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Flashcards in small intestine and appendix Deck (187):
1

the duodenum

-extends from pylorus to ligament of treitz
-retroperitoneal
-4 segments: duodenal bulb and descending duodenum which house major/minor duodenal papillae

2

minor and major papilla

minor- drainage of dorsal pancreatic duct (accessory duct of Santorini)

major- drains common bile duct and main pancreatic duct (duct of wirsung)

3

jejunum

more prominent plica circualres and longer vasa recta than ileum

4

blood supply of small intestine

primarily the superior mesenteric artery (SMA)

duodenum also supplied by gastroduodenal artery, originating from celiac axis via common hepatic artery

5

venous drainage of small intestine

superior mesenteric vein (SMV) which is joined by splenic and inferior mesenteric veins to constitute the portal vein

6

lymphatic drainage of small intestine

lacteals and lymphatic channels paralleling the venous drainage, joining at the cisterna chyli in upper abd below the aortic hiatus of the diaphragm

7

lymphatic tissue of terminal ileum

known as Peyer's patches and terminates at ileocecal valve

8

nerve supply of small intestine and appendix

autonomic nervous system

parasympathetic fibers from vagus nerve and traverse to gut via celiac plexus

sympathetic fibers travel via splanchnic nerves from ganglion cells in superior mesenteric plexus

intestinal distention- sympathetic visceral afferent fibers

9

appendix

arises from the cecum at the confluence of the taenia coli and accompanied by an adjacent mesentery (mesoappendix) which courses the appendiceal artery as a terminal branch of ileocolic artery

10

how is the primary function of digestion and absorption of the small intestine accomplished

intestinal motility, activity of digestive enzymes, secretion of digestive juices, and absorptive processes predicted on both simple diffusion and active transport

autonomic and endocrine regulation

11

4 phases of migrating motor complex (MMC)

1. quiescent w no spikes or contractions
2. accelerating and intermittent spike and contractile activity
3. sequence of high amplitude spiking activity and corresponding strong, rhythmic gut contractions
4. brief migrate down the small intestine

total duration of cycle is 90-120m

12

where is vit b12, a, d,e,k and bile salts, calcium and iron absorbed

b12,a,d,e,k,bile salts- terminal ileum
ca/fe- duodenum and proximal small bowel

13

what does IgA for the gut immune system

suppress bacterial growth and adherence to epithelial cells

neutralizes bacterial toxins and viruses

14

what happens with SBO

lumen of the small intestine is blocked causing small bowel effluent to back up resulting in abd distension, n, v

mesentery can be compromised causing strangulation of the intestine w resulting ischemia and potentially bowel necrosis

15

closed loop bowel obstruction

complete obstruction where a portion of small intestine is obstructed both proximally and distally

high risk for strangulation and requires immediate surgery

16

intraluminal causes of SBO

foreign bodies, barium inspissation (colon), bezoar, inspissated feces, gallstone, meconium (cystic fibrosis), parasites, intussusception, polypoid

17

intramural causes of SBO

congenital (atresia, stricture, stenosis, web, meckels diverticulum)
inflammatory process (crohns, diverticulitis, ischemia, radiation enteritis, medication induced)
neoplasms (primary bowel, seconday)
trauma

18

extrinsic causes of SBO

adhesions, congenital (ladd/meckels bands, postop, postinflammatory)
hernias (ext/int)
volvulus
external mass effect (abscess*, annular pancreas, carcinomatosis, endometriosis, pregnancy, pancreatic pseudocyst)

19

MC SBO cause in industrialized and nonindustrialized

indust- postsurgical adhesions or scar tissue

nonind- inguinal or umbilical hernia

20

SBO due to internal hernias after laparoscopic gastric bypass

small mesenteric defects can be created through which small bowel can herniate and cause obstruction and potentially strangulation

21

metastatic peritoneal cancer as cause of extrinsic SBO

metastatic peritoneal implants, commonly from ovarian or colon cancer, may compress the small bowel lumen causing an intestinal obstruction

