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Section II General Surgery P203Surgical Recall Sixth > Small Intestine, C44 P286-293 > Flashcards

Small Intestine, C44 P286-293 Flashcards

1
Q 
SMALL BOWEL
ANATOMY
What comprises the small
bowel?
P286
A

Duodenum, jejunum, and ileum

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2
Q

SMALL BOWEL
ANATOMY
How long is the duodenum?
P286

A

≈12 inches—thus the name: duodenum!

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3
Q 
SMALL BOWEL
ANATOMY
What marks the end of the
duodenum and the start of
the jejunum?
P286
A

Ligament of Treitz

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4
Q 
SMALL BOWEL
ANATOMY
What is the length of the
entire small bowel?
P286
A

≈6 meters (20 feet)

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5
Q 
SMALL BOWEL
ANATOMY
What provides blood supply
to the small bowel?
P286
A

Branches of the superior mesenteric

artery

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6
Q

SMALL BOWEL
ANATOMY
What does the small bowel do?
P286

A

Major site of digestion and absorption

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7
Q 
SMALL BOWEL
ANATOMY
What are the plicae
circulares?
P286
A

Plicae means “folds,” circulares means
“circular”; thus, circular folds of mucosa
(a.k.a. valvulae conniventes) in small bowel
lumen

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8
Q 
SMALL BOWEL
ANATOMY
What are the major
structural differences
between the jejunum and
the ileum?
P287
A 
Jejunum—long vasa rectae, large plicae
    circulares, thicker wall
Ileum—shorter vasa rectae, smaller
    plicae circulares, thinner wall
    (Think: Ileum = Inferior vasa rectae,
       Inferior plicae circulares, and
       Inferior wall thickness in comparison
       to the jejunum)
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9
Q 
SMALL BOWEL
ANATOMY
What does the terminal
ileum absorb?
P287
A

B12, fatty acids, bile salts

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10
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What is small bowel
obstruction (SBO)?
P287
A

Mechanical obstruction to the passage of

intraluminal contents

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11
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What are the signs/
symptoms?
P287
A

Abdominal discomfort, cramping,
nausea, abdominal distention, emesis,
high-pitched bowel sounds

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12
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What lab tests are
performed with SBO?
P287
A

Electrolytes, CBC, type and screen,

urinalysis

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13
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What are classic electrolyte/
acid-base findings with
proximal obstruction?
P287
A

Hypovolemic, hypochloremic,

hypokalemia, alkalosis

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14
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What must be ruled out on
physical exam in patients
with SBO?
P287
A 
Incarcerated hernia (also look for surgical
scars)
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15
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What major AXR findings
are associated with SBO?
P287 (picture)
A

Distended loops of small bowel air-fluid

levels on upright film

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16
Q

SMALL BOWEL
SMALL BOWEL OBSTRUCTION
Define complete SBO.
P288

A

Complete obstruction of the lumen;

usually paucity or no colon gas

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17
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What is the danger of
complete SBO?
P288
A

Closed loop strangulation of the bowel

leading to bowel necrosis

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18
Q

SMALL BOWEL
SMALL BOWEL OBSTRUCTION
Define partial SBO.
P288

A

Incomplete SBO; some colon gas

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19
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What is initial management
of all patients with SBO?
P288
A

NPO, NGT, IVF, Foley

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20
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What tests can differentiate
partial from complete bowel
obstruction?
P288
A

CT with oral contrast, small bowel

follow-through

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21
Q

SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What are the ABCs of SBO?
P288

A

Causes of SBO:

  1. Adhesions
  2. Bulge (hernias)
  3. Cancer and tumors
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22
Q

SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What are other causes of SBO?
P288

A 
The acronym “GIVES BAD CRAMPS”:
    Gallstone ileus
    Intussusception
    Volvulus
    External compression
    SMA syndrome
Bezoars, Bowel wall hematoma
Abscesses
Diverticulitis
    Crohn’s disease
    Radiation enteritis
    Annular pancreas
    Meckel’s diverticulum
    Peritoneal adhesions
    Stricture
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23
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What is superior mesenteric
artery (SMA) syndrome?
P288
A

Seen with weight loss—SMA compresses

duodenum, causing obstruction

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24
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What is the treatment of
complete SBO?
P288
A

Laparotomy and lysis of adhesions

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25
Q

SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What is LOA?
P288

A

Lysis Of Adhesions

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26
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What is the treatment of
incomplete SBO?
P289
A

