Pathology of the Small Bowel

Question 1

What can cause ischaemia of the small bowel?

Answer 1

Mesenteric artery occlusion or non-occlusive perfusion insufficiency

Question 2

What can cause non-occlusive perfusion insufficiency?

Answer 2

Shock, strangulation obstructing venous return (hernia), drugs, hyperviscosity

Question 3

What usually occurs after a mucosal infarct?

Answer 3

Regeneration and the mucosal integrity is restored

Question 4

What usually occurs after a mural infarct?

Answer 4

Repair and regeneration leading to fibrosis and stricture

Question 5

What usually occurs after transmural infarct?

Answer 5

Gangrene and death if not resected

Question 6

Complications of ischaemia of the small bowel

Answer 6

Resolution, fibrosis, stricture, chronic ischaemia, ‘mesenteric angina’, obstruction, gangrene, perforation, peritonitis, death

Question 7

Meckel’s diverticulum

Answer 7

Result of incomplete regression of vitello-intestinal tract

Question 8

Describe structure and position of Meckel’s diverticulum

Answer 8

Tube structure, 2 inches long, 2 foot above ileocaecal valve in 2% of people

Question 9

Complications of Meckel’s diverticulum

Answer 9

Bleeding, perforation or diverticulitis which mimics appendicitis

Question 10

Primary tumours of the small bowel

Answer 10

Lymphomas, carcinoid tumours, carcinomas

Question 11

Where can secondary tumours of the small bowel metastasise from?

Answer 11

Ovary, colon, stomach

Question 12

What type of lymphoma is associated with the small bowel?

Answer 12

Hodgkins lymphoma

Question 13

Treatment of lymphomas of the small bowel

Answer 13

Surgery and chemotherapy

Question 14

Most common site of carcinoid tumours of the small bowel

Answer 14

Appendix

Question 15

Describe carcinoid tumours of the small bowel

Answer 15

Small, yellow, slow growing, locally invasive

Question 16

What can carcinoid tumours of the small bowel cause?

Answer 16

Intussusception

Question 17

Symptoms of carcinoid tumours of the small bowel

Answer 17

Flushing and diarrhoea

Question 18

Which diseases is carcinoma of the small bowel associated with?

Answer 18

Crohn’s and coeliac disease

Question 19

Where can carcinoma of the small bowel metastasise to?

Answer 19

Lymph node and liver

Question 20

Most common cause of acute abdomen

Answer 20

Appendicitis

Question 21

Pathology of appendicitis

Answer 21

Acute inflammation by neutrophils, mucosal ulceration, serosal congestion, exudate, pus in lumen

Question 22

Complications of appendicitis

Answer 22

• Peritonitis
• Rupture
• Abscess
• Fistula
• Sepsis and liver abscess

Question 23

What is coeliac disease caused by?

Answer 23

Abnormal reaction to a constituent of wheat flour, gluten, which damages enterocytes and reduces absorptive capacity.

Question 24

What is the suspected toxic agent in coeliac disease?

Answer 24

Gliadin

Question 25

Enterocytes in coeliac disease

Answer 25

Increasing loss of enterocytes due to intraepithelial lymphocyte mediated damage

Question 26

Metabolic effects of coeliac disease

Answer 26

- Malabsorption of sugars, fats, amino acids, water and electrolytes - Malabsorption of fats leads to steatorrhea - Reduced intestinal hormone production leads to reduced pancreatic secretion and bile flow leading to gallstones

Question 27

Effects of malabsorption in coeliac disease

Answer 27

Weight loss, anaemia, abdominal bloating, failure to thrive, vitamin deficiencies

Question 28

Complications of coeliac disease

Answer 28

- T-cell lymphomas of GI tract - Increased risk of small bowel carcinoma - Gall stones - Ulcerative-jejenoilleitis

Question 29

Aetiology of appendicitis

Answer 29

Obstruction of lumen by faecolith or tumour, bacterial, viral, parasitic

Question 30

Symptoms of appendicitis

Answer 30

Colicky abdominal pain starting around umbilicus which shifts to the right iliac fossa which is worse on coughing/going over speed bumps etc, put off food, nausea and vomiting, flushed