22

how do instrinsic causes affect the small bowel

causes thickening of the bowel wall and causes lumen to compromise forming a stricture within the small intestine not allowing solids to pass through the narrow lumen causing abdominal crampy pain

23

MC cause for benign stricture

Crohn's disease

less common- radiation enteritis, ulcers from nsaids, previous small bowel resection

24

is strangulation assoc w bowel obstructions caused by strictures

not likely since mesentery is not compromised

25

how a foreign body (intraluminal cause) causes SBO

in some the ileocecal valve produces a slight narrowing that may form a barrier for some larger foreign bodies so they become impacted at the valve and an obstruction develops

26

what is the most serious complication of SBO

strangulation of the involved intestine because the bowel becomes ischemic and eventually infarcts as edema and kinking of the mesentery impact mesenteric vascular patency

27

indicators of a higher risk of strangulation

fever
tachycardia
leukocytosis
localized abd tenderness

28

pt w intermittent, intense, colicky pain relieved by vomiting of the epigastric region

proximal sbo (open loop)

29

pt with intermittent to constant pain that is diffuse and progressive, moderate abd distention, obstipation, and mild vomiting

distal sbo (open loop)

30

pt with progressive diffuse pain that was intermittent but rapidly worsened and is now constant, no abd distention

sbo closed loop

31

pt w continuous diffuse pain, w intermittent vomiting, marked abd distention and obstipation

colon and rectum obstruction

32

what should you be concerned about if pain and tenderness begin to localize in a more somatic pattern

bowel ischemia and peritonitis w attendant parietal peritoneal irritation

33

in an obese pt what may be the only clue to bowel incarceration within an otherwise occult hernia

areas of focal contour change, erythema or tenderness near a surgical scar

34

when will diffuse mild tenderness improve usually w sbo

after acute decompression via a nasogastric tube

35

initial imaging studies for sbo

abd series- supine and upright abd films
upright chest radiograph

36

imaging findings for sbo

bowel distention proximal to point of obstruction and collapse of bowel distal to same point

37

what do air fluid levels on an upright film indicate

lack of normal propulsive activity in affected loops of intestine

38

what represents closed loop obstruction on abd series

focal loops of intestine that are persistently abnormal

39

if the bowel is massively distended with air and it is difficult to distinguish the small and large bowel what should be done

water soluble contrast enema to exclude the possibility of a large bowel obstruction mechanism

40

when are contrast studies of the small intestine useful

pt w persistent partial obstructive symptoms or when it is difficult to distinguish paralytic ileus from mechanical obstruction

41

lab tests for sbo

helpful in excluding other causes

leukocytosis- if persists despite ng decompression and fluid resuscitation can mean progression toward ischemia

electrolytes closely monitored

hypokalemic- contraction of alkalosis w adv dehydration

hyperamylasemia- sbo but w marked degree heighten suspicion for acute pancreatitis

UA- excluding evidence for infection or stone

lactic acidosis- bowel ischemia

42

what is the most frequent ddx considered in setting of possible sbo

paralytic ileus

43

process of paralytic ileus

bowel motility is suppressed as a consequence of systemic or inflammatory illness and bowel may become distended and pt obstipated ; no mechanical obstruction

44

pt with minimal abd pain, n/v, obstipation, cant pass gas, abd distention, dec/absent bowel sounds, gas in small intestine and colon on xray

paralytic ileus

45

pt with crampy abd pain, n/v, obstipation, abd distention, norm/inc bowel sounds, gas in small intestine on xray

sbo

46

cause of POI

stress of surgery, fluid and electrolyte imbalances, pain management with narcotics

47

fast tract protocol

used to try and minimize POI by avoiding ng tubes, early ambulation, avoidance of fluid overload and early intro of diet

48

medication approved to dec length of POI

alvimopan- opioid antagonist that specifically targets the mu receptor responsible for the gi side effects of opioids

doesnt cross bbb so selectively blocks the peripheral receptors contributing to POI wout sig altering central analgesic effects of opioids

49

what does tx for sbo begin with

resuscitation, correction of fluid and electrolyte deficits

50

what is the best tool for assessing adequacy of volume replacement

foley catheter to assess urine output
at least 0.5mL/kg

51

what does an ng tube placement do

control emesis, relieve intestinal distention proximal to obstruction, lower risk of aspiration, allow monitoring of ongoing fluid and electrolyte losses