Initially, conservative treatment with close

observation plus NGT decompression

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27
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
Intraoperatively, how can
the level of obstruction be
determined in patients with
SBO?
P289
A

Transition from dilated bowel proximal to
the decompressed bowel distal to the
obstruction

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28
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What is the most common
indication for abdominal
surgery in patients with
Crohn’s disease?
P289
A

SBO

29
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
Can a patient have complete
SBO and bowel movements
and flatus?
P289
A

Yes; the bowel distal to the obstruction

can clear out gas and stool

30
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
After a small bowel resection,
why should the mesenteric
defect always be closed?
P289
A

To prevent an internal hernia

31
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What may cause SBO if
patient is on coumadin?
P289
A

Bowel wall hematoma

32
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What is the #1 cause of SBO
in adults (industrialized
nations)?
P289
A

Postoperative adhesions

33
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What is the #1 cause of SBO
around the world?
P289
A

Hernias

34
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What is the #1 cause of SBO
in children?
P289
A

Hernias

35
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What are the signs of
strangulated bowel with
SBO?
P289
A 
Fever, severe/continuous pain,
hematemesis, shock, gas in the bowel
wall or portal vein, abdominal free air,
peritoneal signs, acidosis (increased
lactic acid)
36
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What are the clinical
parameters that will lower
the threshold to operate on
a partial SBO?
P289
A

Increasing WBC
Fever
Tachycardia/tachypnea
Abdominal pain

37
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What is an absolute
indication for operation
with partial SBO?
P290
A

Peritoneal signs, free air on AXR

38
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What classic saying is
associated with complete
SBO?
P290
A

“Never let the sun set or rise on complete

SBO”

39
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What condition commonly
mimics SBO?
P290
A 
Paralytic ileus (AXR reveals gas distention
throughout, including the colon)
40
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What is the differential
diagnosis of paralytic
(nonobstructive) ileus?
P290
A 
Postoperative ileus after abdominal
    surgery (normally resolves in 3–5 days)
Electrolyte abnormalities (hypokalemia is
    most common)
Medications (anticholinergic, narcotics)
Inflammatory intra-abdominal process
Sepsis/shock
Spine injury/spinal cord injury
Retroperitoneal hemorrhage
41
Q 
SMALL BOWEL
SMALL BOWEL OBSTRUCTION
What tumor classically
causes SBO due to
“mesenteric fibrosis”?
P290
A

Carcinoid tumor

42
Q 
SMALL BOWEL
SMALL BOWEL TUMORS
What is the differential diagnosis
of benign tumors of
the small intestine?
P290
A

Leiomyoma, lipoma, lymphangioma,

fibroma, adenomas, hemangiomas

43
Q 
SMALL BOWEL
SMALL BOWEL TUMORS
What are the signs and
symptoms of small bowel
tumors?
P290
A

Abdominal pain, weight loss, obstruction

(SBO), and perforation

44
Q 
SMALL BOWEL
SMALL BOWEL TUMORS
What is the most common
benign small bowel tumor?
P290
A

Leiomyoma

45
Q 
SMALL BOWEL
SMALL BOWEL TUMORS
What is the most common
malignant small bowel tumor?
P290
A

Adenocarcinoma

46
Q 
SMALL BOWEL
SMALL BOWEL TUMORS
What is the differential
diagnosis of malignant
tumors of the small
intestine?
P290
A
  1. Adenocarcinoma (50%)
  2. Carcinoid (25%)
  3. Lymphoma (20%)
  4. Sarcomas (<5%)
47
Q 
SMALL BOWEL
SMALL BOWEL TUMORS
What is the workup of a
small bowel tumor?
P291
A

UGI with small bowel follow-through,

enteroclysis, CT scan, enteroscopy

48
Q 
SMALL BOWEL
SMALL BOWEL TUMORS
What is the treatment for
malignant small bowel
tumor?
P291
A

Resection and removal of mesenteric

draining lymph nodes

49
Q 
SMALL BOWEL
SMALL BOWEL TUMORS
What malignancy is
classically associated with
metastasis to small bowel?
P291
A

Melanoma

50
Q

SMALL BOWEL
MECKEL’S DIVERTICULUM
What is it?
P291 (picture)

A

Remnant of the omphalomesenteric duct/
vitelline duct, which connects the yolk sac
with the primitive midgut in the embryo

