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Surgery Finals 2nd Sem > Small Intestine Part 1 > Flashcards

Small Intestine Part 1 Flashcards

1
Q

Embryology

The duodenum arises from the

A

Junction of the foregut and midgut

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2
Q

Embryology

The jejunum and upper part of the ileum develop from

A

Proximal limb of the midgut loop

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3
Q

Embryology

The distal ileum develops from the

A

Caudal limb of the midgut loop

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4
Q

Microscopic anatomy

Mucosa

A

Epithelium
Muscularis mucosa
Lamina propia

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5
Q

Microscopic anatomy

Submucosa

A

Blood vessels
Lymphatics
Myenteric meissners plexus

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6
Q

Microscopic anatomy

Produce an alkaline secretion to protect against acidic gastric chyme

A

Duodenal brunners gland

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7
Q

Microscopic anatomy

Lymph node aggregates called___________ are most prevalent in the ileum

A

Peyers patches

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8
Q

Layers of the small intestine

Muscularis

A

Inner - circular
Outer - longitudinal layers
Between - myenteric auerbach’s plexus

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9
Q

Layers of the small intestine

Single layer of mesoepithelial cells lining the exterior of the SI

A

Serosa

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10
Q

Layers of the small intestine

Mucosa

A

Epithelium
Lamina propria
Muscularis mucosa

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11
Q

Layers of the small intestine

Sub mucosa

A

Meissners plexus

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12
Q

Layers of the small intestine

Muscularis propria

A

Circular muscle
Auerbach’s plexus
Longitudinal muscle

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13
Q

Layers of the small intestine

The strongest layer of the small intestine
This should be included when performing intestinal anastomoses

A

Submucosa

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14
Q

Specific cells

Arise from pluripotential cells in the crypts of Liberkuhn and migrate to the tips of villi

A

Enterocytes

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15
Q

About 95% of the epithelial cells are enterocytes and it is specialized for

A

Digestion and absorption of dietary nutrients

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16
Q

Specific cells

Found at the base of the crypts of lieberkuhn
Function include, phagocytosis
Mucosal defense
Regulation of intestinal flora
Secretion of variety antimicrobial peptides

A

Paneth cells

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17
Q

Specific cells

Located above the peyers patches
Specialized for antigen presentation

A

Microfold M cells

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18
Q

Specific cells

Specialized for mucous secretion

A

Goblet cells

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19
Q

Specific cells

Specialized to produce and secrete hormones

A

Entero endocrine cells

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20
Q

Properties of small intestine

Mucosal folds visible upon gross inspection
Also visible radio graphically and help in the distinction from the colon, which not contain them.
More prominent in the proximal intestine than in the distal small intestine.

A

Plicae circulares or valvulae conniventes

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21
Q

Properties of small intestine

Seen on gross examination of the small intestinal mucosa follicles.
Located in the ileum, are the most prominent and designated peyers patches

A

Aggregates of lymphoid follicles

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22
Q

Helpful both upon gross inspection in the OR and on abdominal x rays, to differentiate between the small and large bowel

A

Plicae circulares

Colon doesn’t have

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23
Q

Describe jejunum

A 
Larger diameter
Thicker wall
More prominent plicae circulares
Few arcade 1-2
Long vasa recta
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24
Q

Describe ileum

A

Many aracades
Short vasa recta
Fatty messentery

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25
Q

Innervation

Para sympathetic innervation

A

Vagus

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26
Q

Innervation

Sympathetic innervation

A

Splanchnic nerves

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27
Q

Innervation

Provides enteric nervous system innervation

A

Meissners and Auerbach plexuses

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28
Q

The entire small bowel is supplied by branches of the SMA except the

A

Proximal duodenum

Supplied by celiac trunk

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29
Q

Small bowel obstruction

Foreign bodies
Gallstones
Meconium

A

Intraluminal

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30
Q

Small bowel obstruction

Tumors
Chronhs

A

Intramural

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31
Q

Small bowel obstruction

Adhesion
Hernias
Carcinomatosis

A

Extrinsic

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32
Q

Small bowel obstruction

The most common causes of small bowel obstruction are

A 
Hernia
Adhesions
Volvolus
Intussusception
Crohns
Gallstone ileus
SMA syndrome
Neoplasm
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33
Q

Small bowel obstruction

Related to prior abdominal surgery account for up to 75% of the cases of small bowel obstruction

A

Intra abdominal adhesion

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34
Q

Small bowel obstruction

Commonly due to extrinsic or invasion by advanced malignancies arising in organs other than the small bowel.

