Small Intestine

Question 1

The first main artery that branches off the abdominal aorta is :

Answer 1

The celiac artery 
and then give off 3 of its own brnaches : 
1)splenic artery 
2) left gastric artery 
3) common hepatic

Question 2

The peritoneum :

Answer 2

Double layer of serous membrane or mesothelium with 2 parts : parietal and visceral
It forms folds such as mesentries , omenta and ligaments

Question 3

The 2 types of contractions of small bowel:

Answer 3

1) to and fro- motion mixes chyme digestive juices

2) peristaltic- contraction moves food distallyb

Question 4

Enteroclysis :

Answer 4

Is washing out of the intestine
Minimally invasive radiographic procedure ( catheter introduction) for the small intestine followed by injection of barium and methylcellulose

Question 5

Advantages of enteroclysis:

Answer 5

1) increase in the distention of the lumen , which will help to determine : 
Fold thickness
Polyps
Ulceration
Constrictions 
Adhesive bands

Question 6

USS of the abdomen can differentiate :

Answer 6

Can differentiate Fluid filled dilated small bowel loop from abdominal cystic structures

• can assess free fluid within the peritoneal cavity
• can assess solid mass belonging to small bowel if large enough

Question 7

Estimation of fecal fat -normal fecal fat output is :

Answer 7

Less than 6g/day ( if standard diet of 100gr)

Most sensitive test of disorders of digestion and absorbtion

Question 8

Causes of intestinal obstruction:

Answer 8

1) mechanical (dynamic) ->
intraluminal ( foreign bodies, faecal impaction, gallstones..)
Intramural(stricture, malignancy, volvulus..)
Extramural(bands/adhesions, hernia)
2)ileus (adynamic)->
Paralytic ileus
Pseudo-obstruction

Question 9

Clinical features of intestinal obstruction:

Answer 9

1) colicky central abdominal pain
2) vomiting
3) abdominal distention
4) constipation

Question 10

Treatment of acute intestinal obstruction:

Answer 10

1) GI drainage via nasogastric tube
2) fluid and electrolyte replacement
3) relief of obstruction
* surgical treatment is done after complete resuscitation

Question 11

Indication for early surgical intervention:

Answer 11

• obstruction of external hernia
• clinical features suspicious of intestinal strangulation
• obstruction in a ‘virgin’ abdomen

Question 12

Paralytic ileus:

Answer 12

Failure of transmission of peristaltic waves 2nrdy to neuromuscular failure

-will lead to accumulation of fluid an gas within the bowel
With associated distention, vomiting , absence of bowel sounds and constipation .

Question 13

Symptoms of acute mesenteric ischemia:

Answer 13

Sudden abdominal pain
Passage of altered blood
Shock

Question 14

Sympt. Of chronic mesenteric ischemia:

Answer 14

Abdominal angina

Weight loss Or diarrhea

Question 15

Treatment of mesenteric ischemia :

Answer 15

Resuscitation
Gut resection
Embolectomy
Vascular bypass or endarterectomy

Question 16

Pathological features of Crohn’s disease:

* disease of uncertain etiology characterized by full thickness inflammatory process

Answer 16

1) Full thickness inflammation
2) Edema
3) Fissures/ ulcerations
4) Non caseating foci of epithelioid and giant cells

Question 17

Clinical features of acute Crohn’s disease :

Answer 17

• Pain R. Iliac fossa with tenderness
• features of low small intestine obstruction
• rare, perforation causing peritonitis

Question 18

Clinical features of chronic Crohn’s diseases :

Answer 18

• colicky abdominal pain + diarrhea
• weight loss
• perianal fistulas
• fistulation into adjacent organs

Question 19

Treatment of Crohn’s disease :

Answer 19

✅corticosteroid 
✅aminosalicylates 
✅immunomodulators (ex. Azathioprine) 
✅monoclonal Ab
✅ Antibiotics for perianal disease 
✅ surgery: resections , strictureplasty or colectomies

Question 20

Intestinal tuberculosis:

Answer 20

Starts when ingested from infected source or from swallowed sputum from open pulmonary tuberculosis

-Pathology: ulcerations , stricture formation and LN enlargement
-General clinical features: wight loss , low grade fever , fatigue
Abdominal clinical features : distention, borborygmi, diarrhea , constipation and ulceration , palpable mass in R. Iliac fossa

Question 21

Borborygmi:

Answer 21

Rumbling or gurgling noise made by the movement of fluid and gas in the intestine

Question 22

Treatment of intestinal TB:

Answer 22

✅ Anti-tuberculosis drugs (RIFAMPIN, isoniazid, pyrazinamide, ethambutol)
✅ surgery for complications ( stricture , perforation, hemorrhage)

Question 23

Small bowel diverticulosis:

Answer 23

-duodenal diverticula: 90% asymptomatic
-Meckel’s diverticulum 40cm of the ileocecal valve, congenital anomaly, may cause bleeding, obstruction and acute inflammation
*asymptomatic Meckel’s diverticulum are left as they found , while narrow necked , inflamed or symptomatic are excised
✅treatment : resection with enterorrhaphy (stitching an intestine)

Question 24

Etiological factors for tumors of the small intestine include :

Answer 24

1) inherited conditions - polyposis coli , peutz-jegherz synd., gardner’s syndrome
2) immunocompromised states ( AIDS, coeliac disease ..)
3) geographical areas ( lymphomas more common in middle east )

Question 25

Hyper-plastic polyps: | *benign tumors have a slow growth and delayed clinical presentations.

