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Surgery > Small Intestine > Flashcards

Small Intestine Flashcards

1
Q

What is the most retroperitoneal part of the small intestine?

A

Duodenum

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2
Q

[Segment of the small intestine]

wider in diameter, thicker wall, more vascular, less fatty, fewer arcades, longer vasa recta

A

jejunum

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3
Q

Vitilline duct is obliterated at what age of gestation?

A

6 weeks AOG

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4
Q

Age of gestation wherein there is extracoelomic herniation

A

5th week AOG

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5
Q

What is the anatomic marker for the intestinal 270 degree counterclockwise rotation?

A

superior mesenteric artery

10th week AOG rotation

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6
Q

What is the most common surgical disorder of the small intestine?

A

mechanical small bowel obstruction

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7
Q

What is the most common cause of mechanical small bowel obstruction?

A

adhesions

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8
Q

Most common cause of congenital adhesions?

A

Ladd or Meckel bands

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9
Q

Proximal obstruction suggests that the regions involved are ____

A
  1. Pylorus
  2. Duodenum
  3. Proximal jejunum
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10
Q

What are the cardinal signs on small bowel obstruction?

A
  1. Vomiting
  2. Obstipation
  3. Distention
  4. Crampy/colicky abdominal pain
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11
Q

What are the triad of radiographic findings in SBO?

A
  1. Dilated small bowel loops >3cm
  2. Air-fluid level
  3. Paucity of air in the colon
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12
Q

Mucosal thumb printing in radiographic findings in strangulated SBO is indicative of

A

bowel edema

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13
Q

What is the gold standard to to differentiate partial from complete obstruction?

A

Small Bowel Series

Delay in passage of contrast and caliber change at site of obstruction

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14
Q

What are the contraindications to non-operative management of small bowel obstruction?

A
  1. Suspected Ischemia
  2. Large bowel obstruction
  3. Closed loop obstruction
  4. Strangulated hernia
  5. Perforation
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15
Q

After ingestion of 100mL water soluble contrast through NG in a patient with adhesive SBO with no signs and symptoms of intestinal ischemia, when will you do a KUB xray?

A

after 8 hours

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16
Q

After ingestion of 100mL water soluble contrast through NG in a patient with adhesive SBO with no signs and symptoms of intestinal ischemia, when will you do a consider surgery?

A

if the contrast has not reached the colon after 72 horus

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17
Q

Most common cause of intestinal fistulas?

A

post-operative complications

Enterotomies, anastomotic leaks

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18
Q

A high output physiologic fistula has an output of that is more than?

A

> 500mL

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19
Q

How many percent of intestinal fistula close spontaneously after 2 months?

A

10%

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20
Q

What are the anatomic features that favors spontaneous intestinal fistula closure?

A
  1. Continuity maintained
  2. End fistula
  3. No associated abscess
  4. Free flow distally
  5. Duodenal stump
  6. Jejunal
  7. Tract >2cm
  8. Defect <1cm
  9. optimal nutritional status
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21
Q

What are the anatomic features that makes spontaneous closure of intestinal fistula unfavorable?

A
  1. Complete disruption
  2. Lateral fistula
  3. Associated abscess
  4. Diseased adjacent bowel
  5. Distal obstruction
  6. Lateral duodenal
  7. Ileal
  8. Tract <2cm
  9. Defect >1cm
  10. Poor nutritional status
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22
Q

What are the factors that inhibit spontaneous closure of fistulas?

A
  1. Foreign body within fistula tract
  2. Radiation enteritis
  3. Infection
  4. Neoplasm at fistula origin
  5. Distal obstruction of the intestine
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23
Q

If the fistula fails to close at ____ month, surgical intervention is warranted

A

2-3 months

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24
Q

When is the most favorable time to re-operate an intestinal fistula?

A
  1. Within 10 days of diagnosis

2. After 4 months

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25
Q

[Surgical intervention for small bowel neoplasm]

Duodenal adenoma that is <2cm

A

endoscopic polypectomy

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26
Q

[Surgical intervention for small bowel neoplasm]

duodenal adenoma that is >2cm

A

transduodenal polypectomy or segmental resection or pancreaticoduodenectomy

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27
Q

[Surgical intervention for small bowel neoplasm]

jejunal or ileal tumor

A

segmental resection with 5cm of tumor-free proximal and distal margins

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28
Q

What is the ODC for unresectable metastatic GIST?

A

Imatinim (Gleevec)

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29
Q

What is the most prevalent congenital anomaly of the GIT?

A

Meckel diverticulum

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30
Q

What is the rule of two’sin Meckel diverticulum?

A

2% of the population
2:1 male predominance
2 feet proximal to ICV
2 years old (1/2 of symptomatic)

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31
Q

What is the etiology of meckel diverticulum?

A

persistence of vitilline/ omphalomesenteric duct

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32
Q

What is the surgical management for symptomatic meckel diverticulum?

A
  1. Diverticulectomy (wedge resection)
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33
Q

What is the most common cause of mesenteric ischemia?

A

arterial embolus

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34
Q

Mesenteric ischemia due to venous thrombosis usually affects what vein?

