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Surgery > Small Intestine > Flashcards

Small Intestine Flashcards

1
Q

Primitive gut appears at the

A

4th week

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2
Q

Arises from junction of fore and midgut

Make up first 20cm

A

duodenum

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3
Q

Develops from proximal limb of midgut

A

Jejunum and upper part of ileum

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4
Q

Develops from caudal limb of midgut loop

A

Distal ileum

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5
Q

Midgut rotates at week

A

11

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6
Q

Midgut rotation

A

270 counterclockwise around SMA

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7
Q

Failure of duodenal recanalization

A

Duodenal stenosis or atresia

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8
Q

Layers of SI

A

Mucosa
Submucosa
Muscularis
Serosa

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9
Q

Layer that contains Brunner’s glands

Vessels, lymphs, myenteric plexus meissner

A

Submucosa

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10
Q

Produce alkaline secretion against gastric chyme

A

Brunner’s glands

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11
Q

Strongest layer in SI

A

submucosa

include in anastomosis

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12
Q

Remaining 5-6cm

A

Jejunum 40%

Ileum 60%

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13
Q

Differentiated by greater circumference, longer vasa recta and few arcades, longer and greater plicae circulares

A

jejunum

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14
Q

Villi on mucosal surface epithelium:

A

simple columnar with brush border

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15
Q

Arise from pluripotent cells of crypts in Lieberkuhn
Migrate to top of villi
95% of epithelium

A

Enterocyte

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16
Q

Base of crypts of Lieberkuhn

Phagocytosis, mucosal defense, regulation of flora, secretion of antimicrobial peptide

A

Paneth cell

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17
Q

Above Peyer’s

Specialized for APC

A

Microfold M cell

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18
Q

Specialized for mucous secretion

A

Goblet cell

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19
Q

Specialized to produce and secrete hormones (secretin, motilin, somatostatin, cholecystokinin, peptide YY, GLP2, GIP

A

Enteroendocrine

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20
Q

Arterial supply by SMA enters

A

Mesenteric side of jejunum and ileum

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21
Q

First to become ischemic after impaired blood supply

A

Mesenteric side of jejunum and ileum bec of SMA entry

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22
Q

Duodenum bs

A

Celiac artery

SMA

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23
Q

Jejunum and ileum BS

A

SMA

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24
Q

Venous drainage of SI

A

SMV

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25
Q

Parasympathetic innervation of SI

A

Vagus nerve

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26
Q

Sympathetic innervation of SI

A

Splanchnic nerve

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27
Q

Lymph drainage of SI

A

Regional mesenteric lymph node draining into cysterna chyli

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28
Q

Stimulates INTESTINAL epithelial proliferation

A

GLP2

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29
Q

Inhibits GI motility and GI secretion

A

somatostatin

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30
Q

Inhibits INTESTINAL ONLY motility and secretion

A

Peptide YY

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31
Q

Inhibits HCl secretion

A

GIP

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32
Q

Purpose of villi and microvilli

A

Inc surface area of SI making it principal site for digestion and absorption

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33
Q

Volume absorbed in SI each day

Transcellular Na creates osmotic gradient driving water absorption via tight junction and intercellular space

A

2/3 (6 out of 9) L

Na, Cl, K, Ca, Mg, iron and water jejunum

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34
Q

Glucose

Galactose transport

A

SGLT1 (apical brushborder)
GLUT2 (bloodstream)

Secondary active transport (cotransporter)

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35
Q

Fructose transporters

A

GLUT5 (apical brushborder)
GLUT2 (bloodstream)

Facilitated diffusion

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36
Q

Carbohydrate digestion primary location

A

Duodenum

Proximal jejunum

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37
Q

Carbohydrate absorbed forms

A

Monosaccharides

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38
Q

AA and Di and tripeptide transporters

A

Na/AA co transport

Di and tri peptides/H co transport

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39
Q

Site of primary protein digestion

A

Proximal jejunum

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40
Q

Absorbed form of protein

A

AA

Di and tripeptide

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41
Q

Lipid mode of transport

A

Monoglyceride and FFA via passive diffusion

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42
Q

Absorbed form of lipid

A

Monoglyceride/FFA

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43
Q

Primary location of lipid absorption

A

Duodenum

Proximal jejunum

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44
Q

Bile salt primary site of absorption

A

Ileum

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45
Q

Vitamins ADEK and H20 soluble (B,C,folate) are absorbed in

A

Jejunum

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46
Q

B12 absorbed in

A

ileum

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47
Q 
Key energy source for enterocyte
Dec uptake (stress) impairs defenses leading to
A