Answer 25

* are benign mucosal growth | * generally asymptomatic- has malignant potential

Question 26

Stromal tumors : | Leiomyomas

Answer 26

* most common symptomatic small bowel lesions | * differentiating : between benign gut stromal tumors and malignant is difficult

Question 27

Peutz-Jeghers synd.:

Answer 27

* autosomal dominant disorder | * mucocutaneous pigmentation( face, lips , and buccal mucosa)

Question 28

Frequent complication of hemangiomas :

Answer 28

GI bleeding

Question 29

Causes of malignant tumors in the small intestine :

Answer 29

* genetic risk factors: - familial adenomatous polyposis - hereditary nonpolyposis colorectal cancer - diet - tabacco and alcohol - crohn disease - celiac disease

Question 30

Most common symptoms of small bowel malignant cancer: | Typically asymptomatic in the early stages

Answer 30

Abdominal pain+ weight loss | - bleeding, nausea, vomiting and obstruction are LESS COMMON

Question 31

lab studies in Malignant tumor of small intestine :

Answer 31

- mild anemia - liver function tests - carcinoembryonic Ag levels are ↗️↗️ - imaging studies: plain abd. X ray films , abd. CT scan - procedures : upper GI endoscopy, small bowel enteroscopy, colonoscopy

Question 32

Adjuvant therapy of malignant cancer :

Answer 32

✅irinotecan therapy ✅FOLFOX 4 regimen ( combination of 5-FU, oxaliplatin and leocuvorin) ✅IMATINIB mesylate

Question 33

Surgical care in tumors :

Answer 33

✅generally- wide local excision ✅proximal duodenum- pancreaticduodenectomy ✅palliation in pts with symptomatic advanced disease

Question 34

Carcinoid tumors arise from a special type of cells and produce :

Answer 34

- > enterochromaffin cells - >produce : gastrin , calcitonin , insulin vasoactive intestinal peptide , neurotensin , catecholamines and corticotropin . * pts with these tumors have elevated urinary excretion of 5HIAA

Question 35

Carcinoid synd.:

Answer 35

Pts with this syndrome have commonly been diagnosed with irritable bowel synd. Or idiopathic flushing *characterized : hepatomegaly , diarrhea , flushing in 80% of pt R. Heart valvular diseases in 50% Asthma in 25% *cutaneous flushing is earliest sign of the syndrome

Question 36

Some characteristics in the physical examination of carcinoid synd. :

Answer 36

``` face , neck and upper chest flushing , hT *Skin: Facial telangiectasis + Extremity rash *Abdomen: Disetended , hepatomegaly, bowel sounds * increased lacrimation *fever *lungs- wheezing *heart: tricuspid valve regurgitation Pulmonic stenosis ```

Question 37

Indications for small bowel transplant :

Answer 37

▪️short bowel syndrome( condition where the body cannot absorb enough nutrients from the foods intake bc of no enough SI ). ▪️irreversible intestinal failure ▪️end stage liver disease for combined liver and small intestine transplantation ▪️cong. Mucosal disorders ▪️locally invasive tumors

Question 38

Gastroschisis =

Answer 38

Birth defect where there is a hole in the abdominal wall beside the belly button

Question 39

Hirschsprung disease =

Answer 39

Birth defect in which some nerve cells are missing in the large intestine so the childs intestine cant move stool and becomes blocked

Question 40

Postoperative of small bowel transplantation:

Answer 40

*Induction therapy with : Tacrolimus and steroids Is typically begun most often in conjunction with an interleukin 2 receptor Ab * high levels of immunosuppression early in the post operative period ( when the rejection risk is greatest)

Question 41

Mesentery= | + its function

Answer 41

``` The fan shaped layer of the peritoneum that suspends the jejunum and ileum from the posterior wall of the abdomen Function: -keeping the guts in place -limiting gut movement -protection from injury -conduit ```

Question 42

Intussusception:

Answer 42

Is a serious condition in which part of the intestine slides into an adjacent part of the intestine

Question 43

Medical and surgical treatment of carcinoid syndrome :

Answer 43

Medical= ✅chemotherapy - for palliative purposes ✅radiation- palliative role ✅OCTREOTIDE- reduction of symptomes ✅Antidiarrheal- diarrhea Surgical= ✅larger than 1.5cm segmental resection with lymphadenectomy ✅metastatic stage : resection even if only for palliation ✅obstruction lesions- resection or bypass ✅intraarterial chemotherapeutic infusion

Question 44

Rarity of Small intestinal tumors causes=

Answer 44

1) rapid intestinal transit 2) greater fluidity of small bowel chyme 3) alkaline ph 4) low bacterial colony counts 5) higher levels of benzyl peroxidase 6) increased levels of immunoglobulin A 7) widespread gut lymphoid tissue

Question 45

Mesenteric lymphadenitis:

Answer 45

- inflammation of the LNs in mesentery - usually results from an intestinal infection - occurs mainly in children and teens - often mimics the signs and sympts of appendicitis * unlike appendicitis, it is seldom serous and clears on its own