A

Cancer related SBO

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35
Q

Small bowel obstruction

Should not be forgotten when considering the differential diagnosis of adult patients with acute or chronic symptoms of small Boswell obstruction, especially those without a history of prior abdominal surgery

A

Intestinal Malrotation

Midgut volvulus

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36
Q

Small bowel obstruction

Rare etiology of obstruction

Compression of third portion of duodenum by the superior mesenteric artery

Considered in young asthenic individuals who have chronic symptoms suggestive of proximal small bowel obstruction

A

Superior messenteric artery syndrome

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37
Q

Small bowel obstruction

Pathophysiology

A

Onset of obstruction
Gas and fluid accumulate
Intestinal activity increases

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38
Q

Pathophysiology of SBO

Most of the gas that accumulates originates from

A

Swallowed air

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39
Q

Pathophysiology of SBO

The fluid consist of

A

Swallowed liquids

GI secretions

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40
Q

Pathophysiology of SBO

A 
Gas and fluid accumulate in lumen
Intaluminal and intramural pressure rise
Decrease intestinal motility
Changes in luminal flora and small bowel
Translocation of bacteria
Impaired microvascular perfusion 
Intestinal ischemia
Necrosis
Strangulated obstruction
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41
Q

Small bowel obstruction

Only portion of intestinal lumen is occluded
Strangulation is less likely

A

Partial SBO

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42
Q

Small bowel obstruction

Dangerous form of bowel obstruction

Obstructed both proximal and distal (volvolus)

Rapid progression to strangulation

A

Closed loop obstruction

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43
Q

Clinical presentation of SBO

More prominent symptom with proximal obstructions than distal

A

Vomiting

More feculent more establish obstruction

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44
Q

Clinical presentation of SBO

Continue passage of flatus and or stool beyond 6-12 hours after onset of symptoms

A

Obstipation

More on partial than complete obstruction

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45
Q

Clinical presentation of SBO

Abdominal distention most pronounced if the site of obstruction is in the

A

Distal ileum

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46
Q

Clinical presentation of SBO

Abdominal distention
May be absent if the site of obstruction is in the

A

Proximal small intestine

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47
Q

Clinical presentation of SBO

Bowel sound may be

A

Hyper active initially

But minimal bowel sounds in late

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48
Q

Clinical presentation of SBO

Laboratory findings
Reflect intravascular volume depletion

A

Hemocencentration
Electrolyte abnormalities

Mild leukocytes is is common

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49
Q

Features associated with strangulated SBO include

A 
Tenderness
Tachycardia
Fever
Elevated WBC
Acidosis
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50
Q