51
Q

SMALL BOWEL
MECKEL’S DIVERTICULUM
What is its claim to fame?
P291

A

Most common small bowel congenital

abnormality

52
Q

SMALL BOWEL
MECKEL’S DIVERTICULUM
What is the usual location?
P291

A

Within ≈2 feet of the ileocecal valve on

the antimesenteric border of the bowel

53
Q 
SMALL BOWEL
MECKEL’S DIVERTICULUM
What is the major
differential diagnosis?
P291
A

Appendicitis

54
Q

SMALL BOWEL
MECKEL’S DIVERTICULUM

P291

A

Is it a true diverticulum?

55
Q

SMALL BOWEL
MECKEL’S DIVERTICULUM
What is the incidence?
P291

A

≈2% of the population at autopsy

56
Q

SMALL BOWEL
MECKEL’S DIVERTICULUM
What is the gender ratio?
P292

A

Twice as common in men

57
Q 
SMALL BOWEL
MECKEL’S DIVERTICULUM
What is the average age at
onset of symptoms?
P292
A

Most frequently in the first 2 years of

life, but can occur at any age

58
Q 
SMALL BOWEL
MECKEL’S DIVERTICULUM
What are the possible
complications?
P292
A 
Intestinal hemorrhage (painless)—
    50%; accounts for half of all lower
    GI bleeding in patients younger than
    2 years
Bleeding results from ectopic gastric
    mucosa secreting acid → ulcer →
    bleeding
Intestinal obstruction—25%; most
    common complication in adults;
    includes volvulus and intussusception
Inflammation ( ± perforations)—20%
59
Q 
SMALL BOWEL
MECKEL’S DIVERTICULUM
What are the signs/
symptoms?
P292
A

Lower GI bleeding, abdominal pain, SBO

60
Q 
SMALL BOWEL
MECKEL’S DIVERTICULUM
What is the most common
complication of Meckel’s
diverticulum in adults?
P292
A

Intestinal obstruction

61
Q 
SMALL BOWEL
MECKEL’S DIVERTICULUM
In what percentage of cases
is heterotopic tissue found
in the diverticulum?
P292
A

>50%

62
Q 
SMALL BOWEL
MECKEL’S DIVERTICULUM
What heterotopic tissue type
is most often found?
P292
A

Gastric mucosa (60%), but duodenal,
pancreatic, and colonic mucosa are also
found

63
Q

SMALL BOWEL
MECKEL’S DIVERTICULUM
What is the “rule of 2s”?
P292

A 
2% of patients are symptomatic
Found ≈2 feet from the ileocecal valve
Found in 2% of the population
Most symptoms occur before age 2 years
Ectopic tissue found in 1 of 2 patients
Most diverticula are ≈2 inches long
2 to 1 male:female ratio
64
Q 
SMALL BOWEL
MECKEL’S DIVERTICULUM
What is the role of
incidental Meckel’s
diverticulectomy (surgical
removal upon finding
asymptomatic diverticulum)?
P292
A

Most experts would remove in children

very controversial in adults

65
Q

SMALL BOWEL
MECKEL’S DIVERTICULUM
What is a Meckel’s scan?
P293

A

Scan for ectopic gastric mucosa in
Meckel’s diverticulum; uses technetium
pertechnetate IV, which is preferentially
taken up by gastric mucosa

66
Q 
SMALL BOWEL
MECKEL’S DIVERTICULUM
What is the treatment of a
Meckel’s diverticulum that
is causing bleeding and
obstruction?
P293
A

Surgical resection, with small bowel
resection as the actual ulcer is usually
on the mesenteric wall opposite the
diverticulum!

67
Q 
SMALL BOWEL
MECKEL’S DIVERTICULUM
What is the name of the
hernia associated with
incarcerated Meckel’s
diverticulum?
P293
A

Littre’s hernia (Think alphabetically:

Littre’s, then Meckel’s)

68
Q 
SMALL BOWEL
MECKEL’S DIVERTICULUM
In patients with guaiacpositive
stools and a negative upper- and lower-
GI workup, what must be ruled out?
P293
A

Small bowel tumor; evaluate with

enteroclysis (small bowel contrast study)

69
Q 
SMALL BOWEL
MECKEL’S DIVERTICULUM
What is the most common
cause of small bowel
bleeding?
P293
A

Small bowel angiodysplasia

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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