Small Intestine Flashcards
(96 cards)
1
Q
What is the most retroperitoneal part of the small intestine?
A
Duodenum
2
Q
[Segment of the small intestine]
wider in diameter, thicker wall, more vascular, less fatty, fewer arcades, longer vasa recta
A
jejunum
3
Q
Vitilline duct is obliterated at what age of gestation?
A
6 weeks AOG
4
Q
Age of gestation wherein there is extracoelomic herniation
A
5th week AOG
5
Q
What is the anatomic marker for the intestinal 270 degree counterclockwise rotation?
A
superior mesenteric artery
10th week AOG rotation
6
Q
What is the most common surgical disorder of the small intestine?
A
mechanical small bowel obstruction
7
Q
What is the most common cause of mechanical small bowel obstruction?
A
adhesions
8
Q
Most common cause of congenital adhesions?
A
Ladd or Meckel bands
9
Q
Proximal obstruction suggests that the regions involved are ____
A
- Pylorus
- Duodenum
- Proximal jejunum
10
Q
What are the cardinal signs on small bowel obstruction?
A
- Vomiting
- Obstipation
- Distention
- Crampy/colicky abdominal pain
11
Q
What are the triad of radiographic findings in SBO?
A
- Dilated small bowel loops >3cm
- Air-fluid level
- Paucity of air in the colon
12
Q
Mucosal thumb printing in radiographic findings in strangulated SBO is indicative of
A
bowel edema
13
Q
What is the gold standard to to differentiate partial from complete obstruction?
A
Small Bowel Series
Delay in passage of contrast and caliber change at site of obstruction
14
Q
What are the contraindications to non-operative management of small bowel obstruction?
A
- Suspected Ischemia
- Large bowel obstruction
- Closed loop obstruction
- Strangulated hernia
- Perforation
15
Q
After ingestion of 100mL water soluble contrast through NG in a patient with adhesive SBO with no signs and symptoms of intestinal ischemia, when will you do a KUB xray?
A
after 8 hours
16
Q
After ingestion of 100mL water soluble contrast through NG in a patient with adhesive SBO with no signs and symptoms of intestinal ischemia, when will you do a consider surgery?
A
if the contrast has not reached the colon after 72 horus
17
Q
Most common cause of intestinal fistulas?
A
post-operative complications
Enterotomies, anastomotic leaks
18
Q
A high output physiologic fistula has an output of that is more than?
A
> 500mL
19
Q
How many percent of intestinal fistula close spontaneously after 2 months?
A
10%
20
Q
What are the anatomic features that favors spontaneous intestinal fistula closure?
A
- Continuity maintained
- End fistula
- No associated abscess
- Free flow distally
- Duodenal stump
- Jejunal
- Tract >2cm
- Defect <1cm
- optimal nutritional status
21
Q
What are the anatomic features that makes spontaneous closure of intestinal fistula unfavorable?
A
- Complete disruption
- Lateral fistula
- Associated abscess
- Diseased adjacent bowel
- Distal obstruction
- Lateral duodenal
- Ileal
- Tract <2cm
- Defect >1cm
- Poor nutritional status
22
Q
What are the factors that inhibit spontaneous closure of fistulas?
A
- Foreign body within fistula tract
- Radiation enteritis
- Infection
- Neoplasm at fistula origin
- Distal obstruction of the intestine
23
Q
If the fistula fails to close at ____ month, surgical intervention is warranted
A
2-3 months
24
Q
When is the most favorable time to re-operate an intestinal fistula?
A
- Within 10 days of diagnosis
2. After 4 months
25
[Surgical intervention for small bowel neoplasm]
Duodenal adenoma that is <2cm
endoscopic polypectomy
26
[Surgical intervention for small bowel neoplasm]
duodenal adenoma that is >2cm
transduodenal polypectomy or segmental resection or pancreaticoduodenectomy
27
[Surgical intervention for small bowel neoplasm]
jejunal or ileal tumor
segmental resection with 5cm of tumor-free proximal and distal margins
28
What is the ODC for unresectable metastatic GIST?
Imatinim (Gleevec)
29
What is the most prevalent congenital anomaly of the GIT?
Meckel diverticulum
30
What is the rule of two'sin Meckel diverticulum?
2% of the population
2:1 male predominance
2 feet proximal to ICV
2 years old (1/2 of symptomatic)
31
What is the etiology of meckel diverticulum?
persistence of vitilline/ omphalomesenteric duct
32
What is the surgical management for symptomatic meckel diverticulum?
1. Diverticulectomy (wedge resection)
33
What is the most common cause of mesenteric ischemia?
arterial embolus
34
Mesenteric ischemia due to venous thrombosis usually affects what vein?
