Small Bowel and Appendix Flashcards Preview

My DEMS I > Small Bowel and Appendix > Flashcards

Flashcards in Small Bowel and Appendix Deck (43):
1

Tumors of the appendix

About 1/2= carcinoid (neuroendocrine tumor), mets to liver can produce serotonin syndrome (episodic flushing, diarrhea, wheezing and right sided valvular heart disease)
-Mets rare if tumor pseudomyxoma peritonei charac by diffuse collections of gelatinous material thru the abdomen

2

Appendicitis

-mid abdominal pain that migrates to the RLQ
-Nausea and vomiting -High fever, WBC count and severe pain suggest perforation.
-IV fluids, IV antibiotics and surgical resection are the treatment.

3

Plicae circulares

more in prox jejunum, absent terminal ileum

(ileum empties into cecum of LI)

4

absorption and transport of fluids

9L secreted/ingested
8.9 L absorbed
100 ml excreted

5

Malabsorption/maldigestion

-inadequate absorp of nutrients
-Clinical signs: weight loss, diarrhea, steatorrhea, vitamin deficiencies
-Pale, bulky, malodorous stool: float, hard to flush, oily residue

6

Causes of malabsorption

Surgery:
-gastric bypass
-small bowel resection
Bacterial overgrowth
Meds:
cholestyramine-ADEK
phenytoin, folate
Pancreatic insufficiency
Liver disease
Intestinal inflammation/villous flattening (celiac sprue, Whipple's disease, tropical sprue)
Ulceration
Ischemia
Infiltration (amyloidosis)

7

What test might you use to dx fat malabsorption?

Sudan fat stain

8

Pancreatic insufficiency

90% burned out
Lipid (first) then protein then rarely carb malabsorption
-chronic pancreatitis
-CF

9

Liver disease

bile needed for absorption of lipids
-Cirrhosis (decreased func of hepatocytes, decreased bile formation)
-Biliary obstruction

10

Gastric Bypass

B-II, Roux-en Y

inadequate mixing of food with biliary and pancreatic secretions

11

Gastric Bypass Vitamin Deficiencies

B12, Fe, Ca, Vit D deficiencies are the most common
-Vit C, Cu rare
Prevention: multivitamin
Monitoring recommended

12

Small Bowel Bacterial Overgrowth

Normal:

13

Vitamin levels with bacterial overgrowth and
Dx

fat soluble vitamins and B12 deficiency (bacteria deconjugate bile salts, bacteria consume B12)

Folate: normal to high (bacterial production)

Dx:
-Aspiration of duodenum w/ culture
-Glucose-hydrogen breath test
-empiric treatment with antibiotics
Treatment: antibiotics (eg Ciprofloxacin)

14

Sx of Vit A def

night blindness
xerophthalmia

15

Sx of Vit D def

Osteomalacia
-bone mineralization defects

16

Sx of Vit E def

rare in adults
hemolytic anemia

17

sx of vit K def

clotting dysfunction
-PT

18

Celiac Sprue

-gluten sensitive enteropathy (wheat, barley, rye)
-inflammatory disease of small intestine
-loss of villi, crypt hyperplasia, lymphocytes
-80% asx (0.5-1% of US pop)
-incidence increases with age

19

Signs/sx of celiac sprue

Abdominal distension
Abdominal pain
Anorexia
Bulky, sticky, pale stools
-Steatorrhea
Diarrhea
Flatulence
Failure to thrive
-Weight loss
-Fatigue
Vomiting

20

Atypical signs/sx of celiac sprue

Iron deficiency Anemia
Dermatitis Herpetiformis
Liver function tests
-AST, ALT elevations
Cerebellar ataxia
Osteoporosis
Oral apthous ulcers

21

Celiac pathogenesis

-assoc w/ autoimmune diseases: thyroiditis, Type-I DM
-HLA-DQ2, HLA-DQ8 (40% US)
APC MHC II present gluten peptides

CD4+ Tcell response
All have ab to tissue transglutaminase (TTG)

22

Dx of Celiac sprue

Dx:
-finding on SI biopsy
-Serologic tests: anti-TTG, anti-endomysial antibodies, anti-gliadin IgA and IgG

Tx: gluten free diet

23

Findings on endoscopy for celiac

scalloped duodenal folds

24

Tropical sprue

-residents/visitors of tropics
-Cause: bacterial toxins or colonization of aerobic coliform bacteria