52

reduction en mass

hernia sac is reduced w the contents as a unit and therefore the contents may remain compromised despite being internalized

53

if there is question in regard to bowel viability what is an intraoperative assessment that is done

intraop assessment w fluorescein dye or doppler us to asses perfusion along with clinical evaluations of bowel viability such as color, bleeding, and peristalsis

54

what should be done if intussusception if found in adults

resection because of high likelihood of a lead point lesion

55

what are some complications that may complicate operative intervention for sbo

wound infection, anastomotic leak, abscess, peritonitis, and fistula formation

56

features of crohns ds

involves segments of GI tract other than the colon
sparing or skip lesions between affected areas
transmural involvement and assoc tendency to dev fistulas
noncaseating granulomata on histology

57

gradual onset with progression of abd pain, diarrhea, and weight loss

crohns

as progresses have malaise, fatigue, fever, weight loss, anorexia, n/v

58

dx crohns

colonoscopy w visualization of terminal ileum or barium enema w inspection of terminal ileum and small bowel contrast studies

59

biologies for crohns

infliximab
adalimumab
certolizumab

60

indications for surgery w crohns disease

perforation
fibrotic stricture- acute complete or chronic partial BO
fistula

61

what if a pt w a fistula fails to respond to medical management

resection of the communicating bowel and simple debridement or limited excision of the communicating cutaneous or nonenteric visceral tract

62

how long does the small intestine have to be maintained in order for them to sustain oral intake

100cm

63

complications of crohns

malnutrition, obstruction, fistulous ds, electrolyte distrubances
medication se
progression of ds resistant to medical therapy
wound infx, short bowel syndrome, wound healing problems, fistulae
anal incontinence

64

4 major etiologies for acute mesenteric ischemia (AMI)

sma embolism
sma thrombosis
mv thrombosis
nonocclusive mesenteric ischemia

65

SMA embolism

-originate from heart and assoc w afib
-thrombus forms win the heart and becomes dislodged, the clot passes downt he sma and lodges as the vessel narrows just distal to the take off of the middle colic artery completely occluding downstream flow

66

sma thrombosis

-freq assoc w vascular ds like CAD,PVD, chronic renal insuff
-chronic stenosis of the sma and if the vessel forms an acute thrombosis, ami may occur
-usually begins at origin of SMA and more likely to lead to complete SB infarction

67

smv thrombosis

-result of hypercoag state
-clot forms in smv obstructing venous outflow which results in venous htn, inc bowel wall edema and dec arterial flow

68

nonocclusive mesenteric ischemia (NOMI)

-usually dx in ICu setting in critically ill pts
-hx of toehr sig atherosclerotic ds
-in severe shock, blood shunted away from GI tract and if process cont there can be sig vasospasm of the splanchnic circulation, resulting in ischemia of sm/lg intestine

69

pt presents w severe rapid onset of pain, abd exam unimpressive

AMI

pain out of proportion to PE

70

presentation of SMV thrombosis and NOMI

smv- insidious onset, pain for several days or weeks, diffuse and nonspecific

nomi- min abd pain that is overshadowed,**hemodynamic instability (primary cause)

71

dx mesenteric ischemia

direct visualization of vascular tree via mesenteric arteriogram

delayed films to obtain a venous phase to determine if smv is thrombosed

CT is replacing

72

initial tx for mesenteric ischemia

rapid resuscitation and correction of any metabolic abnorm
abx

rapidly restore blood flow to gut, resect necrotic bowel and min reperfusion injury

73

tx for pt w sma embolism

immediate embolectomy via laparotomy

sma isolated and arteriotomy is performed

catheter placed directly into artery above clot and balloon inflated and catheter removed along with clot

74

tx for sma thrombosis

revasc required since sma chronically narrowed by severe atherosclerotic ds

sma bypass procedure or sma endovasc stent

75

tx for smv thrombosis

supportive and prompt anticoag w iv heparin

76

tx nomi

underlying pathology and aggressive resucitation efforts

avoid alpha adrenergic vasopressors and digoxin since the induce spasm and vasospasm is major part of nomi