1. SMV
35
How will you medically manage non-occlusive mesenteric ischemia?
Mesenteric vasodilator - Papaverine infusion
36
What is the diagnostic modality of choice for arterial mesenteric ischemia?
CT scan/Angiography
37
What is the diagnostic modality of choice for venous mesenteric ischemia?
US duplex scan
38
[Diagnosis and surgical management]
intermittent vomiting, abdominal distention and tenderness, melena
AbXR: bowel loops spiraling about the axis of the mesenteric vessels
UGIS: abnormal C loop of duodenum
Barium enema: cecum at RUQ
Malrotation
Ladd procedure - untwisting of the bowels, divide ladd bands, incidental appendectomy
39
[Diagnosis and surgical management]
intermittent, colicky, abdominal pain, vomiting lethargy, sausage-shaped mass, currant jelly stools
UTZ: two rings of low echogenicity separated by a hyperechoic ring
Intussusception
1. Air then hydrostatic reduction via Barium enema
40
___ sign refers to the absence of bowel in the RLQ associated with intusussception
Dance sign
41
[Diagnosis and surgical management]
Feeding intolerance, maternal polyhydramnios, bilious emesis, abdominal distantion, non-passage of meconium in the first day of life
AbXR: dilated bowel loops with differential air-fluid level
Barium enema: microcolon
Intestinal atresia
Resection of proximal bulbous bowel and atretic segment and primary end-to-end anastomosis
42
[Diagnosis and surgical management]
Feeding intolerance, bilious emesis, family history of cystic fibrosis, abdominal distention
AbXR: gas filled loop
Barium Enema: microcolon and inspissated meconium
Meconium ileus
1. Ileostomy with mucus fistula
2. Ileostomy take down after 2 to 3 weeks
43
Double bubble sign is usually seen in?
duodenal obstruction
44
Eggshell pattern is seen in?
meconium ileus
45
What is the most common and lethal GI disorder affecting a preterm neonate?
necrotizing enterocolitis
46
What is the indication for surgery in patients with necrotizing enterocolitis?
Pneumoperitoneum
47
What is the remnant length of the small bowel of adults that warrants a permanent parenteral nutrition therapy?
Length <120cm if without colon in continuity
Length <60cm if with colon continuity
Children:
Length less than 30cm
48
What is the normal small bowel length in adults?
300 to 600cm
49
What is the normal small bowel length in full term infants?
200 to 250cm
50
What is the most common subtype of short bowel syndrome?
Type 2
small bowel resection with partial colon resection and resulting entero-colonic anastomosis
51
What type of short bowel syndrome is the most challenging to manage?
Type 1
small bowel resection with high-output jejunostomy
52
What type of short bowel syndrome that is best tolerated with the most adaptive potential?
Type 3
small intestine resection with small bowel anastomosis and intact colon
53
What are the adaptive changes in patients with short bowel syndrome?
1. Elongation and dilation of the small bowel
2. Hyperplasia of the mucosal epithelium
3. Increase in villous height, crypt depth, cell proliferation, enzyme activity
54
What is teh most potent intestinotrophic hormone?
Glucagon-like peptide-2 (GLP-2)
55
What is the surgical management of choice to improve the intestinal function and motility to maximize remnant intestine?
autologous intestinal reconstruction surgery
56
What is the surgical management of choice to increase the absorptive area of the short bowel?
Longitudinal intestinal lengthening and tailoring (LILT/Bianchi STEP)
57
What are the contents of the mesoappendix?
Vessels and nerves
58
What is the landmark used to identify the location of the appendix?
Anterior taenia
59
The appendiceal artery is a branch of ____-
posterior cecal branch of the ileocolic artery
60
what is the most common location of the tip of appendix?
retrocecal
61
What is the most common cause of acute surgical abdomen?
Acute appendicitis
62
What is the most constant clinical manifestation in patients with acute appendicitis?
anorexia
63
What is the prime symptom in patients with acute appendicitis?
