Chapter 11, part 2 Flashcards Preview

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Flashcards in Chapter 11, part 2 Deck (55):
1

What is the most common true diverticulum of the GI tract?

Meckel's diverticulum

2

Approximately 50% of symptomatic Meckel's diverticulum contain ______

Ectopic gastric mucosal cells

3

What is the most common presenting symptom in adults of Meckel's diverticulum?

Obstruction
Acute inflammation is also common and can mimic appendicitis

4

What is necessary in the pt with Meckel's diverticulum who presents with GI bleeding? Why?

Segmental ileal resection
To eliminate the base of the diverticulum where ectopic gastric mucosa may be found and the adjacent small bowel

5

Rule of 2s in Meckel's diverticulum

~2% are asymptomatic
2 types of mucosa possible (small intestine and gastric)
Located within 2 feet of the ileocecal valve
2x more common in males
Commonly presents within the first 2 yrs of life

6

What is the most common acquired or false diverticula of the small bowel?

Duodenal diverticula

7

Where are >60% of duodenal diverticula found?

In the periampullary region projecting from the medial wall

8

Clinical manifestations of duodenal diverticula

Obstruction
Perforation
Bleeding into the small bowel

9

Tx of duodenal diverticula- if pancreatic and biliary structures not involved

The most common and effective tx is diverticulectomy
Kocher maneuver (dissecting the lateral peritoneal attachments of the duodenum to allow access to the pancreas, duodenum, and other retroperitoneal structures) is performed, and a duodenectomy is made

10

Tx of duodenal diverticula- if pancreatic and biliary structures are involved

A choledochoduodenostomy or a choledochojejunostomy to a Roux-en-Y limb may be indicated

11

Jejunoilial diverticula

Acquired pulsion pseudodiverticula associated with increasing age
Marker for underlying dysmotility syndrome
Most are located where blood vessels perforate the muscularis propria

12

Dx of jejunoilial diverticula

Enterocylsis is the study of choice

13

Complications of enterocylsis for jejunoilial diverticula

Diverticulitis
Obstruction
Perforation

14

What does jejunoilial diverticula have an associated increased risk with?

Lymphoma

15

What can acute mesenteric ischemia result from?

SMA embolization
SMA thrombosis
Nonocclusive mesenteric ischemia
Acute mesenteric venous thrombosis

16

RFs of acute mesenteric ischemia

Atrial fibrillation
CHF
Atherosclerotic coronary, carotid, or PVD
Hx of hypercoagulability

17

Labs for acute mesenteric ischemia

Leukocytosis
Hyperkalemia
Metabolic acidosis
Elevated levels of:
Lactate
LDH
ALT
AST
CPK

18

Dx of acute mesenteric ischemia

CT:
Bowel dilation
Wall thickening
Intestinal pneumatosis
Portal venous gas
Mesenteric stranding

19

Tx of acute mesenteric ischemia

Correction of metabolic derangements and acidosis is a goal of initial therapy + cardiac monitoring + Foley catheter

20

Tx of acute mesenteric ischemia when SMA embolus suspected

Surgical laparotomy and embolectomy
Alternative: local infusion of thrombolytic therapy if there is no evidence of bowel infarction

21

Tx of acute mesenteric ischemia when SMA thrombus suspected

Bypass graft or endovascular stent is often needed to reestablish flow to the affected bowel in conjunction with thrombectomy

22

After the intial tx of acute mesenteric ischemia, what is indicateds?

Anticoagulation with warfarin for at least 6 mos

23

What may be used as an adjunct during arteriography for acute mesenteric ischemia?

Vasodilating agents, such as papverine and tolazoline

24

What is chronic mesenteric ischemia caused by?

Atherosclerotic dz of the celiac axis, SMA, or IMA

25

What are the common collateral circuits in chronic mesenteric ischemia?

The celiac artery and the gastroduodenal artery
The SMA and pancreatic branches
The SMA and IMA through the meandering mesenteric artery and the marginal artery of Drummond
The left colic and middle colic arteries

26

What is present only in occlusive disease?

The meandering mesenteric artery

27

Gold standard of dx of chronic mesenteric ischemia

Arteriography, which detects occlusion or stenosis of the celiac axis, the SMA, and the presence of collateral vessels

28

Tx of chronic mesenteric ischemia

Surgical reconstruction or percutaneous transluminal angioplasty with or without a stent

29

When is surgery used for chronic mesenteric ischemia?

Often used in younger pts with fewer comorbidities, while endovascular approaches may be preferred for the elderly and infirm

30

Contraindications to surgery for chronic mesenteric ischemia

Extrinsic compression of the celiac axis by the median arcuate ligament because it has a high failure rate

31

Frequently described techniques of surgical reconstruction for chronic mesenteric ischemia

Bypass grafting
Endarterectomy
Reimplantation

32

Small bowel neoplasms

The rapid transit of material through the samll bowel and low intraluminal pH may protect the mucosa from contact with carcinogens + highly evolved immune system

33

What is the most common type of benign neoplasm?

Adenoma

34

What are the three types of adenomas?

Tubular
Vilious
Brunner's gland

35

Where are vilious adenomas most commonly found?

Duodenum

36

What is considered a large vilious adenoma?

>5 cm
Significant malignant potential

37

Brunner's gland adenoma

Found in the duodenum and are caused by hyperplastic proliferation of nl submucosal exocrine glands
No malignant potential
Resection reserved for sx

38

Tx for benign neoplasms

Surgical intervention is indicated bc of the possibility of CA and the risks of mechanical complications
Operation usually consists of segmental resection and primary anastomosis, though small lesions may simply be excised

39

What are the most common symptomatic benign tumor of the small bowel?

Leiomyomas

40

Where are leiomyomas most commonly located?

Jejunum

41

What is the most common indication for operative management of leiomyomas?

Bleeding

42

Where are lipomas most commonly located?

Most often intramural and located in the ileum

43

Hamartoma

Commonly occur as part of Peutz-Jegher's syndrome, an autosomal dominant-inherited syndrome characterized by mucocutaneous melanotic pigmentation and GI polyps
Increased risk for the development of malignancies

44

Where are hemartomas usually located?

Jejunum and ileum

45

Presentation of hemartomas

Pts have small, 1-2 mm brown-black spots on the circumoral region of the face, buccal mucosa, palms and soles, lips, digits, and perianal area

46

Where are hemangiomas most commonly found?

Jejunum

47

Presentation of hemangiomas

Onset of bleeding may be the only presenting symptom

48

Diagnostic test for hemangiomas

Angiography and Tc-labeled RBC scanning

49

Tx for hemangiomas

If the lesion can be localized, conservative resection is recommended
If the lesion cannot be localized, intraoperative or localization via intra-operative enteroscopy may be helpful

50

What are the most common malignant neoplasms of the small bowel?

Adenocarcinoma
Sarcoma
Lymphoma
Carcinoid tumors

51

Presentation of malignant neoplasms

Weight loss
Diarrhea
Obstructive sx

52

Tx options for malignant neoplasms

Wilde surgical resection with regional lymph node bx
Palliative resection
Intestinal bypass to relieve sx or prevent complications

53

Where are adenocarcinomas more common?

Duodenum and jejunum

54

~50% of adenocarcinomas involve what?

Ampulla of Vater

55

RFs for adenocarcinomas

Adenomatous polyps
Polyposis syndromes
Crohn's dz
FHx of hereditary nonpolyposis colorectal cancer