77

mc benign lesion of small intestine

leiomyomas, which occur mc in jejunum but can occur anywhere in digestive tract are on the benign spectrum of mesenchymal tumors of the GI tract and now referred to as GI stromal tumors (GISTs)

78

where do leiomyomas or GISTs arise from

interstitial cells of cajal

79

other nonepithelial benign small bowel lesions

hemangiomas important potential cause of occult bleeding Osler Weber Rendu syndrome
hamartomas- peutz jeghers syndrome
lymphangiomas
neurogenic tumors (schwannomas, neurofibromas)

80

epithelial benign lesions of small intestine

tubular adenomas
villous adenomas- more likely malignant so need to be excised
brunner's gland adenomas- duodenum, asymp

81

mc malignancy affecting individuals w familial polyposis after proctocolectomy

duodenal carcinoma of periampullary region

82

adenocarcinomas of small intestine

mc in duodenum w dec incidence as move distally
obstruction assoc w wl mc presentation
occult bleeding and anemia
endoscopic screening of periampullary region

83

carcinoid tumors of small intestine

-arise from kulchitsky cells in crypts of lieberkuhn part of APUD
-mc in ileum
-obstruction is mc finding due to intense desmoplastic reaction that occurs in adjacent bowel mesentery, others inlcude anorexia, fatigue and wl
-dx made laparotomy
-tx wide excision of bowel and adjacent mesentery

84

carcinoid syndrome

-episodic cutaneous flushing, bronchospasm, intestinal cramping/diarrhea, vasomotor instability, pellagre like skin lesions and right sided valvular heart ds
-dx urinary measurement of 5-hiaa, serum measurement of serotonin or chromogranin a
-tx resection

85

lymphoma (small intestine mc site of extranodal lymphoma)

-ileum mce to peyers patches
-nonspecific symp: vague abd pain, wl, fatigue, malaise
-nodularity and thickening of wall on contrast studies or ct
-surgical resection w subsequent chemo or radiation

86

what is the mc congenital anomaly of small intestine

meckel's diverticulum- represents a remnant of the embryonic vitelline or omphalomesenteric duct

87

rule of twos for meckels diverticulum

2% of population
2:1 male to female
2 types mucosae
located within 2 ft of ileocecal valve

88

anatomy of meckels diverticula, where does the diverticulum arise from, and blood supply

-evolve when there is incomplete obliteration of the viteline duct which arises from the midgut and typically closes between 8th and 10th week of gestation
-arises from antimesenteric border of ileum usually within 60cm (2ft) of ileocecal valve
-blood supply from vitelline vessels, arising from ileal blood supply

89

what is the most common type of heterotopic mucosa found within the diverticulum

gastric-may cause ulceration of adjacent small intestinal mucosa and hemorrhage because of its capacity to produce acid in direct proximity to small bowel mucosa

less freq is pancreatic and colonic

90

what happens if there is a complete persistence of vitelline duct

sinus from the umbilicus to ileum may result presenting as an enteric fistula at the umbilicus itself

91

what happens if the vitelline duct obliterates but leaves a fibrous cord remnant

remnant may act as a point of fixation of the small intestine to the abd wall and facilitate bowel obstruction

92

clinical presentations in meckels diverticula

hemorrhage-bright red/maroon per rectum, painless, infants under 2
ileus
intussusception
diverticulitis
perforation
misc.- obstruction, inflammation, umbilical fistula

93

how i hemorrhage related to meckels dx

radionuclide scanning using technetium-99m pertechnetate which is taken up by ectopic gastric mucosa

enhanced by cimetidine or pentagastrin

94

how does an intestinal obstruction occur in meckels

because of volvulus of the small bowel around the diverticulum or constrictive effect of a mesodiverticular band

