Small Bowel 2

Question 1

what is angiodysplasia

Answer 1

vascular abnormality of the GI tract

caused by the formation of arteriovenous malformations between previously healthy blood vessels

presents with rectal bleeding

Question 2

where is angiodysplasia most commonly found

Answer 2

caecum and ascending colon

Question 3

pathophysiology of acquired angiodysplasia

Answer 3

reduced submucosal venous drainage in the colon due to chronic intermittent contraction of the colon, giving rise to dilated and tortuous veins

this results in loss of pre-capillary sphincter competency and in turn causes the formation of small arteriovenous communications characterised by a small tuft of dilated vessels

Question 4

clinical features of angiodysplasia

Answer 4

rectal bleeding and anaemia - typically presents as painless PR bleeding

chronic angiodysplasia can present with symptoms of anemia such as fatigue, weakness or dyspnoea

Question 5

difference in symptoms between upper GI bleed vs lower GI bleed

Answer 5

upper GI = haematemesis and malaena

lower GI = haematochezia (fresh PR bleeding)

Question 6

investigations into angiodysplasia

Answer 6

routine bloods + clotting screen

exclude malignancy - upper GI endoscopy or colonoscopy

mesenteric angiography can also be used to confirm the location of the lesion

Question 7

management of angiodysplasia

Answer 7

depends on severity - 10% present with major GI bleeds

conservative; IV fluids and bed rest (potentially tranexamic acid), argon plasma coagulation

surgical; bowel resection (last resort in patients with major life-threatening GI bleed)

Question 8

what is the main artery supplying the jejunum

Answer 8

superior mesenteric artery

Question 9

what are the different sections of small intestine called

Answer 9

duodenum, jejunum and ileum

Question 10

what is the most common initial presentation of a patient with a small bowel tumour

Answer 10

abdo pain, vomiting and constipation

Question 11

from what part of the small intestine do most tumours arise from

Answer 11

duodenum

Question 12

names of benign small bowel tumours vs malignant small bowel tumours

Answer 12

benign = adenomas

malignant = adenocarcinomas or neuroendocrine tumours

Question 13

difference between adenocarcinomas vs neuroendocrine tumours of the small bowel

Answer 13

adenocarcinomas commonly affect the duodenum

neuroendocrine tumours most commonly affect the ileum

Question 14

risk factors for small bowel adenocarcinomas

Answer 14

non-modifiable = increasing age, crohn’s, coeliac disease, FAP

modifiable; smoking, obesity, low fibre intake, high red meat intake, alcohol excess

Question 15

clinical features of small bowel cancer

Answer 15

initially asymptomatic - first presents with small bowel obstruction due to luminal narrowing

a palpable mass may be found in 25% of cases

Question 16

investigations into suspected small bowel cancer

Answer 16

CT imaging

if proximal then an upper GI endoscopy can be performed and a histological sample taken via biopsy

Question 17

management of small bowel cancer

Answer 17

any symptomatic small bowel tumour requires resection - the type of resection depends on the location

duodenal tumours may require pancreaticduodenectomy (whipple’s procedure)

adjuvant chemo used in metastatic disease

Question 18

when would whipple’s procedure be indicated

Answer 18

duodenal tumours

Question 19

when would chemo be used in patients with small bowel disease

Answer 19

when it is lymph node positive - i.e. the lymph nodes have become involved

Question 20

what would be the best management option for a previously healthy patient with a lymph node negative small bowel adenocarcinoma

Answer 20

wide local small bowel resection

Question 21

what are neuroendocrine cells

Answer 21

any cell that receives input from neurotransmitters to release hormones into the bloodstream

Question 22

what are Gastroenteropancreatic neuroendocrine tumours (GEP-NETs)

Answer 22

neuroendocrine tumours originating from the neuroendocrine cells within the GI tract or the pancreas

Question 23

how are GEP-NETs further classified

Answer 23

into; non-functioning tumours (which have no hormone related clinical features) and functioning tumours (which cause symptoms due to peptide and hormone release)

Question 24

what is Carcinoid syndrome

Answer 24

occurs following the metastasis of a carcinoid tumour whereby the metastasised cells begin to oversecrete bioactive mediators, such as serotonin, prostaglandins and gastrin into the circulation

present with symptoms of flushing, palpitations, abdo pain, diarrhoea

Question 25

what specific blood tests need to be done to detect a GEP-NET

Answer 25

chromogranin A and 5-HIAA levels

also pancreatic polypeptide (PP)

(+ endoscopic and CT imaging)

Question 26

management of GEP-NETs

Answer 26

only curative option is surgery

those with metastatic disease - palliative chemo alone is typically advised

Question 27

what medication is used in symptomatic control of carcinoid syndrome to avoid carcinoid crisis

Answer 27

somatostatin analogues

Question 28

what is carcinoid crisis

Answer 28

caused by an overwhelming release of hormones from the NET, resulting in resistant severe hypotension