A
  1. SMV
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35
Q

How will you medically manage non-occlusive mesenteric ischemia?

A

Mesenteric vasodilator - Papaverine infusion

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36
Q

What is the diagnostic modality of choice for arterial mesenteric ischemia?

A

CT scan/Angiography

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37
Q

What is the diagnostic modality of choice for venous mesenteric ischemia?

A

US duplex scan

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38
Q

[Diagnosis and surgical management]

intermittent vomiting, abdominal distention and tenderness, melena

AbXR: bowel loops spiraling about the axis of the mesenteric vessels

UGIS: abnormal C loop of duodenum

Barium enema: cecum at RUQ

A

Malrotation

Ladd procedure - untwisting of the bowels, divide ladd bands, incidental appendectomy

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39
Q

[Diagnosis and surgical management]

intermittent, colicky, abdominal pain, vomiting lethargy, sausage-shaped mass, currant jelly stools

UTZ: two rings of low echogenicity separated by a hyperechoic ring

A

Intussusception

  1. Air then hydrostatic reduction via Barium enema
40
Q

___ sign refers to the absence of bowel in the RLQ associated with intusussception

A

Dance sign

41
Q

[Diagnosis and surgical management]

Feeding intolerance, maternal polyhydramnios, bilious emesis, abdominal distantion, non-passage of meconium in the first day of life

AbXR: dilated bowel loops with differential air-fluid level

Barium enema: microcolon

A

Intestinal atresia

Resection of proximal bulbous bowel and atretic segment and primary end-to-end anastomosis

42
Q

[Diagnosis and surgical management]

Feeding intolerance, bilious emesis, family history of cystic fibrosis, abdominal distention

AbXR: gas filled loop

Barium Enema: microcolon and inspissated meconium

A

Meconium ileus

  1. Ileostomy with mucus fistula
  2. Ileostomy take down after 2 to 3 weeks
43
Q

Double bubble sign is usually seen in?

A

duodenal obstruction

44
Q

Eggshell pattern is seen in?

A

meconium ileus

45
Q

What is the most common and lethal GI disorder affecting a preterm neonate?

A

necrotizing enterocolitis

46
Q

What is the indication for surgery in patients with necrotizing enterocolitis?

A

Pneumoperitoneum

47
Q

What is the remnant length of the small bowel of adults that warrants a permanent parenteral nutrition therapy?

A

Length <120cm if without colon in continuity

Length <60cm if with colon continuity

Children:
Length less than 30cm

48
Q

What is the normal small bowel length in adults?

A

300 to 600cm

49
Q

What is the normal small bowel length in full term infants?

A

200 to 250cm

50
Q

What is the most common subtype of short bowel syndrome?

A

Type 2

small bowel resection with partial colon resection and resulting entero-colonic anastomosis

51
Q

What type of short bowel syndrome is the most challenging to manage?

A

Type 1

small bowel resection with high-output jejunostomy

52
Q

What type of short bowel syndrome that is best tolerated with the most adaptive potential?

A

Type 3

small intestine resection with small bowel anastomosis and intact colon

53
Q

What are the adaptive changes in patients with short bowel syndrome?

A
  1. Elongation and dilation of the small bowel
  2. Hyperplasia of the mucosal epithelium
  3. Increase in villous height, crypt depth, cell proliferation, enzyme activity
54
Q

What is teh most potent intestinotrophic hormone?

A

Glucagon-like peptide-2 (GLP-2)

55
Q

What is the surgical management of choice to improve the intestinal function and motility to maximize remnant intestine?

A

autologous intestinal reconstruction surgery

56
Q

What is the surgical management of choice to increase the absorptive area of the short bowel?

A

Longitudinal intestinal lengthening and tailoring (LILT/Bianchi STEP)

57
Q

What are the contents of the mesoappendix?

A

Vessels and nerves

58
Q

What is the landmark used to identify the location of the appendix?

A

Anterior taenia

59
Q

The appendiceal artery is a branch of ____-

A

posterior cecal branch of the ileocolic artery

60
Q

what is the most common location of the tip of appendix?

A

retrocecal

61
Q

What is the most common cause of acute surgical abdomen?

A

Acute appendicitis

62
Q

What is the most constant clinical manifestation in patients with acute appendicitis?

A

anorexia

63
Q

What is the prime symptom in patients with acute appendicitis?