95

tx of meckels

resection of the diverticulum

if outside of pediatric age- narrow base, when a mesodiverticular band is present, or when heterotopic tissue is evident

base of diverticulum is closed transversely to minimize luminal narrowing

96

intestinal malrotation

-4th-10th weeks of gestation
-270deg rotation of proximal midgut places duodenum in retroperitoneum behind superior mesenteric vessels
-270deg rotation of distal midgut places cecum in rlq and transverse colon draped anterior to superior mesenteric vessels
-if both turns are incomplete or not made at all abnorm exist

97

what is the mc manifestation of malrotation

midgut volvulus in an infant w an incomplete rotation

-the proximal midgut fails to rotate beyond the midline remaining to the right of sup mes vessels w the duodenum covered ant by Ladd's bands
-distal midgut only rotates 90-180 and cecum becomes fixed to abd wall in ruq near duodenum
-twisting becomes small bowel volvulus leading to ischemia and necrosis

98

signs, dx and tx of midgut volvulus

-bilious emesis w progression to distention, tenderness/shock late findings
-radiographic upper GI series
-emergent laparotomy w detorsion of the bowel, division of Ladd's bands, broadening of the mesentery and placement of the small intestine on the right and colon on the left side of abdomen
-also do appendectomy

99

what is short bowel syndrome (short gut)

100

vermiform appendix anatomy

-located in rlq at confluence of taenia coli on cecal apex
-appendiceal artery travels in mesoappendix and originates from ileocolic artery
-lined by columnar epithelium and rich in lymphatic follicles

location determines the location of tenderness as ds progresses

101

what causes acute appendicitis

-consequence of obstruction of appendiceal lumen
-mc is lymphoid hyperplasia causing luminal obstruction
-also accumulation of fecal material or fecalith

102

what happens as the appendiceal lumen becomes compromised

-mucus secretion by the epithelium leads to distention of the appendix distal to the narrowed lumen w eventual compromise of venous outflow as the organ becomes increasingly turgid and ischemic

103

what can progression of swelling, infection and ischemia assoc w acute appendicitis lead to

gangrene and perforation

the resulting peritonitis may be walled off by omentum or other adjacent visceral structures

if ifx not controlled, spread of infx into portal system via venous effluent (pylephlebitis)may result giving rise to air in portal system or liver abscesses

104

mcburneys point

located 1/3 of distance from anterior superior iliac spine to the umbilicus (appendicitis)

105

tx for appendicitis

-preop IV fluid resucitation coverage suitable for colonic flora
-2nd gen ceph, broad spectrum penicillin or fluroquinolone and anaerobic coverage w metronidazole (no perf=24hr, perf=afebrile,norm wbc, gi function)
-surgery

106

open appendectomy

open: muscle splitting incision centered on McBurneys pt, appendix mobilized into wound and mesoappendix taken down allowing isolation of base of appendix where it joins the cecum; appendix removed after ligature control of its base

107

lap appy

less postop pain and lower wound infection rates allows inspection of peritoneal cavity before committing to given operative exposure

108

complications of appy

wound infx, pelvic abscess, fecal fistula, appendiceal remnants

109

appendiceal tumors

-carcinoid, carcinoma, mucocele
-2cm in diameter, a right hemicolectomy to allow removal of lymphatic drainage pathway

110

43yo w 3d hx abd distention, n, v, dec urine outpt. hx of total abd hysterectomy 5yrs ago for benign ds. no meds. pulse is 110beats/min. abd distended and mild diffuse tenderness. bowel sounds hyperactive. serum electrolytes are sodium 140, chloride 90, bicarb 32, potassium 4.0. most appropriate initial iv fluid to administer

normal saline

K not added until volume restoration is achieved, lactated ringers may worsen metabolic alkalosis because lactate converted to bicarb in the liver, and colloidal solutions do not correct the hypochloremia and electrolyte imbalances and are not called for in resuscitating hypovolemic dehydrated pt

111

what 3 segments is the small intestine composed of

duodenum- pylorus to ligament of treitz
jejunum-first 40% of small bowel distal to duodenum
ileum- remaining 60%

112

A 38-year-old man has undergone four operations for Crohn’s disease in the last 10 years and recently underwent the last of these for treatment of recurrent disease proximal to a prior ileocolic anastomosis. Which of the following agents Is most useful for managing acute exacerbations rather than helping to maintain him in remission from active disease?