Diagnosis of SBO

Goals

A

Mechanical vs ileus
Etiology
Partial vs comple
Simple vs strangulated

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51
Q

Symptoms of small bowel obstructions are

A

Colicky abdominal pain
Nausea
Vomiting
Obstipation

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52
Q

Diagnosis of SBO

Important elements to obtain on history

A

Prior abdominal operations

Presence of abdominal disorders

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53
Q

Diagnosis of SBO

PE

Search for

A

Hernias

Abdominal scars

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54
Q

Diagnosis of SBO

LABS

Full labs

A

Normal at initial stage

Progression

Leukocytosis
Hemocencentration
Electrolyte abnormalities

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55
Q

Diagnosis of SBO

The stool should be checked for gross or occult blood

A

Presence of strangulation

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56
Q

Diagnosis of SBO

Confirmed by

A

Radiographic examination

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57
Q

Diagnosis of SBO

Abdominal series of Radiographic evaluation

A

Abdomen - supine
Abdomen - upright
Chest - upright

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58
Q

Diagnosis of SBO

Radiographic

Triad

A

Dilated stool bowel loos >3 cm
Air fluid levels
Paucity of air

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59
Q

Diagnosis of SBO

Radiographic

Sensitivity range from

A

70-80%

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60
Q

Diagnosis of SBO

Radiographic

Specificity is low because

A

Mimic small bowel obstruction

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61
Q

Diagnosis of SBO

CT scan

Sensitivity and specificity

A

Sensitive - 80-90%

Specific - 70-90%

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62
Q

Diagnosis of SBO

CT scan

Findings

A

Discrete transition zone, dilation of bowel proipximally, decompression distally

Intra luminal contrast that dose not pass beyond transition zone

Colon containing little gas or fluid

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63
Q

Closed loop obstruction
CT scan

Is suggested by the presence of

A

U shaped or C shaped dilated bowel loop

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64
Q

Closed loop obstruction
CT scan

Depend on 2 things

A

Length of bowel segment

Orientation of the loop

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65
Q

Closed loop obstruction
CT scan

If we have a short closed loop oriented with the plane of imaging, we will see a

A

U or C shaped loop of bowel

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66
Q

Strangulated obstruction
CT scan

The cause of this radiologic finding was intestinal ischemia
Patient was taken emergently to the operating room

A

Intestinal pneumatosis

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67
Q

Limitation of CT scan

Detection of grade or partial small bowel obstruction

A

Low sensitivity

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68
Q

Other limitation of CT scan

Subtle transition zone may be difficult to identify in the

A

Axial images obtained during CT scan

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69
Q

Standard small bowel series

Although barium can be used water soluble contrast agents, such as _____________ should be used if the possibility of intestinal perforation exists.

A

Gastrografin

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70
Q

An x ray examination of the small intestine that looks at how the liquid contrast material moves through the small intestine

A

Enteroclysis

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71
Q

Enteroclysis

Double contrast technique used for better assessment of

A

Mucosal surface and detection of small lesions

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72
Q

Enteroclysis

200 - 250 ml of barium followed by 1-2 L of a solution of ___________ in water is instilled into the proximal jejeunum via a___________

A

Methylcellulose

Long nasoenteric catheter

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73
Q

Treatment of SBO

Trial of non operative mangy

A

NPO
Isotonic fluid
NGT
Foley catheter

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74
Q

Treatment of SBO

May be necessary to assist with fluid management, particularly in patients with underlying cardiac disease.

A

Central venous or pulmonary artery catheter monitoring

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75
Q

Treatment of SBO

Given by some because of concerns that bacterial translocation may occur in the setting of small bowel obstruction;

A

Broad spectrum antibiotics

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76
Q

Treatment of SBO

Standard therapy for complete SBO has been

A

Surgery

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77
Q

Treatment of SBO

The goal is

A

Operate before the onset of irreversible ischemia

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78
Q

Treatment of SBO

Others note, however, that a period of observation and NG decompression , providing

A

No tachycardia
No tenderness
No increase in white cell count

79
Q

Conservative treatment of SBO

Partial SBO

Do not improve within 48 hours after initiation of non operative therapy should

A

Undergo surgery

80
Q

Conservative treatment of SBO

Partial SBO

Patients undergoing non operative therapy should be closely monitored for signs suggestive of

A

Peritonitis

81
Q

Conservative treatment of SBO

Obstruction in early post operative period

Greater risk for developing

A

PT undergoing pelvic surgery

82
Q

Conservative treatment of SBO

Obstruction in early post operative period

Should considered if symptoms of intestinal obstruction occur

A

After initial return of bowel function
If bowel function fail to return

3-5 days after surgery

83
Q

Conservative treatment of SBO

Obstruction in early post operative period

A

Ususally partial and rarely strangulation

84
Q

Conservative treatment of SBO

Obstruction in early post operative period

Treatment

A period of extended non operative therapy 2-3 weeks consisting of

A

Bowel rest
Hydration
TPN

85
Q

Conservative treatment of SBO

Obstruction in early post operative period

Treatment

If complete obstruction is demostrated or if signs suggestive of peritonitis are detected

