(Iii-Surgery) Small Ball

Front 1

Which portion of the duodenum is most commonly involved in duodenal ulcers?

Back 1

First portion (bulb)

Front 2

This structure can easily be injured during ligation of bleeding duodenal ulcers:

Back 2

Common bile duct due to its location

Front 3

Describe teh demarcation between the jejunum and ileu:

Back 3

No clear demarcation.

Front 4

The transverse portion of teh duodenum is almost completely retroperitoneal,.

Where on the pancreas does it attach?

Back 4

Uncinae process.

Front 5

The transverse portion of the duodenum is between these two blood vessles:

Back 5

Passes between superior mesenteric artery and the aorta:

Front 6

Stimulus for secretion of cholecystokinin:

Back 6

Fats and proteins in the lumen of the jejunum.


Recall that CCK increases pancreatic enzyme ouput, and stimulates gallbladder contraction.

Front 7

Gastric inhibiory peptide is produced in the duodenum and jejunum.

What does it do?

Back 7

In response to fats and glucose it causes insulin release from the pancreas and slows down gastric secretion.

Front 8

This enterohormone causes an increase in water and bicarbonate output from the pancreas.

Back 8

Secretin

Released from duodenum and proximal jejunum upon acidification of the duodenum

Front 9

This enterohormone inhibits all gastric pancreatic and enterohormone secretion. It also decreases gastric emptying and small bowel motility.

Back 9

Somatostatin

Front 10

Name two enterohormones that are produced in the duodenum:

Back 10

GIP, Secretin

Also, somatostatin (produced in entire small bowel)

Front 11

Name the four layers of the small bowel wall:

Back 11

Mucosa
Submucosa - Strongest layer, site of payer patches, and meissner plexus)
Muscular: Syte of myenteric nervous plexus
Serosa: Thin layer of mesothelial cells over loose connective tissue

Front 12

What does the myenteric (aurbach) plexus do?

Back 12

Controlls motility (located in the muscularis layer)

Front 13

What does the submucosal (Meissner) plexus do?

Back 13

Controls secretion and absorpion

Front 14

Describe the digestion and absorption of carbhoydrates:

Back 14

Starch is first broken by salivary amylase, and completed by pancreatic amylase.

Brush border enzymes cleave disaccharides to monosaccharides in the JEJUNUM.

Monosaccharides are absorbed by Na - linked facilitated diffusion

Front 15

Describe the digestion and absorption of proteins:

Back 15

Starts in the stomach (pepsin)
Proteolysis in the small bowel by proteases, which are secreted by the pancrease as inacive precurosrs.

Dipeptides and tripeptides and AA absobed in jejunum

Front 16

Describe the digestion and absorption of lipids:

Back 16

Fat in the small bowel stimulates CCK from duodenum which causes lipase and cholesterol esterase from the pancreas.

Micelle formation (also aids in vitamin absorption (fat soluble))

Micelles diffuse into terminal ILEUM cells to the Golgi body

Turned into chylomicrons

Front 17

Is calcium absorption passive or active?

Back 17

Trick question - Both! Depending on level of calcium in the body.

Front 18

Where is iron taken up in the small intestine?

Back 18

Proximal jejunum and duodenum

Front 19

Is this Crohn's: or Colitis?

Back 19

Transmural lymphocytic inflammation wiht noncaseating granulomatas

Thicened mesentery with enlarged friable lymph nodes

Front 20

Percentage of Crohn's patients end up undergoing surgery?

Back 20

90%

Front 21

Absolute and relative indications for bowel surgery in patient with Crohns?

Back 21

Absolute: Perforation, hemorrhage, cancer suspicion, non-resolving obstruction

Relative indications are symptommatic fistula, or abscess, or failure to thrive.

Front 22

Why does small bowel cancer caused by crohn's have such a poor prognosiis?

Back 22

Has nothing to do with the disease itself, it's just that they aren't diagnosed early since symptoms of CA can mimic IBD

Front 23

Causes of gallstone ileus:

Back 23

Chronic cholecystitis with fistula between gallbladder and duodenum.