prednisone

113

A 65-year-old woman comes to clinic with a vague history of diffuse abdominal discomfort over the past 3 weeks. She denies any history of trauma or prior abdominal surgery and has no known stigmata of peripheral vascular disease. She takes vitamin D and calcium supplements. On exam, she has diffuse mild to moderate subjective tenderness without guarding or peritoneal signs. She is In sinus rhythm on EKG. Which of the following is the most likely diagnosis?

mesenteric venous thrombosis

114

A 63-year-old woman comes to clinic with symptoms of nonspecific abdominal pain. Her past medical history is unremarkable. She takes vitamins and calcium supplements. A recent CT scan shows a small bowel mass lesion. Laboratory evaluations show an elevated serum level of c-kit protein, with normal chromogranin A. Which of the following intestinal tumors is this consistent with?

gastrointestinal stromal tumor

The elevated c-kit level is specific to gastrointestinal stromal tumor (GIST) tumors and Is the key information leading to this answer. The other small bowel lesions mentioned could present with similar vague symptoms but are not associated with the c-kit proto-oncogene mutation and associated serum protein marker. Carcinoid tumors may be associated with elevated levels of 5-HIAA (5-hydroxyindole acetic acid) on 24 urine testing. Osler-Weber-Rendu lesions are telangiectasias and may be associated with bleeding and characteristic visible telangiectasias in other mucosal areas including the oral cavity and skin. Hamartomas may be associated with Peutz-Jeghers syndrome. Brunner’s gland adenomas are seen In the proximal duodenum, where these glands are part of the mucus and alkaline mucosal protection mechanism of the proximal small Intestine.

115

A 24-year-old female graduate student comes to the emergency department because of abdominal pain for the past 12 hours. Initially she had vague mid-abdominal pain that has localized to the RLQ about 3 hours ago. She is otherwise healthy and takes no medications. Her temperature is 37°C. There Is guarding and rebound tenderness in the right lower quadrant and a positive Rovsing’s sign. A CT scan shows fat stranding around a dilated appendix. At surgery, there is a 2.5-cm firm, smooth yellowish mass at the base of an inflamed appendix. There Is no evidence of perforation and no other abnormalities are found. Frozen section biopsy is consistent with a neuroendocrine tumor. Which of the following is the most appropriate management at this time?

right hemicolectomy

This patient has a carcinoid tumor. A right hemicolectomy Is needed because of the heightened risk of lymph node metastases. A simple appendectomy would not be appropriate for a carcinoid at the base of the appendix but would be appropriate for a carcinoid tumor

116

A 38-year-old man has undergone four operations for Crohn’s disease in the last 10 years and recently underwent the last of these for treatment of recurrent disease proximal to a prior ileocolic anastomosis. Which of the following agents Is most useful for managing acute exacerbations rather than helping to maintain him in remission from active disease?

prednisone

117

A 65-year-old woman comes to clinic with a vague history of diffuse abdominal discomfort over the past 3 weeks. She denies any history of trauma or prior abdominal surgery and has no known stigmata of peripheral vascular disease. She takes vitamin D and calcium supplements. On exam, she has diffuse mild to moderate subjective tenderness without guarding or peritoneal signs. She is In sinus rhythm on EKG. Which of the following is the most likely diagnosis?

mesenteric venous thrombosis

118

A 63-year-old woman comes to clinic with symptoms of nonspecific abdominal pain. Her past medical history is unremarkable. She takes vitamins and calcium supplements. A recent CT scan shows a small bowel mass lesion. Laboratory evaluations show an elevated serum level of c-kit protein, with normal chromogranin A. Which of the following intestinal tumors is this consistent with?

gastrointestinal stromal tumor

The elevated c-kit level is specific to gastrointestinal stromal tumor (GIST) tumors and Is the key information leading to this answer. The other small bowel lesions mentioned could present with similar vague symptoms but are not associated with the c-kit proto-oncogene mutation and associated serum protein marker. Carcinoid tumors may be associated with elevated levels of 5-HIAA (5-hydroxyindole acetic acid) on 24 urine testing. Osler-Weber-Rendu lesions are telangiectasias and may be associated with bleeding and characteristic visible telangiectasias in other mucosal areas including the oral cavity and skin. Hamartomas may be associated with Peutz-Jeghers syndrome. Brunner’s gland adenomas are seen In the proximal duodenum, where these glands are part of the mucus and alkaline mucosal protection mechanism of the proximal small Intestine.