Question 31

Signs of appendicitis

Answer 31

Mild pyrexia, mild tachycardia, guarding, rebound tenderness, high WCC

Question 32

Signs specific to appendicitis

Answer 32

Rosving's sign, Psoas, Obturator

Question 33

Rosving's sign

Answer 33

Pressing on left side causes pain in right

Question 34

Psoas

Answer 34

Patient keeps the right hip flexed as this lifts an inflamed appendix off the psoas

Question 35

Obturator

Answer 35

If appendix is touching obturator internus, flexing the hip and internally rotating will cause pain

Question 36

Differential diagnosis of appendicitis in children

Answer 36

- Gastroenteritis – vomiting profusely and lots of diarrhoea - Mesenteric adenitis – lymph nodes in mesentery swell up and stretch the peritoneum and causes pain - Meckel’s diverticulum - Intussusception - Henoch-Schonlein purpura – rash on ankles - Lobar pneumonia

Question 37

Differential diagnosis of appendicitis in adults

Answer 37

- Terminal ileitis – colicky paint that comes and goes - Ureteric colic - Acute pyelonephritis - Perforated ulcer - Pancreatitis - Rectus sheath haematoma - Ectopic pregnancy

Question 38

Differential diagnosis of appendicitis in elderly

Answer 38

- Sigmoid diverticulitis - Intestinal obstruction - Carcinoma of the caecum

Question 39

Investigations for appendicitis

Answer 39

Clinical diagnosis, ultrasound, abdominal X-ray, bloods (CRP, WCC), urinanalysis

Question 40

What score can be used to clinically diagnose appendicitis?

Answer 40

MANTRELS score

Question 41

MANTRELS score

Answer 41

``` M = migration of pain to RLQ A = anorexia N = nausea and vomiting T = tenderness in right lower quadrant R = rebound pain E = elevated temperature L = leucocytosis S = shift of white blood count to left ```

Question 42

Management of appendicitis

Answer 42

Analgesia, antipyretics, antibiotics, appendectomy

Question 43

Treatment for appendix mass

Answer 43

Antibiotics, can operate (if able to), theatre if antibiotics failed or complications

Question 44

Complications of appendix mass

Answer 44

Tachycardia, worsening pain, increase in size, vomiting or copious NG aspirated

Question 45

Complications of appendectomy

Answer 45

Pelvic abscess, wound infection, intra-abdominal abscess, ileus, DVT/PE, portal pyaemia, faecul fistula, adhesions, right sided inguinal hernia

Question 46

Carcinoid of the appendix - what is it a tumour of?

Answer 46

Crypts of Lieberkuhn

Question 47

Clinical presentation of small bowel obstruction

Answer 47

Colicky pain, absolute constipation, nausea and vomiting (may be faeculent), burping, abdominal distension, loud vomiting ischaemia and perforation

Question 48

Causes of small bowel obstruction (within the lumen)

Answer 48

Gallstone, food, bezoar

Question 49

Causes of small bowel obstruction (within the wall)

Answer 49

Tumour, Crohn's radiation

Question 50

Causes of small bowel obstruction (outside the wall)

Answer 50

Adhesions, herniation

Question 51

Treatment of small bowel obstruction

Answer 51

"drip and suck" - put in a drip and suck out air via NG tube, ABC, analgesia, catheterise, antithromboembolise

Question 52

How long do you drip and suck?

Answer 52

Up to 72 hours

Question 53

In surgery, how is the obstruction of the bowel found?

Answer 53

By following the collapsed or dilated bowel

Question 54

Causes of mesenteric ischaemia

Answer 54

Embolus usually from atrial fibrillation, in situ thrombosis from general gubbedness

Question 55

Diagnosis of mesenteric ischaemia

Answer 55

Pain out of proportion to clinical findings, acidosis, elevated lactate

Question 56

Investigations for mesenteric ischaemia

Answer 56

CT angiogram

Question 57

Which surgical procedure is required for treatment of mesenteric ischaemia

Answer 57

Laparotomy

Question 58

Haemorrhage of the small bowel: - Often caused by what? - Investigation - Management

Answer 58

- Vascular malformations or ulceration - CT angiography - Interventional radiology

Question 59

Complications of Meckel's diverticulum

Answer 59

Bleed, ulceration, Meckel's diverticulitis, obstruction, malignancy