RLQ pain
64
___ point is suggestive of acute appendicitis wherein the right third point of the interspinal line is tender
Lanz point
65
___ point is suggestive of acute appendicitis wherein the right side below the umbilicus is tender
Kummel point
66
[Special signs on PE of Acute Appendicitis]
referred pain or feeling of distress in epigastrium or precordial region on continued firm pressure over the mcburney poin
Arron sign
67
[Special signs on PE of Acute Appendicitis]
sharp pain elicited by pinching appendix between thumb of examiner and iliacus muscle
bassler sign
68
[Special signs on PE of Acute Appendicitis]
transient abdominal wall rebound tenderness
Blumberg sign
69
[Special signs on PE of Acute Appendicitis]
exacerbation of pain when the uterus is shifted to the right side
Bryan sign
acute AA in pregnancy
70
[Special signs on PE of Acute Appendicitis]
pain in areas supplied by T10, T11, T12 on the right
Cutaneous hyperesthesia
71
[Special signs on PE of Acute Appendicitis]
increased abdominal pain on coughing
Dunphy sign
72
[Special signs on PE of Acute Appendicitis]
migration of pain from the umbilical region to the right iliac region
Kocher Sign
73
[Special signs on PE of Acute Appendicitis]
grimace when examiner performs a firsm swish with index and middle finger across abdomen from epigastrium to right iliac fossa
Massouh sign
74
[Special signs on PE of Acute Appendicitis]
tenderness in RLQ increases when patient moves from supine position to a recumbent posture on the left side
Rosenstein sign
75
[Special signs on PE of Acute Appendicitis]
Pain at RLQ when palpatory pressure exerted at LLQ
Rovsing Sign
76
[Special signs on PE of Acute Appendicitis]
Patient lies on left side , examiner slowly extends right thigh, stretching the iliopsoas muscle
Ilopsoas sign
Positive if extensions produces pain
77
[Special signs on PE of Acute Appendicitis]
Passive internal rotation of the flexed right thigh with the patient in supine position
Obturator sign
positive if with hypogastric pain on stretching the obturator internus muscle
78
[Special signs on PE of Acute Appendicitis]
Increased abdominal muscle tone ont he exceedingly gentle palpation of right iliac fossa
Summer sign
79
[Special signs on PE of Acute Appendicitis]
pain caused by gentle traction fo the right spermatic cord
Ten Horn Sign
80
What are the components of your alvarado score?
MANRELS
```
1 Migratory RLQ pain
1 Anorexia
1 Nausea/vomiting
2 RLQ tenderness
1 Rebound tenderness right iliac fossa
1 Elevation in temperatire
2 Leukocytosis
1 shift to the left of neutrophils
```
81
What are the direct signs of acute appendicitis in UTZ?
1. Non-compressible appendix
2. Diameter >6mm
3. Single wall thickness >/ 3mm
4. Target sign
5. Appendicolith
82
What are the indirect signs of acute appendicitis in UTZ?
1. Free fluid surrounding appendix
2. Local abscess formation
3. Increased echogenicity of local mesenteric fat
4. Enlarged local mesenteric LN
5. Thickening of the peritoneum
6. Signs of secondary small bowel obstruction
83
What are the CT scan criteria for Acute appendicitis?
1. Diameter >6mm
2. Wall thickness >2mm
3. Periappendiceal inflammation
4. Presence of fecalith
5. Thickened cecum funneling contrast toward appendiceal orifice
84
Ruptured appendicitis is common in what age group?
Pediatric and geriatric age group
85
What are the most common findings in erroneous diagnosis of AA?
1. Acute mesenteric lymphadenitis
2. No organic pathologic condition
3. Acute PID
4. Twisted ovarian cysts
5. Ruptured Graafian follicle
6. AGE
86
What is the most common extrauterine surgical emergency?
Appendicitis in the pregnancy
87
When can you do a conservative management in patients with complicated appendicitis?
1. Confined abscess or phelgmon
| 2. Limited peritonitis
88
What is a Valentino appendicitis?
RLQ pain from perforated peptic ulcer
89
What are the indications of incidental appendectomy?
1. Children about to undergo chemotherapy
2. Disabled individuals
3. Crohn disease
4. Individuals about to travel to remote places
90
What is the most common site of GI carcinoid?
Appendix
Carcinoid - Best prognosis
91
What will be your management for a 3cm appendiceal carcinoid?
Right hemicolectomy
Remember, >2cm appendiceal carcinoid, Right hemicolectomy
92
What will be your management in a patient with 1.5cm appendiceal tumor at the mid of appendix?
Appendectomy
Remember, appediceal tumor >1 or 2cm in the tip and mid appendix, do appendectomy
93
What will be your management in a patient with 1.5cm appendiceal tumor at the base of appendix?
Right hemicolectomy
Remember, appediceal tumor >1 or 2cm in the base of appendix, do right hemicolectomy
94
Type of Appendiceal CA that is rare and has the worst survival
Signet ring CA
Tx: Right hemicolectomy
95
___ refers to diffuse collection of gelatinous fluid and mucinous implants on peritoneal surfaces and omentym
Pseudomyxoma peritonei
96
What is the CT scan finding of appendiceal lymphoma?
1. Diameter >2.5 cm
| 2. Surrounding soft tissue thickening