119

A 24-year-old female graduate student comes to the emergency department because of abdominal pain for the past 12 hours. Initially she had vague mid-abdominal pain that has localized to the RLQ about 3 hours ago. She is otherwise healthy and takes no medications. Her temperature is 37°C. There Is guarding and rebound tenderness in the right lower quadrant and a positive Rovsing’s sign. A CT scan shows fat stranding around a dilated appendix. At surgery, there is a 2.5-cm firm, smooth yellowish mass at the base of an inflamed appendix. There Is no evidence of perforation and no other abnormalities are found. Frozen section biopsy is consistent with a neuroendocrine tumor. Which of the following is the most appropriate management at this time?

right hemicolectomy

This patient has a carcinoid tumor. A right hemicolectomy Is needed because of the heightened risk of lymph node metastases. A simple appendectomy would not be appropriate for a carcinoid at the base of the appendix but would be appropriate for a carcinoid tumor

120

what marks the end of the duodenum and start of the jejunum

ligament of treitz

121

what provides blood supply to small bowel

branches of superior mesenteric artery

122

what does the terminal ileum absorb

b12, fatty acids, bile salts

123

pt w abd discomfort, cramping, n, abd distention, emesis, high pitched bowel sounds

sbo

124

what labs are performed w sbo

electrolytes, cbc, type/screen, ua

125

what are electrolyte/acid base findings w proximal obstruction

hypovolemic hypochloremic, hypokalemia, alkalosis

126

what must be ruled out on pe in pts with sbo

incarcerated hernia

127

what major axe findings are assoc w sbo

distended loops of small bowel air fluid levels on upright film

128

what is the danger of complete sbo

close loop strangulation of the bowel leading to bowel necrosis

129

initial manage of all pts w sbo

npo, ngt, ivf, foley

130

abc's of sbo

adhesions
bulge (hernia)
cancer/tumors

131

besides abc's what are other causes of sbo

gallstone ileus
intussusception
volvulus
external compression
sma syndrome

bezoars, bowel wall hematoma
abscesses
diverticulitis

crohns
radiation enteritis
annular pancreas
meckels diverticulum
peritoneal adhesions
stricture

132

what is sma syndrome

seen w wl, sma compresses duodenum causing obstruction

133

tx for complete sbo

lap and lysis of adhesions (LOA)

134

tx for incomplete sbo

conservative tx w close observation plus ngt decompression

135

intraop how can level of obstruction be determined in pts w sbo

transition from dilated bowel proximal to decompressed bowel distal to obstruction

136

mc cause abd surgery w crohns

sbo due to strictures

137

after sb resection why should mesenteric defect always be closed

prevent internal hernia

138

what may cause sob if pt is on coumadin

bowel wall hematoma

139

what are the signs of strangulated bowel w sbo

fever, shock, peritoneal signs, acidosis

severe/cont pain, hematemesis, gas in bowel wall or portal veing, abd free air

140

absolute indication for operation w partial sbo

peritoneal signs, free air on axr

141

what tumor classically causes sob due to mesenteric fibrosis

carcinoid tumor

142

s/sx of sb tumor

abd pain, wl, obstruction, perforation

143

mc benign sb tumor

leiomyoma

144

mc malignant sb tumor

adenocarcinoma

145

workup of small bowel tumor

ugi w small bowel follow through, enteroclysis, ct scan, enteroscopy

146

tx for malignant sb tumor

resection and removal of mesenteric draining lymph nodes

147

what malignancy is classically assoc w metastasis to small bowel

melanoma

148

usual location of meckels diverticulum

within 2ft of ileocecal valve on anti mesenteric border of bowel

149

major ddx assoc w meckels

appendicitis

150

complications of meckels

intestinal hemorrhage, intestinal obstruction, inflammation

151

s/sx meckels

lower gi bleed, abd pain, sbo

152

meckels scan

scan for ectopic gastric mucosa in meckels diver; uses technetium pertechnetate iv which is taken up by gastric mucosa

