

Answer 25

Rectal bleeding
Obstruction
Perforation

Question 26

How is the diagnosis of Meckel’s diverticulum made?

Answer 26

Technicium Tc 99M scan - detects ectopic gastric mucosa

Approximately 50% of symptomatic Meckel’s diverticula have ectopic gastric or pancreatic cells contained within them

Question 27

What is Meckel’s diverticulum an embryological remnant of?

Answer 27

A vestigial remnant of the omphalomesenteric duct

Question 28

What is the rule of 2’s of Meckel’s diverticulum?

Answer 28

Affects 2% of the population
Is approximately 2ft from the ileocaecal valve
Is a small pouch of roughly 2cm
2 types of common ectopic tissue (gastric and pancreatic)

Question 29

Why might small bowel ischaemia be confused with pancreatitis in investigation results?

Answer 29

Increased amylase