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138 Cards in this Set
- Front
- Back
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What is the function of the small intestine? |
nutrient and water absorption |
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What is the main function of the large intestine? |
Water absorption |
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Where do 90% of peptic ulcer occur? |
duodenal bulb |
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Where in the duodenum are the ampulla of vater and the duct of santorini? |
D2 |
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Which portions of the duodenum are retroperitoneal |
D2 and D3 |
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What is the vascular supply to the duodenum? |
superior (GDA) and inferior (off SMA) pancreaticoduodenal arteries (anterior and posterior branches |
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Which part of the small bowel absorbs the most? |
jejunum (except for B12, bile, iron, folate) 90 % water absorbed here, 95% salt |
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How long is the jejunum? |
100cm, long vasa recta, circular muscle folds |
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How long is the ileum? |
150cm, short vasa recta, flat folds |
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What is absorbed in the terminal ileum? |
B12, conjugated bile acids, folate |
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Where is iron absorbed? |
duodenum |
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What are the brush border enzymes? |
maltase, sucrase, limit dextrinase, lactase |
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what is the normal diameter of the small bowel |
3cm |
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what is the normal diameter of the transverse colon? |
6cm |
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what is the normal diameter of the cecum? |
9cm |
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What do goblet cells in the small bowel secrete? |
mucin |
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What do paneth cells in the small bowel secrete? |
secretory granules, enzymes |
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What do enterochromaffin cells in the small bowel do? |
Amine precursor uptake, 5-hydroxytryptamine release , carcinoid precursor |
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What do Brunner's glands secrete? |
alkaline fluid |
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Where is the concentration of Peyer's patches the greatest |
ileum |
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What are M cells? |
Antigen presenting cells in the intestinal wall |
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What is phase 1 of the migrating motor complex? |
Rest |
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What is phase 2 of the migrating motor complex? |
acceleration of gallbladder contraction |
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What is phase 3 of the migrating motor complex? |
peristalsis (motilin) |
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What is phase 4 of the migrating motor complex? |
deceleration |
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What percentage of bile salts are reabsorbed? |
95% |
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Where does passive reabsorption of bile salts take place? |
Non-conjugated bile salts are reabsorbed in the colon (5%) and ileum (45%) |
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Where does active reabsorption of conjgated bile salts occur? |
terminal ileum (50% of bile salts) |
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How much bowel do you need without an ileocecal valve? |
75cm |
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How much bowel do you need with an ileocecal valve? |
50cm |
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Treatment for short gut syndrome? |
restrict fat, PPI ( reduce gastric acid hypersecretion), lomotil |
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What are the causes of nonhealing fistulas? |
Foreign body Radiation Inflammatory bowel disease Epithelialization Neoplasm Distal obstruction Sepsis/infection |
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What is a high output fistula? |
> 200 cc/day more likely with more proximal bowel, often dont close with conservative tx |
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If patient has a fistula with persistent fever what should you look for? |
abscess |
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What is the classic finding on a patient with gallstone ileus? |
air in the biliary tree, SBO |
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What is a gallstone ileus? |
caused by a fistula between gallbladder and D2 |
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What is the treatment for gallstone ileus |
remove stone from terminal ileum, leave gallbladder and fistula if patient too sick |
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What is the rule of 2s for Meckels diverticulum? |
2 ft from the ileocecal valve, 2% of the population, presents by age 2 |
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What is a Meckels diverticulum? |
caused by failure of omphalomesenteric duct , true diverticulum |
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What is the most common tissue found in meckels diverticula? |
pancreatic (can cause diverticulitis) |
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What is the most common tissue that causes symptoms (bleeding)? |
gastric |
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What is the most common way for Meckels to present in adults |
obstruction |
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What is the treatment for Meckels diverticulum? |
Do not need to remove unless symptomatic or with very narrow neck. |
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When do you have to do a segmental resection for Meckels? |
perforated diverticulitis, neck >1/3rd diameter of bowel, diverticulitis involving base |
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When you find a duodenal diverticula what must you rule out? |
gallbladder duodenal fistula |
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What is the treatment for duodenal diverticula? |
observe unless symptomatic, otherwise segmental resection |
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How do you treat a juxta-ampullary duodenal diverticula? |
choledochojejunostomy for biliary symptoms vs ERCP with stent for pancreatitis (avoid whipple) |
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What are the extra-intestinal manifestations of Crohn's disease? |
arthritis, arthralgias, pyoderma gangrenosum, erythema nodosum, ocular diseases, growth failure |
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What nutritional deficiencies can occur in patients with Crohn's disease? |
folate and vitB12 deficiency (megaloblastic anemia) |
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What is the most commonly involved segment in Crohn's disease? |
terminal ileum (can occur anywhere but usually spares rectum) - 40% initially present with TI issues |
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What percentage of patients initially present with perianal Crohns? |
5% |
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What percentage of patients present with only colonic involvment of Crohn's? |
35% |
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What percentage of patients present with only small bowel involvment of Crohn's?