Glutamine

Bacterial translocation and sepsis

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48
Q

Also known as intestinal housekeeper

Key regulator hormone

A

MMC Migrating Myoelectric Complex

Motilin

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49
Q

Immune and barrier function of SI

A

Peyer’s patches
M cells for AP
B cells secreting IgA

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50
Q

Has more adaptive capacity

A

Ileum

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51
Q

Basal pacemaker rhythm of SI

A

interstitial cells of Cajal

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52
Q

Highly coordinated contraction moving contents through SI

Peristaltic reflex

A

Propulsive (propagating)

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53
Q

Mixing of contents (chyme, digestive enzyme) exposes contents to absorptive surface

Non propagating

A

Segmental

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54
Q

Pattern of contraction that occurs during fasting state
Conducts peristaltic contraction from distal stomach to ileum every 90-120 min
Controlled by enteric ns

A

Migrating myoelectric complex

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55
Q

Phase I MMC

A

Quiesence

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56
Q

Phase II

A

Irregular disorganized electrical and mechanical activity

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57
Q

Regular high altitude electric burst and contraction

A

Phase III

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58
Q

Enhances GI motility as agonist at motilin receptor

A

Erythromycin

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59
Q

Post op return of bowel function

A

SI 1 day
Stomach 2 days
Large intestine 3-5 days

60
Q

70, F
s/p Sigmoid colectomy

12 yrs prior crescendo-decrescendo abdominal pain, vomiting and dec passage of flatus and stool

Mx of SBO?

A

Clinical exam
CT scan
Most likely by adhesion

NPO
IV fluids
NGT

61
Q

Most common surgical disorder of SI

Accompanied by inc secretion dec absorption

A

SBO

62
Q

Complete obstruction where lumen is occluded proximally and distally
High risk of necrosis as inc intraluminal pressure may limit perfusion and result in ischemia

A

Closed loop obstruction

volvulus

63
Q

Most commonly caused by failure of peristalsis

Affects all ages

A

Non mechanical obstruction

paralytic ileus

64
Q

Causes of mechanical obstruction

A 
adhesion
neoplasm
hernia 
Crohn’s
Congenital anomaly
Gallstone ileus
Cystic fibrosis
Diverticular disease
SMA
foreign body stricture
volvulus
65
Q

Most common cause of pediatric SBO

A

hernia

66
Q

Crampy intermittent pain
Nonfeculent emesis
Scaphoid abdomen

A

Proximal SBO

67
Q

Pain with late and feculent emesis

A

Distal SBO

68
Q 
Abdominal sx
Cancer
Previous SBO
leukocytosis, hemoconcentration, hypochloremic hypokalemic metabolic alkalosis by emesis
lactic acidosis
A

SBO

69
Q

SBO dx

A

Abdominal series (supine, upright)

airfluid level, gasless colon, dilated SI loops >3cm in ladder-like pattern

70
Q

Higher sensitivity and specificity

A

CT scan

90% in series

71
Q

Useful in identifying etiologic factors and strangulation

A

CT: wall edema, portal venous gas, pneumatosis intestinalis, poor enhancement of SI)
will not show adhesion

72
Q

Most cases of partial SBO due to adhesions resolve in 48h

A

expectant management

73
Q

SBO tx

A

Fluid resuscitation
Electrolyte correction
Antibiotics if ischemic

74
Q

Partial SBO mx

A

IV
NPO
NGT

with serial abdominal exam and radiographs

avoid narcotics

75
Q

Operative intervention in SBO warranted if

A

Persistence beyond 5-7 days
Progresses to complete
Clinical status deteriorates (peritonitis, hemodynamic instability, fever, leukocytosis)

76
Q

Complete SBO mx

A

Early operative intervention to minimize mobidity and mortality

77
Q

Viability of SI may be assessed by

A

color
peristalsis
marginal arterial pulses

via fluorescein or Doppler

78
Q

SBO in Crohn’s tx

A

Nonoperatively with TPN
Treat Crohn’s if stable without peritonitis

SBO beyond 7 - 10 days, operative intervention

79
Q

Virgin abdomen SBO tx

A

operative intervention

rule out pathologic cause with follow up studies if resolves on its own

80
Q

Intraabdominal cancer SBO

A

adhesion or obstruction, adhesiolysis or bypass

if carcinoma, nonoperative

81
Q

Recent intraabdominal infection SBO tx

A

Pelvic or colorectal non operative 10-20 days

Risk of ischemia low but failure to improve with conservative course, operate

82
Q

2nd-4th decade
Ashkenazi Jews
Environmental exposure in genetically predisposed

Abd pain, diarrhea, fever, weight loss
Anywhere in GI tract but most commonly:

A

Crohn’s disease

Distal ileum 75% with B12 deficiency

83
Q

Crohn’s dx

A

CT scan

Upper GI with small bowel follow-through or endoscopy

84
Q

CT findings of Crohn’s

A 
Transmural inflammation
Skip lesion
Granuloma
Fissure
Creeping mesenteric fat
85
Q

Surgical indication for Crohn’s

A 
Failure of medical management
Development of obstruction #1 
Perforation
Perianal disease
Abscess
Fistula
Toxic megacolon

FATPOP

86
Q

POD6 s/p ileal resection for Crohn’s
45, M
Low grade fever, vague abdominal pain, ileus
Wound is erythematous with feculent discharge

Appropriate work up?

A

Enterocutaneous fistula

NGT
NPO
initiate TPN
protect skin

Confirm with fistulogram and identify abscess with CT

Initiate 4-6w course conservative management
Drain abscess
Start antibiotics if septic

87
Q

communication between two epithelial lined surface

A

Intestinal fistula

88
Q

Low fistula

A

<200 ml

89
Q

Moderate fistula

A

200-500 ml daily

90
Q

High fistula

A

> 500 ml daily output

91
Q

Fistula in 5-6d post op

Low grade fever, abdominal pain and ileus

A

Phase I

Recognition, resuscitation, skin protection and drainage control

92
Q

Does not improve spontaneous closure rate but may dec output

A

Somatostatin

93
Q

After 7-10 days diagnostic options include CT scan to identify drainable abscess or fistulogram (anatomy)
Abscess should be drained

A

Phase II

Investigation

94
Q

If fistula fails to close spontaneously over 4-6w period
Operative repair necessary
30-50%

A

Phase III

Conservative management and decision making

95
Q

Extensive adhesiolysis or resection of involved area
G or J tube might be necessary for decompression or enteral feeding
Close fascia tension-free

A

Phase IV

Operative repair

96
Q

Enteric feeding should advance gradually to goal

A

Phase V

Healing

97
Q

95% of fistulas occur

A

after surgical procedure

98
Q

Impede closure of fistulas

A 
Foreign bodies
Radiation
Inflammatory bowel/infection
Epithelialization
Neoplasm
Distal obstruction
Sepsis
99
Q

Factors with higher chance of spontaenous closure

A

favorable location
favorable initiating factor
absence of infection or malnutrition
healthy bowel, small nonepithelialized defect with tract >2cm in length

100
Q

Mortality in fistula is due to

A

sepsis

101
Q

Congenital true diverticula

A

Meckel

Duodenal wind-sock diverticula

102
Q

Present in adult as SBO

Managed conservatively

A

Meckel’s

103
Q

Outpouchings at site of vessels

Involve mucosa, submucosa and from abnormality in motility

A

False diverticula

104
Q

Most SI diverticula are

A

asymptomatic

105
Q

Sx for diverticular complication

A

Diverticulectomy with patch or Roux-en-Y duodenojejunostomy if large
Duodenal diverticulization
Resection of affected segment with anastomosis

106
Q

1% of retrograde ERCP

Asymptomatic to peritonitis with shock

Dx confirmed by CT revealing retroperitoneal or free intraperitoneal air

NPO, NGT, abdominal series and IV antibiotics if mild
Lap if unstable

A

Post ERCP duodenal perforation

107
Q

Majority of SI diverticula are found in

A

jejunum

108
Q

Comprise about 2% of GI malignancies

5th-6th decades

A

SI neoplasm

109
Q

Benign SI tumors are commonly

A

adenoma on duodenum

may be associated with FAP

110
Q

Most common SI malignancy

Found on

A

Adenocarcinoma

duodenum: inc risk with Crohn’s, FAP, HNPCC

111
Q

Less frequent than appendiceal lesion found within 2ft of ileocecal valve

A

Carcinoid

112
Q

May be primary or disseminated disease
B cell are most common primary

Affects the:

A

Lymphoma

Ileum

113
Q

Rf for lymphoma

A

Immunosupression (posttransplant lymphoprolif disorder, AIDS, celiac sprue, Crohn’s)