A

Re operation should be undertaken without delay

86
Q

Conservative treatment of SBO

Carcinomatosis

A

Adhesion

87
Q

Conservative treatment of SBO

Carcinomatosis

Recurrent malignancy

A

Palliative resection or bypass

88
Q

Surgical treatment of SBO

The operative procedure for small bowel obstruction varies according to the etiology of obstruction.

A

Adhesions are lysed
Tumors are resected
Hernias are reduced and repaired

89
Q

Surgical treatment of SBO

Criteria suggesting viability of bowels

A

Normal color
Peristalsis
Marginal arterial pulsations

90
Q

Surgical treatment of SBO

Used to check for pulsation flow to the bowel

A

Doppler probe

91
Q

Surgical treatment of SBO

Arterial perfusion can be verified by visualizing intravenously administered

A

Fluorescein dye

92
Q

Surgical treatment of SBO

For hemodynamic ally stable patient

Should be resected and primarily anastomosis

A

Short lenght

93
Q

Surgical treatment of SBO

For hemodynamic ally stable patient

The bowel of uncertain viability should be left intact and patient

LARGE

A

Re explored in 24 to 48 hours in a second look operation

94
Q

Surgical treatment of SBO

Success is being reported with greater frequency
Quicker recovery and less post operative discomfort

Presence of bowel distention and multiple adhesion can cause these procedures

A

Laparoscopic surgery for SBO.

95
Q

Prognosis of SBO

A

Related to the etiology

96
Q

Prognosis of SBO

Majority of patients

A

Do not require future re admissions

97
Q

Prognosis of SBO

Mortality

A

5% non strangulating elderly

8-25% strangulated

98
Q

Prevention of SBO

A

Adhesion prevention
Laparoscopic surgery
Seprafilm

99
Q

Prevention of SBO

Cornerstone of adhesion prevention consists of

A

Good surgical technique
Careful handling of tissue
Minimal use and exposure of peritoneum to foreign bodies

100
Q

Prevention of SBO

Hyaluran based agents
Reduce incidence of post operative bowel adhesion

A

Seprafilm

101
Q

Clinical syndromes caused by impaired intestinal motility

Characterized by SS of intestinal obstruction in the absence of a lesion causing mechanical obstruction

A

Ileus and intestinal pseudo obstruction

102
Q

Major caused of morbidity in hospitalized patients

A

Ileus

103
Q

Most frequently implicated cause of delayed discharge following abdominal operations

A

Post operative ileus

104
Q

A temporary motility disorder that is reversed with time as the inciting factor is corrected

A

Ileus

105
Q

Compromises a spectrum of specific disorders associated with irreversible intestinal dysmotility

A

Chronic intestinal pseudo obstruction

106
Q

Pathophysiology of ileus

Responsible for dysmotility

A

Surgical stress
Inflammatory response
Anesthetic or analgesics

107
Q

Pathophysiology of ileus

Post operative return of bowel function varies by

A

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

108
Q

Pathophysiology of ileus

Not reliable indicator

A

Bowel sounds

109
Q

Pathophysiology of ileus

More useful indicator

A

Passing flatus or bowel movement

110
Q

Pathophysiology of ileus

Resolution of ileus may be delayed in the presence of other factors capable of inciting ileus such as

A

Intra abdominal abscesses

Electrolyte abnormalities

111
Q

Pathophysiology of ileus

Can caused by a large number of specific abnormalities affecting intestinal smooth muscle,

A

Chronic intestinal pseudo obstruction

112
Q

Constitute a group of diseases characterized by degeneration and fibrosis of the intestinal muscularis propria.