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20% |
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What are the typical pathologic features of Crohn's? |
Transmural inflammation, skip lesions, cobblestoning, deep ulcers, creeping fat, fistulas |
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What percentage of Crohn's patients will eventually need an operation? |
90% |
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What is the rate of perforation for toxic megacolon from Crohn's? |
15% |
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What do you not do in a fissure from Crohn's disease? |
lateral internal sphincteroplasty |
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What is the rule of thumb for margins in Crohn's? |
get 2cm away from gross disease with surgery |
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When do you consider a stricturoplasty |
Not good for 1st surgery as leaves disease behind. Good to save bowel length |
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What are the complications from stricturoplasty? |
10% leakage, abscess, fistula rate |
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What is the risk for recurrence in a Crohn's patient that has undergone surgery? |
60% 5 years postoperatively 20 years postoperatively 75% to 95% of patients have symptomatic recurrences. 2% will need reoperation per year after initial surgery (4% if in multiple intestinal segments) |
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What are the complications following resection of the terminal ileum |
low B12 uptake, low bile salt absorption (diarrhea, gallstones), low oxalate binding to calcium due to increased intraluminal fat --> increased oxalate in colon and urine--> calcium oxalate stones |
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What cells in the bowel produce serotonin? |
Kulchitsky cells (enterochromograffin or argentaffin cells) |
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What are the products of carcinoid tumors |
serotonin (5-HIAA) (diarrhea), bradykinin(asthma)/kallikrein (flushing), right valve lesions |
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What causes carcinoid syndrome |
bulky liver metastases from carcinoid syndrome, or tumor in bronchus or retroperitoneum (no monoamine oxidase to break down serotonin) |
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What is the best test for detecting carcinoid? |
Chromogranin A level |
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What is the best test for localizing carcinoid tumor? |
octreotide scan |
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What is the most common site for carcinoid ? |
appendix (50%) followed by ileum (most metastatic) and rectum |
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what is the treatment for carcinoid in the appendix <2cm |
appendectomy |
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what is the treatment for carcinoid in the appendix >2cm or involving the base |
right hemicolectomy |
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What is the chemotherapy for unresectable carcinoid? |
streptozocin and 5FU Octreotide for symptom palliation |
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What is the treatment for carcinoid bronchospasm? |
albuterol inhalers, aprotinin |
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What is the treatment for carcinoid flushing? |
alpha blockers (ex. phenothiazine) |
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What is the cancer risk of crohn's pancolitis? |
same as ulcerative colitis |
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What is the most common benign small bowel tumor |
duodenal adenoma (present with bleeding or obstruction) Resect |
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What is Peutz-Jeghers syndrome? |
hamartomas throughout GI tract, mucocutaneous melanotic skin pigmentation , extra-intestinal malignancies (breast Ca) Do Not need prophylactic colectomy |
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What is the most common malignant small bowel tumor? |
adenocarcinoma (most commonly in duodenum) |
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What is the treatment for duodenal adenocarcinoma |
resection (whipple if in 2nd portion of duodenum) |
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What diseases are risk factors for duodenal cancer? |
FAP, Gardner's, polyps, adenomas, von Recklinghausen's |
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Where do small bowel leiomyosarcoma develop |
jejunum, ileum (often extraluminal) |
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Ifyou find a small bowel leiomymoma what is the work up? |
must resect, check for a GIST (c-kit), more likely a sarcoma if >5 mitoses/HPF, atypia, necrosis |
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Where do small bowel lymphoma occur |
in ileum |
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What are small bowel lymphomas associated with ? |
Wegener's, SLE, AIDS, Crohn's, celiac sprue |
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What type of lymphoma is most common in small bowel? |
NHL B cell type lymphoma |
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What are the complications associated with post-transplantation small bowel lymphoma? |
bleeding and perforation |
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How do you diagnose small bowel lymphoma |
abdominal CT, node sampling |
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What is the treatment for small bowel lymphoma |
wide en bloc resection to include the nodes If involves 1st or 2nd portion of duodenum do chemo and XRT (no whipple) |
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What is the 5 year survival of small bowel lymphoma |
40% |
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What is the most common stoma infection? |
candida |
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What is diversion colitis ? |
After a Hartmans pouch, due to lack of short chain fatty acids (administer short chain fatty acid enemas) |
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What is the most common cause of stenosis of a stoma? |
ischemia (dilate if mild) |
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What is the most common cause of fistula near stoma site? |
Crohn's |
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What is the most common cause of abscess near a stoma? |
Due to irrigation device |
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What are some complications from having an ileostomy? |
dehydration, electrolyte abnormalities, gallstones, uric acid kidney stones |
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What are the CT criteria for diagnosing appendicitis |
>7mm diameter >2mm thick fat stranding, no contrast in appendiceal lumen, can give rectal contrast |