114
Q

Less frequent than gastric lesion

A

GIST

115
Q 
Include melanoma
Lung
Renal cell
Pancreatic
Breast gastric
A

Metastases

116
Q

Most common primary SI malignancy

A

Adenocarcinoma
Carcinoid
Lymphoma
Stromal tumor

ACLS

117
Q

Anemia

Guaiac + stool

A

Adenocarcinoma SI

118
Q

Carcinoid patients have increased

A

5-HIAA or chromogranin A

119
Q

SI carcinoma dx

A

EGD proximal lesion
Enteroclysis (diagnosis)
CT scan

120
Q

80% of SI adenocarcinoma have

A

metastases at time of diagnosis

121
Q

SI adenocarcinoma

A

No role for chemoradiation except lymphoma

122
Q

AD
associated with hamartoma of small and large bowel
mucocutaneous hyperpigmentation

Also assoc with increased risk of malignancies (gastric, esophageal, pancreatic, breast, endometrial, testicular, lung)

A

Peutz-Jeghers

123
Q

Surveillance for Peutz-Jeghers

A

EGD and colonoscopy every other year beginning in adolescence as well as UTS, mammography, breast, gyne and testicular exam

124
Q

Peutz Jeghers sx

A

Hemorrhage
Obstruction
Adenomatous lesion

125
Q

Any age group
Extensive resection

Pediatric: nec enterocolitis, midgut volvulus, intestinal atresia, gastroschisis

Adult: Crohn’s, mesenteric ischemia, trauma, malignancy, radiation enteritis

A

Short bowel syndrome

126
Q

Clinical syndrome of SBS occur with

A

<200cm of jejunoileal length

= 30% normal jejunoileal length for age

127
Q

SBS dx

A

Hx of extensive resection or abdominal catastrophe

Albumin, LFT, electrolyte, Hct, vitamin levels, fecal fat (Sudan stain), gastrin

128
Q

SBS mx

A 
Fluid and electrolyte 
Nutritional support with TPN
H2 blocker or PPI
Anti diarrheal agents (diphenoxylate, loperamide)
Antibiotics
Enteral introduction
129
Q

SBS sx

A

Nontransplant procedure to inc bowel length, absorptive capacity, transit time

130
Q

Prolonged TPN may lead to

A

Liver failure

Cholangitis

131
Q

Placed through rectal muscle away from belt line in area easily visualized and assessed by patient

A

Intestinal ostomy

132
Q 
For protection of anastomosis
Temporary
Diarrhea, skin irritation
Dehydration, electrolyte imbalance
Necrosis, obstruction, stenosis, retraction, prolapse, parastomal hernia
A

Loop ileostomy

Divided loop ileostomy

133
Q

Decompression of distal (neoplasm) diversion after distal resection
Permanent or temporary
Diarrhea, dehydration, electrolyte imbalance, necrosis, obstruction, stenosis, retraction, prolapse, parastomal hernia

A

Brooke end ileostomy

134
Q

Decompression of distal (neoplasm) diversion after distal resection
Permanent or temporary
Valve dislodgement
Incompetence, pouchitis, diarrhea, dehydration electrolyte imbalance, necrosis, retraction, parastomal hernia, prolapse

A

Kock continent ileostomy

135
Q

Decompression of distal protection of low anastomosis
Treatment of perforation
Diversion after resection
Permanent or temporary
Necrosis, parastomal hernia, prolapse, obstruction

A

Colostomy (end, double barrel or loop, mucuous fistula)

136
Q

Most likely malignancy of duodenum

A

Adenocarcinoma

137
Q

Most likely malignancy of ileum

A

Carcinoid

138
Q

Peutz Jeghers is associated with the mutation of

A

STK11 ch19

139
Q

Determines mortality in eterocutaneous fistula

A

Site of origin
Output
Complication

15-20%

140
Q

Most common cause of SI hemorrhage in

adult

children

A

AVM

Meckel’s

141
Q

55, M
Cholecystectomy with incidental Meckel

Indication for resection

A

Resection not indicated for asymptomatic adult

Perform diverticulectomy for complication:
bleeding, diverticulitis, obstruction

142
Q

Factors that influence adaption after SBS

A

Luminal nutrient
Hormones
Growth factors
Enteral feeding

143
Q

Exploration for AA reveal normal appendix, thickened and erythematous terminal ileum and creeping fat

Dx?

Mx?

A

Crohn’s

If appendiceal stump not involved, perform appendectomy but do not resect ileum

144
Q

Most common indication for surgery in Crohn’s

A

Obstruction

145
Q

After extensive SI ileocecal valve resection for AMI with necrosis, patient develops diarrhea and malnutrition

What is initial medical management?

A

SBS

Fluid resusc
TPN
H2 blocker or PPI
Antidiarrheal agents

Surgery (17 decks)

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