A

Visceral myopathies

113
Q

Encompasses a variety of degenerative disorders of the myenteric and sub mucosal plexuses

A

Visceral neuropathies

114
Q

Chronic intestinal pseudo obstruction

Primary causes

A

Familial types

Sporadic types

115
Q

Chronic intestinal pseudo obstruction

Secondary causes

A 
Smooth muscle disorders
Neurologic disorders
Endocrine disorders
Miscellaneous disorders 
Pharmacologic causes
116
Q

Chronic intestinal pseudo obstruction

Familial type

A

Familial visceral myopathies type 1,2&3
Familial visceral neuropathies type 1&2
Childhood visceral myopathies type 1&2

117
Q

Clinical presentation

Ileus

A 
Inability to tolerate liquid
Nausea
Lack of flatus
Vomiting
Abdominal distention
No bowel sounds
118
Q

Clinical presentation

CIPO

A

Variable degrees of nausea and vomiting

Abdominal pain and distention

119
Q

Diagnosis

Ileus

Known to be associated with impaired intestinal motility

A

Opiates

120
Q

Diagnosis

Ileus

Measurement of serum electrolytes abnormalities

A

Hypokalemia
Hypocalcemia
Hypomagnesemia
Hypermagnesemia

121
Q

Diagnosis

Ileus

Distinction between ileus and mechanical obstruction may still be difficult

A

Abdominal x rays

122
Q

Diagnosis

Ileus

Test of choice in post operative setting

A

Ct scan

123
Q

Diagnosis

CIPO

May be required to establish the specific underlying causes

A

Laparotomy or laparoscopy

124
Q

Treatment of ileus

A

Limit oral intake
NGT
Fluid and electrolytes
TPN

125
Q

Treatment of CIPO

A

Palliative of symptoms
Fluids
Surgery should be avoided

126
Q

Treatment of CIPO

Has been associated with palliation of symptoms, however because of cardiac toxicity and reported death, restricted

A

Cisapride (propulsid)

127
Q

Chrons disease

Chronic, idiopathic trans mural inflammatory disease with a propensity to affect the

A

Distal ileum

128
Q

Chrons disease

Most common in

A

Female

3rd decade and 6th decade

129
Q

Features of chrons

A 
Genetic and environmental factors
First degree relatives
Monozygotic twins
Higher socioeconomic status
Smokers

Breast feeding protective against developing chrons

130
Q

Pathophysiology of Chrons disease

Causative agents

A 
Chlamydia
Listeria monocytogenes
Pseudomonas species
Reovirus
Mycobacterium para tuberculosis
131
Q

Pathophysiology of Chrons disease

Genetic host susceptibility

A

Non pathogenic commensal enteric flora.

132
Q

Pathophysiology of Chrons disease

Pathologic hallmark

A

Focal trans mural inflammation of the intestine

133
Q

Other pathologic lesions of chrons disease

Earliest lesions characterized

A

Aphthous ulcer

Arise over lymphoid aggregates

134
Q

Other pathologic lesions of chrons disease

Highly characteristic of chrons disease

A

Granulomas

Noncaseating
Found in any layer of the bowel wall and mesenteric lymph node

135
Q

Other pathologic lesions of chrons disease

Form as disease progresses, aphthae coalesce into larger ulcers.

A

STELLATE-SHAPED ULCERS

136
Q

Chrons disease

Form when multiple ulcers fuse in a direction parallel to the longitudinal axis of the intestine.

A

LINEAR OR SERPIGINOUS ULCERS

137
Q

Chrons disease

Form with transverse coalescence of ulcers

A

COBBLESTONE MUCOSA

138
Q

Chrons disease

  • Occurs with advanced disease.
  • Serosal involvement results in adhesion of the inflamed bowel to other loops of bowel or other adjacent organs.
A

Transmural inflammation

139
Q

Chrons disease

•Inflammation in Crohn’s disease can affect discontinuous portions of intestine: so-called skip lesions that are separated by intervening normal appearing intestine.