A

RLQ pain

64
Q

___ point is suggestive of acute appendicitis wherein the right third point of the interspinal line is tender

A

Lanz point

65
Q

___ point is suggestive of acute appendicitis wherein the right side below the umbilicus is tender

A

Kummel point

66
Q

[Special signs on PE of Acute Appendicitis]

referred pain or feeling of distress in epigastrium or precordial region on continued firm pressure over the mcburney poin

A

Arron sign

67
Q

[Special signs on PE of Acute Appendicitis]

sharp pain elicited by pinching appendix between thumb of examiner and iliacus muscle

A

bassler sign

68
Q

[Special signs on PE of Acute Appendicitis]

transient abdominal wall rebound tenderness

A

Blumberg sign

69
Q

[Special signs on PE of Acute Appendicitis]

exacerbation of pain when the uterus is shifted to the right side

A

Bryan sign

acute AA in pregnancy

70
Q

[Special signs on PE of Acute Appendicitis]

pain in areas supplied by T10, T11, T12 on the right

A

Cutaneous hyperesthesia

71
Q

[Special signs on PE of Acute Appendicitis]

increased abdominal pain on coughing

A

Dunphy sign

72
Q

[Special signs on PE of Acute Appendicitis]

migration of pain from the umbilical region to the right iliac region

A

Kocher Sign

73
Q

[Special signs on PE of Acute Appendicitis]

grimace when examiner performs a firsm swish with index and middle finger across abdomen from epigastrium to right iliac fossa

A

Massouh sign

74
Q

[Special signs on PE of Acute Appendicitis]

tenderness in RLQ increases when patient moves from supine position to a recumbent posture on the left side

A

Rosenstein sign

75
Q

[Special signs on PE of Acute Appendicitis]

Pain at RLQ when palpatory pressure exerted at LLQ

A

Rovsing Sign

76
Q

[Special signs on PE of Acute Appendicitis]

Patient lies on left side , examiner slowly extends right thigh, stretching the iliopsoas muscle

A

Ilopsoas sign

Positive if extensions produces pain

77
Q

[Special signs on PE of Acute Appendicitis]

Passive internal rotation of the flexed right thigh with the patient in supine position

A

Obturator sign

positive if with hypogastric pain on stretching the obturator internus muscle

78
Q

[Special signs on PE of Acute Appendicitis]

Increased abdominal muscle tone ont he exceedingly gentle palpation of right iliac fossa

A

Summer sign

79
Q

[Special signs on PE of Acute Appendicitis]

pain caused by gentle traction fo the right spermatic cord

A

Ten Horn Sign

80
Q

What are the components of your alvarado score?

A

MANRELS

1 Migratory RLQ pain
1 Anorexia
1 Nausea/vomiting
2 RLQ tenderness
1 Rebound tenderness right iliac fossa
1 Elevation in temperatire
2 Leukocytosis
1 shift to the left of neutrophils
81
Q

What are the direct signs of acute appendicitis in UTZ?

A
  1. Non-compressible appendix
  2. Diameter >6mm
  3. Single wall thickness >/ 3mm
  4. Target sign
  5. Appendicolith
82
Q

What are the indirect signs of acute appendicitis in UTZ?

A
  1. Free fluid surrounding appendix
  2. Local abscess formation
  3. Increased echogenicity of local mesenteric fat
  4. Enlarged local mesenteric LN
  5. Thickening of the peritoneum
  6. Signs of secondary small bowel obstruction
83
Q

What are the CT scan criteria for Acute appendicitis?

A
  1. Diameter >6mm
  2. Wall thickness >2mm
  3. Periappendiceal inflammation
  4. Presence of fecalith
  5. Thickened cecum funneling contrast toward appendiceal orifice
84
Q

Ruptured appendicitis is common in what age group?

A

Pediatric and geriatric age group

85
Q

What are the most common findings in erroneous diagnosis of AA?

A
  1. Acute mesenteric lymphadenitis
  2. No organic pathologic condition
  3. Acute PID
  4. Twisted ovarian cysts
  5. Ruptured Graafian follicle
  6. AGE
86
Q

What is the most common extrauterine surgical emergency?

A

Appendicitis in the pregnancy

87
Q

When can you do a conservative management in patients with complicated appendicitis?

A
  1. Confined abscess or phelgmon

2. Limited peritonitis

88
Q

What is a Valentino appendicitis?

A

RLQ pain from perforated peptic ulcer

89
Q

What are the indications of incidental appendectomy?

A
  1. Children about to undergo chemotherapy
  2. Disabled individuals
  3. Crohn disease
  4. Individuals about to travel to remote places
90
Q

What is the most common site of GI carcinoid?

A

Appendix

Carcinoid - Best prognosis

91
Q

What will be your management for a 3cm appendiceal carcinoid?

A

Right hemicolectomy

Remember, >2cm appendiceal carcinoid, Right hemicolectomy

92
Q

What will be your management in a patient with 1.5cm appendiceal tumor at the mid of appendix?

A

Appendectomy

Remember, appediceal tumor >1 or 2cm in the tip and mid appendix, do appendectomy

93
Q

What will be your management in a patient with 1.5cm appendiceal tumor at the base of appendix?

A

Right hemicolectomy

Remember, appediceal tumor >1 or 2cm in the base of appendix, do right hemicolectomy

94
Q

Type of Appendiceal CA that is rare and has the worst survival

A

Signet ring CA

Tx: Right hemicolectomy

95
Q

___ refers to diffuse collection of gelatinous fluid and mucinous implants on peritoneal surfaces and omentym

A

Pseudomyxoma peritonei

96
Q

What is the CT scan finding of appendiceal lymphoma?

A
  1. Diameter >2.5 cm

2. Surrounding soft tissue thickening

Surgery (19 decks)

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