Front 24

When gallstone ileus causes bowel obstruction, where is the stone most likely to be located?

Back 24

Terminal ileum

Front 25

Patient is over age 18 and presents with intussusception. What should you do once you fix the intussusception?

Back 25

Go exploring for a cause, such as cancer

Front 26

Treatment for gallstone ileus:

Back 26

First rehydrate the patient due to vomiting.

Then move teh stone back into dilated bowel and extract through enterotomy.

Front 27

Clues that tip you off to thinking patient has radiation enteritis as a cause of obstruction (besides history of radiation exposure)

Back 27

Obliterative vasculitis
Muscular fibrosis

Front 28

Diagnostic strategies for small bowel obstruction:

Back 28

80% of patients diagnosed by plain films (look for air-fluid levels)

Contrast studies with hydrophilic agent

*CT scan - Just as good as contrast studies and may showw secondary signs of obstruction.

Front 29

Diagnostic method iif patient presents with ileus but does not have a cause:

Back 29

CT scan to look for secondary signs.

Front 30

How does a meckel diverticulum usually present in adults?

Back 30

Symptoms and signs of small bowel obstruction due to the following reasons:.

1. Diverticulitis (leading to fibrous stricture)

2. Ectopic tissue

3. Internal herniation

4. Volvulus aroudn vitelloumbilical band.

Front 31

Preoperatively Meckel diverticulum is most often mistaken for this disease:

Back 31

Acute appendicitis

Front 32

Say you discover a meckel diverticulum in a patiet by accident. Do you remove it?

Back 32

Depends.

In children, yes

In adults, maybe. More likely to dissect if ectopic tissue is found, or diverticular length is less than 2 cm.

ALso if vitelloumbilical bands are found, just dissect them. On the other hand, Mesodiverticular bands cannot be divided.

Front 33

Hyperplastic polyps of the small bowel usually do not cause symptoms, except in this case:

Back 33

Can lead to intususeption.

Front 34

Although leiomyomatas tend to be benign, why would you want to dissect them out?

Back 34

There is no clinical way to determine if it is really a GIST tumor.

Front 35

This is a germline mutationleading to hamartomas in all three germ layers, carries an increased risk of thyroid, breast, and endometrial cancer.

Back 35

Cowden syndrome

Front 36

This is an autosomal dominant disorder that is characterized by mucocutaneous pigmentation and GI hamartomas:

Back 36

Peutz-Jeghers

Front 37

Although the hamartomas seen in Peutz-Jeghers are benign, does this mean that the patient is not at risk for malignant cancers of the bowel?

Back 37

No! Adenocarcenomas are also found in pts with Peutz-Jeghers

Front 38

What is more common, benign or malignant small bowel neoplasms?

Back 38

Malignant (2/3)

Front 39

Risk factors for small bowel cancer:

Back 39

FAP / Gardner disease
HNPCC
Diets high in fat and animal meat
Crohn disease
Celiac disease
Males
AA race

Front 40

Most common location of cancer of the small bowel?

Back 40

Duodenal (50%).

Note that duodenal cancers tend to present earlier and at a lower stage.

Front 41

In patients with advanced small bowel cancer, does extensive resectioning help?

Back 41

No

Front 42

All suspected small bowel smooth muscle tumors (sarcomas) should be tested for this gene expression:

Back 42

c-kit

Front 43

Primary location for GIST tumors:

Back 43

Stomach

Front 44

Which is more often assocated with small bowel lymphomas: Hodgkin's, or non-Hodgkins

Back 44

Non-Hodgkins

Front 45

Average age of presentation for a patient with small bowel cancer

Back 45

60

Front 46

Treatment of patients with lymphoma cancer of the small bowel:

Back 46

In early stage, resect all disease and possibly spleenectomy (if enlarged), and adjacent lymph nodes should be tagged for future radiation.

In more advanced cancer, don't do resection unless for symptommatic Rx. Due chemo and radiation instead.