A

SKIP LESIONS

140
Q

Chrons disease morphology symptoms

A

Christmas

141
Q

Crowns disease

  • A feature of Crohn’s disease that is grossly evident and helpful in identifying affected segments of intestine during surgery.
  • Encroachment of mesenteric fat onto the serosal surface of the bowel
  • This finding is virtually pathognomonic of Crohn’s disease.
A

Fat wrapping

142
Q

•Layers of the bowel wall affected:

Ulcerative and chrons

A

UC: Limited to mucosa and submucosa

•CD: May involve the full thickness of the bowel wall

143
Q

•Longitudinal extent of inflammation

Ulcerative colitis and chrons

A

UC: Inflammation is continuous and affects the rectum

•CD: May be discontinuous and spares the rectum

144
Q

It is also important to remember that, although ulcerative colitis is a disease of the colon, it can be associated with inflammatory changes in the distal ileum

A

Backwash ileitis

145
Q

The most common symptoms of Crohn’s disease are

A

abdominal pain, diarrhea, and weight loss

146
Q

•Patients with Crohn’s disease can be classified by their PREDOMINANT clinical manifestation:

A

a) fibrostenotic disease
(b) fistulizing disease
(c) aggressive inflammatory disease.

147
Q

•Constitutional symptoms, particularly _______________________________, may also be prominent and are occasionally the sole presenting features of Crohn’s disease.

A

weight loss and fever, or growth retardation in children

148
Q

Crohn’s disease

•The disease affects the small bowel in 80% of cases and majority have

A

ileocecal disease.

149
Q

Crohn’s disease

•Uncommon sites of involvement include the

A

esophagus, stomach, and duodenum.

150
Q

•An estimated one fourth of all patients with Crohn’s disease will have an _______________ of their disease.

A

EXTRAINTESTINAL MANIFESTATION

151
Q

Diagnosis of Crohn’s disease

A

No single symptom, sign, or diagnostic test establishes the diagnosis of Crohn’s disease.

152
Q

Dx Crohn’s disease

•Main diagnostic tool
Can reveal focal ulcerations adjacent to areas of normal appearing mucosa along with polypoid mucosal changes that give a “cobblestone appearance.”
•Skip areas of involvement are typical.
•Pseudopolyps, as seen in ulcerative colitis, are also often present.

A

COLONOSCOPY with intubation of terminal ileum

153
Q

Dx of Crohn’s disease

•May reveal strictures or networks of ulcers and fissures.

A

•2)CONTRAST EXAMINATIONS of the small bowel and colon:

154
Q

Dx of Crohn’s disease

  • May reveal intra-abdominal abscesses
  • Useful in acute presentations to rule out the presence of other intra-abdominal disorders.
A

•3)CT SCANNING:

155
Q

Dx of Crohn’s disease

•Is done for disease of the proximal alimentary tract.

A

4)ESOPHAGOGASTRODUODENOSCOPY (EGD)

156
Q

Dx of Crohn’s disease

  • Has been increasingly used because Crohn’s disease often affects the small bowel, which is difficult to image.
  • Capsule endoscopy is a technology that uses a swallowed video capsule to take photographs of the inside of the esophagus, stomach, and small intestine.
A

5)CAPSULE ENDOSCOPY

157
Q
  • 5)CAPSULE ENDOSCOPY
  • Large capsule-larger than the largest pill-is swallowed by the patient.
  • The capsule contains one or two video chips (cameras), a light bulb, a battery, and a radio transmitter.
  • As the capsule travels through the esophagus, stomach, and small intestine, it takes photographs rapidly.
  • The photographs are transmitted by the radio transmitter to a small receiver that is worn on the waist of the patient who is undergoing the capsule endoscopy.
  • At the end of the procedure, approximately 24 hours later, the photographs are downloaded from the receiver into a computer, and the images are reviewed by a physician.
  • The capsule is passed by the patient into the toilet and flushed away.
A

Nice to know

158
Q
  • is associated with a diagnosis of Crohn’s disease
A

ASCA+/pANCA

159
Q

+ is correlated with ulcerative colitis.

A

ASCA–/pANCA

160
Q

•Because of the insidious, and often, nonspecific presentation, the diagnosis of Crohn’s disease typically is made only after symptoms have been present for .