153

hernia assoc w incarcerated meckels diver

Littre's hernia

154

mc cause small bowel bleeding

small bowel angiodysplasia

155

what vessel provides blood supply to appendix

appendiceal artery- branch of ileocolic artery

156

mesentery of appendix

mesoappendix

157

how to locate appendix once find cecum

follow taenia coli down

158

what is appendicitis

inflammation of appendix causes by obstruction of appendices lumen, producing closed loop w resultant inflammation that can lead to necrosis and perforation

159

causes of appendicitis

lymphoid hyperplasia, fecalith

160

s/sx appendidicitis

periumbilical pain
n/v
anorexia
pain migrates to rlq

161

valentines sign w append

rlq pain/peritonitis from succus drainage down to rlq from perforated gastric or duodenal ulcer

162

labs for append

cbc- inc wbc w left shift
ua- look for pyelo or stones (can have hematuria/pyuria w append)

163

in acute append what comes first pain or vomiting

pain

164

radiographic signs of append on axr

fecalith, sentinel loops, scoliosis away from right because of pain, abscess, loss of psoas shadow, loss of pre peritoneal fat stripe, free air

165

ct findings of append

periappendiceal fat stranding, appendiceal diameter >6mm, periappendiceal fluid, fecalith

166

preop meds/prep

rehydration w iv fluids (LR)
abx

167

tx for nonperf acute append

prompt appy, 24hrs of abx, discharge home POD 1

168

tx for perf acute append

iv fluid resuscitation and prompt appy
all pus is drained w postop abx cont for 3-7d
wound left open in most cases of perf after closing fascia

169

tx appendiceal abscess that is dx preop

percutaneous drainage of abscess
abx
elective appy 6 wks later

170

duration abx for nonruptured append and what abx

24hrs
cefoxitin, cefotetan, unasyn, cipro, flagyl

171

abx for perf appy

broad spectrum abx- amp/cipro/clinda or penicillin like zosyn

until normal abc, afebrile, ambulating, eating reg diet

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complications of append

pelvic abscess, liver abscess, free perf, portal pylethrombophlebitis

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what bacteria assoc w mesenteric adenines closely mimic acute append

yersinia enterolytica

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complications of appy

sbo, enterocutaneous fistula, wound infx, infertility w perf, inc incidence of right inguinal hernia, stump abscess

175

mc postop complication of appy

wound infx

176

difference between mcburneys incision and rocky davis incision

mcburnerys is angled down (follows ext oblique fibers)
rocky straight across (transverse)

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layers of abd wall during mcburney incision

skin
subq fat
scarpai fascia
ext oblique
int oblique
transversus muscle
trasversali fascia
pre peritoneal fat
peritoneum

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steps in lap appy

1. id append
2. staple mesoappendix
3. staple and transect appendix at base
4. remove append from abdomen
5. irrigate and aspirate until clear

179

which way should finger sweep trying to find appendix

lateral to medial along lateral peritoneum so don't tear mesoappendix

180

how to get to retrocecal and retroperitoneal appendix

divide lateral peritoneal attachments of cecum

181

why use electrocautery on exposed mucosa on appendices stump

kill mucosal cells so don't form mucocele

182

if find crowns in terminal ileum, will you remove appendix

yes if cecal/appendiceal base is not involved

183

mc appendiceal tumore

carcinoid tumor

184

tx of appendices carcinoid

appy

185

tx of appendices carcinoid >1.5cm

right hemicolectomy

186

what type of appendices tumor can cause pseudomyxoma peritonea if appendix ruptures

malignant mucoid adenocarcinoma

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appendicitis definition

inflammation of the appendix caused by obstruction of the appendiceal lumen, producing a closed loop w resultant inflammation that can lead to necrosis and perforation