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Most likely area to perforate in appendicitis |
midpoint of antimesenteric border |
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Pathophysiology of appendicitis and perforation? |
luminal obstruction followed by distention of the appendix, venous congestion and thrombosis, ischemia, gangrene |
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Following nonoperative management of perforated appendicitis what must you rule out before performing an interval appendectomy |
perforated colon cancer (do barium enema, colonoscopy) |
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What is the most common cause of acute abdominal pain in the 1st trimeter of pregnancy |
appendicitis (most commonly happens in 2nd trimester but not the most common cause of abdominal pain) |
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When is pregnancy most likely to perforate in pregnancy? |
3rd trimester (confused with contractions) |
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What is the most common location for pain in pregnant patients with appendicitis |
RUQ |
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What is the fetal mortality rate of patients with perforated appendicitis |
35% |
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What is an appendiceal mucocele |
benign or malignant mucous papillary tumor, need resection often open. Need right hemicolectomy if malignant |
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What happens when you rupture an appendiceal mucocele? |
pseudomyxoma peritonei -->SBO (most common cause of death) |
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What is typhoid enteritis ? |
Salmonella causes it RLQ abd pain, diarrhea, fevers, headaches, maculopapular rash, leukopenia, can cause bleeding and perforation (rare) |
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What is the treatment for typhoid enteritis? |
bactrim |
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CT signs indicative of small bowel ischemia |
free fluid volume greater than 500 cc, mesenteric edema, lack of a “small bowel feces sign”, abnormal swirling of mesenteric vessels, pneumatosis intestinalis, and reduced bowel wall enhancement. |
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In an obstruction with air in the bowel, where does most of the air come from? |
80% swallowed air (nitrogen) |
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What are indications for operation in intussusception? |
Long length, wide diameter, lead point, obstructive symptoms kids can be managed with radiologic decompression first |
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What length of stricture can you perform a Heineke Mikulicz stricturoplasty? |
5-7cm |
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What length of stricture can you perform a Finney stricturoplasty? |
10-15cm |
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What is the frequency of early postoperative bowel obstruction? |
10% |
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Which types of carcinoid are often multiple? |
small bowel (not appendix). 30-40% multiple, need to follow with colonoscopy 30% to 50% of small-bowel carcinoids are associated with second primary malignant tumors, most frequently of the breast and colon. |
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Where is calcium absorbed? |
the duodenum |
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What extra-intestinal symptom of Crohns is not affected by therapy? |
sclerosing cholangitis, ankylosing spondylitis |
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Where in the bowel is pneumatosis intestinalis most common? |
jejunum, followed by the ileocecal region and colon. |
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Where is cystic pneumatosis found? |
in the submucosa |
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Where is linear pneumatosis found? |
between the muscularis and submucosa |
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earliest symptom of closed loop obstruction |
abdominal pain |
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Most common Xray finding for intussusception? |
nonspecific air-fluid levels |
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What anatomic landmark delineates the transition between D3 and D4? |
Aorta and SMA for acute angle around duodenum |
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Test for fecal fat? |
sudan red |
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Test for B12 absorption |
Schilling test (radiolabeled B12 in urine) |
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Causes of steatorrhea |
gastric hypersecretion of acids (increased intestinal motility) interruption of bile salt resorption decreased pancreatic enzymes |
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What accounts for 50% of painless GI bleeding in kids? |
Meckels |
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Medical treatment of Crohn's |
sulfasalazine, loperamide steroids for flares Remicade (anti-TNF) for steroid resistant or fistulas |
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Treatment for perianal crohns or fistulas? |
flagyl |
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treatment for toxic megacolon |
cipro and flagyl |
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How do you manage a perineal fistula in crohn's |
rule out abscess draining seton |
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How do you treat an anorectovaginal fistula from Crohn's |
rectal advancement flap, possible colostomy |
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Treatment of patient with presumed appendicitis that has crohns of TI |
resect appendix if base of cecum not involved |
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What is found on pathology for mucocele of appendix? |
signet ring cells |
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What percentage of people with regional ileitis go on to develop crohn's? |
10% |
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What type of gastric reconstruction is most associated with blind loop syndrome? |
antecolic Billroth II loop reconstructions with a long (>30 cm) afferent limb |
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how long should you treat a GIST with adjuvant imantinib ? |
3 or more years |
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treatment of duodenal stricture at D2 in Crohn's |
gastrojejunostomy and vagotomy |
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Most common location for pneumatosis intestinalis ? |
Jejunum |
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What gastric reconstruction is associated with blind loop syndrome? |
Billroth 2 with antecolic anastamosis long afferent limb (>30cm) |