A

several years

161
Q

•The initial manifestation of Crohn’s disease can consist of

A

right lower quadrant pain mimicking acute appendicitis.

162
Q
  • In some patients, the initial manifestation of Crohn’s disease is an acute abdomen related to small bowel obstruction, intra-abdominal abscess, or free intestinal perforation.
  • In other patients, perianal abscesses and fistulas requiring surgical therapy may be the first manifestation of Crohn’s disease.
A

Nice to know

163
Q

Management of Crohn’s disease

A
  • NO curative therapies are available for Crohn’s disease.
  • GOAL of treatment is to palliate symptoms rather than to achieve cure.
  • Medical therapy is used to induce and maintain disease remission.
  • Surgery is reserved for specific indications.
164
Q

Crohn’s disease

1)ANTIBIOTICS:for treatment of:

A

Infectious complications associated with Crohn’s disease

  • Perianal disease
  • Enterocutaneous fistulas
  • Active colonic disease
165
Q

Crohn’s disease

•
•Have shown to be superior to placebo in inducing disease remission.

•Its efficacy in the maintenance of remission is less clear.

A

Oral 5-aminosalicylic acid (5-ASA) drugs (e.g., mesalamine):

166
Q

Crohn’s disease

  • Parent compound of 5-ASA
  • Widely used in UC but has been shown to be less effective than 5-ASA in CD.
A

Sulfasalazine

167
Q

Crohn’s disease

•For patients with mildly to moderately severe disease that does not respond to aminosalicylates.

A

Oral glucocorticoids:

168
Q

Crohn’s disease

  • For patients with severe active disease.
  • Are effective in inducing remission, but are ineffective in preventing relapse
  • Their adverse side-effect profile makes long-term use hazardous. Therefore, they should be tapered once remission is achieved.
A

IV glucocorticoids:

169
Q

Crohn’s disease

Some patients are unable to undergo glucocorticoid tapering without suffering recurrence of symptoms. Such patients are said to have

A

STEROID DEPENDENCE.

170
Q

Crohn’s disease

For STEROID-DEPENDENT patients, along with those who do not respond to steroids at all (STEROID RESISTANT) patients, use of ______________ should be considered

A

immune modulators

171
Q

Crohn’s disease

  • Effective in inducing remission, in maintaining remission, and in allowing for glucocorticoid tapering in glucocorticoid-dependent patients.
  • Response to the medications is usually observed in 3 to 6 months.
  • they can decrease the risk of relapse after intestinal resection for Crohn’s
A

4)IMMUNOMODULATORS:
•THIOPURINE ANTIMETABOLITES:
•Azathioprine and its active metabolite, 6-mercaptopurine

172
Q
  • 4)IMMUNOMODULATORS:(Cont.)
  • THIOPURINE ANTIMETABOLITES:
  • SE:
A

can induce bone marrow suppression and promote infectious complications.

173
Q

•For patients who do not respond to the thiopurines, _____________ is an alternative that usually is given IM before switching to oral form after achieving symptomatic control.

A

methotrexate

174
Q

•There is little role for cyclosporine in Crohn’s disease; its efficacy/toxicity profile in this disease is poor.

A

Nice to know

175
Q
  • Chimeric monoclonal anti–tumor necrosis factor α-antibody
  • Has shown to have efficacy in inducing remission and in promoting closure of enterocutaneous fistulas.
  • It generally is used for patients resistant to standard therapy to help taper steroid dosage.
A

Infliximab

176
Q

•Infliximab generally is well tolerated but should not be used in patients with ongoing septic processes, such as

A

undrained intra-abdominal abscesses.

177
Q

Crohn’s disease

  • For patients with PERIANAL DISEASE:
  • __________________________ is the primary step.
  • Two to 4 weeks of therapy is needed before improvements are seen, and often long-term therapy is required to prevent relapse.
A

METRONIDAZOLE or CIPROFLOXACIN

178
Q

In cases of relapse: ____________ can be considered.