Classic presentation: Megaloblastic anemia from B12 and folate deficiency

Diagnosis: intestinal biopsy with villous flattening and travel history

Treatment: Antibiotics, B12, and folate

25

Whipple's Disease

RARE (

26

Mesenteric Ischemia

Atherosclerosis, Clot, Radiation

Chronic: 2 of 3 major vessels occluded
post-prandial abdominal pain, weight loss, sitophobia, malabsorption

Acute: embolus, severe abdominal pain

27

Malabsorption diagnostic tests

Focused testing-clinical scenario
Fecal Fat
Vitamin levels
CBC, albumin
CT-small bowel, liver, pancreas, bile ducts
Endoscopy

28

Small Intestinal Tumors

RARE primary tumors (

29

Two main causes of diarrhea

decreased fluid/elec absorption
increased secretion

-occurs when colonic water load exceeds absorptive capacity

30

Diarrhea classification

Fatty
-malabsorption
-maldigestion

Watery
-osmotic
-secretory

Inflammatory/exudative

Functional

31

Watery diarrhea-- osmotic

Carb malabsorption:
lactose
sorbitol (gum)
fructose (non-diet drinks and many commercial foods)

Osmotic laxatives:
-Magnesium containing
-Phosphate, sulfate (colonoscopy bowel preps)

Osmotic diarrhea: presence of OSMOLAR GAP

*ie presence of poorly absorbed luminal osmols

32

Osmotic vs secretory diarrhea

Osm gap= 290-2(stool sodium + potassium)

diff >50mOsm, diarrhea is osmotic

33

Lactose intolerance

>50% of world down-regulates lactase after weaning

-->diarrhea (osmotic), flatulence (colonic bacteria)

34

Secretory watery diarrhea

Bacterial toxins
-V. cholerae, E. coli enterotoxins
Neuroendocrine tumors
-gastrinoma, VIPoma, carcinoids, calcitonin
Ileal bile salt malabsorption
Stimulant laxatives
Disordered motility/regulation
-Diabetic neuropathy, postvagotomy, irritable bowel syndrome

35

Bile acid induced diarrhea

-from ileal dysfunction (only site of ACTIVE bile acid absorption
-increased bile acid into colon--> colonic secretion of fluid/elec--> diarrhea

36

Fatty diarrhea

Malabsorption syndromes
-Mucosal diseases (Celiac disease, Whipple’s disease)
-Short-bowel syndrome
-Small bowel bacterial overgrowth
Maldigestion/Malabsorption
-Pancreatic insufficiency
-Inadequate luminal bile salt concentration (chronic liver disease, biliary obstruction)

37

Inflammatory diarrhea

Infection

Inflammatory Bowel Disease
-Crohn’s Disease
-Ulcerative Colitis

Ischemia

38

Fecal leukocytes in intestinal infections

Present:
Shigella
Campylobacter
Enterohemorrhagic, enteroinvasis E. coli

Variable:
Salmonella
Yersinia
Clostridium difficile (pseudomembranous colitis)

Absent:
V. cholerae
Enterotoxigenic E. coli
Giardia lamblia

39

Inflammatory diarrhea dx

Infection:
Usually Stool Culture
Endoscopy

Ischemia:
CT scan
Endoscopy-colon

Inflammatory Bowel Disease:
Endoscopy

40

IBS

Abdominal Pain and altered bowel habits in the absence of an organic cause:
Pain improved with defecation
Pain onset with change in stool frequency
Pain onset with change in stool appearance
Constipation and/or Diarrhea
10-15% of the population North America

Possible mechanisms:
Visceral hypersensitivity
Carbohydrate malabsorption
-FODMAPS fermentable oligo-, di-, and monosaccharides and polyols (Fructose, fructans (wheat polymers e.g.inulin) sorbitol, lactose,)
Low grade inflammation

41

When to be concerned about IBS

Weight Loss
Rectal bleeding
Anemia
Nocturnal symptoms
Electrolyte abnormalities
Elevated inflammatory markers

42

What could be the result of longstanding Celiac?

T cell lymphoma

43

Arterial supply to SI, LI

SMA: part of duodenum, entire SI, half of colon

IMA: left colon and rectum

Collateral circ bt SMA and IMA via marginal arteries and Arc of Riolan