A

AZATHIOPRINE

179
Q

•In patients with fistulas: _________ and AZATHIOPRINE are drugs of choice.

A

INFLIXIMAB

180
Q

Surgical treatment of Crohn’s disease

A
  • Fifty to 70% of patients with Crohn’s disease will ultimately require at least one surgical intervention for their disease.
  • Surgery generally is reserved for patients whose disease is unresponsive to aggressive medical therapy or who develop complications of their disease.
  • FAILURE of medical management may be the indication for surgery if symptoms persist despite aggressive therapy for several months or if symptoms recur whenever aggressive therapy is tapered.
181
Q

Crohn’s disease

One of the most common indications for surgical intervention

A

Intestinal obstruction

182
Q

Crohn’s disease

______________ frequently are encountered during operations performed for intestinal obstruction.

A

Abscesses and fistulas

183
Q

Crohn’s disease

unless associated with symptoms or metabolic derangements do not require surgical intervention.

A

Fistulas

184
Q
  • INTRAOPERATIVE DISCOVERY OF INFLAMMATION LIMITED TO TERMINAL ILEUM (“TERMINAL ILEITIS”) during operations performed for presumed appendicitis.
  • An uncommon but not rare scenario in patients with Crohn’s disease.
  • This scenario can result from:
  • An acute presentation of Crohn’s disease or
  • From acute ileitis caused by bacteria such as
A

Yersinia or Campylobacter.

185
Q
  • The usual procedure of choice for grossly evident disease.
  • Microscopic evidence of Crohn’s disease at the resection margins does not compromise a safe anastomosis, and frozen-section analysis of resection margins is unnecessary.
  • Recurrence rates were similar whether margins were histologically free of or involved with Crohn’s disease.
A

SEGMENTAL RESECTION AND PRIMARY ANASTOMOSIS:

186
Q

:
•Alternative to segmental resection for obstructing lesions is stricturoplasty

  • This technique allows for preservation of intestinal surface area
  • Well-suited for patients with extensive disease and fibrotic strictures who may have undergone previous resection and are at risk for developing short bowel syndrome.
  • In this technique, the bowel is opened LONGITUDINALLY to expose the lumen. Any intraluminal ulcerations should be biopsied to rule out the presence of neoplasia.
A

STRICTUROPLASTY

187
Q

Crohn’s disease

•For strictures less than 12 cm in length)

A

HEINECKE-MICULICZ PYLOROPLASTY type of repair:

188
Q

Crohn’s disease

•For longer strictures as much as 25 cm in length

A

FINNEY PYLOROPLASTY type of repair:

189
Q

Crohn’s disease

•For longer strictures, with mean lengths of 50 cm.

A

ISOPERISTALTIC ENTEROENTEROSTOMY (side to side)

190
Q

Crohn’s disease

  • Are sometimes required in the presence of intramesenteric abscesses or if the diseased bowel is coalesced in the form of a dense inflammatory mass, making its mobilization unsafe.
  • Bypass procedures (gastrojejunostomy) also are used in the presence of duodenal strictures, for which stricturoplasty and segmental resection can be technically difficult.
A

INTESTINAL BYPASS PROCEDURES:

191
Q

Outcomes of chrons disease

A

•Overall complication rates following surgery for Crohn’s disease: range from 15 to 30%.

  • SURGICAL COMPLICATIONS include:
  • Wound infections
  • Postoperative intra-abdominal abscesses
  • Anastomotic leaks

OUTCOMES of CROHN’S DISEASE

192
Q
  • CLINICAL RECURRENCE:
  • Defined as the return of symptoms confirmed as being due to Crohn’s disease, affects 60% of patients by 5 years and 94% by 15 years after intestinal resection.

•REOPERATION becomes necessary in approximately one third of patients by 5 years after the initial operation, with a median time to reoperation of 7 to 10 years.

A

Nice to know

193
Q

Embryology

Primitive GUT appears

A

4th week of gestation

Surgery Finals 2nd Sem (5 decks)

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