Term
| Mechanism of action of Entereg (Alvimopan) |
|
Definition
| Mu-opiod receptor antagonist that selectively inhibits opiod effects on GI function while not inhibiting analgesic effects of opioids |
|
|
Term
| Mechanism of action and uses of Phenergan (Metoclopramide) |
|
Definition
| dopaminergic antagonist with anti-emetic and prokinetic properties |
|
|
Term
| Mechanism of action and uses of erythromycin |
|
Definition
| Motilin receptor agonist which promotes gastric motility |
|
|
Term
| MC primary surgical disease of the small bowel |
|
Definition
|
|
Term
| 7 risk factors for Crohn disease |
|
Definition
1. living in northern latitudes
2. living in urban areas
3. high socioeconomic status
4. smoking
5. Ashkenazie decent
6. familial inheritance (RR 14-15x higher)
7. Accutane (taking also exacerbates existing Crohn's |
|
|
Term
|
Definition
|
|
Term
| Factor protective from Crohn disease |
|
Definition
|
|
Term
| Earliest lesion indicative of Crohn disease and definition |
|
Definition
| Apthous ulcers superficial ulcers surrounded by halo of erythema resulting from submucosal lymphoid follicle expansion |
|
|
Term
| 4 hallmarks of Crohn disease |
|
Definition
1. Cobblestoning (coalescence of aphthous ulcers
2. non-caseating granulomas (found in diseased bowel and grossly normal)
3. skip lesion (discontinuous diseased portions)
4. transmural inflammation (leads to strictures, abscesses and fistulas) |
|
|
Term
| Intra-operative finding pathognomonic of Crohn disease |
|
Definition
| Extensive mesenteric fat wrapping aka "Creeping fat" |
|
|
Term
| Causes of terminal ileitis |
|
Definition
1. Crohn disease
2. Yersinia (enterocolitica and pseudotuberculosis)
3. Mycobacterium
4. CMV (as in AIDS)
5. Salmonella
6. Campylobacter
7. Shigella |
|
|
Term
| 7. Indications for surgery for Crohn dz |
|
Definition
1. Failure of medical management
2. Bleeding
3. Obstruction
4. Perforation
5. Fistula
6. absecss
7. growth retardation (in children) |
|
|
Term
| Bowel resected at surgery for a complication of Crohn dz |
|
Definition
| Only the portion causing the complication, not obviously diseased portions that aren't causing current problem |
|
|
Term
| Recommended margin for resection in Crohn Dz |
|
Definition
| 2 cm beyond grossly visible disease |
|
|
Term
| More effective for Crohn dz strictures: stricturoplasty or resection |
|
Definition
|
|
Term
| Types of stricturoplasty for Crohn Dz and indication |
|
Definition
1. Heinecke-Mikulicz for strictures < 12 cm
2. Finney for strictures < 25 |
|
|
Term
| Drawback of stricturoplasty over resection and how to avoid it |
|
Definition
| potentially leaving malignancy behind; biopsy any intraluminal ulcerations |
|
|
Term
| Management of Crohn dz strictures by area of intestin |
|
Definition
1. Duodenum: bypass stricture (gastrojej and duodenojej)
2. Jejunum: stricturoplasty
3. Ileum: stricturoplasy
4. Colon: resection (but only symptomatic portion) |
|
|
Term
| Role of Sulfasalazine in treating Crohn Dz and MOA |
|
Definition
# maintenance pharmocologic agent for mild active Crohn Dz
# aminosalicylate which acts as anti-inflammatory agent |
|
|
Term
| Role of Mesalamine, in treating Crohn Dz and MOA |
|
Definition
# maintenance pharmocologic agent for mild active Crohn Dz
# aminosalicylate which acts as anti-inflammatory agent, but has fewer side effects than sulfasalazine and is a slow release formulation |
|
|
Term
| Best pharmocologic agents for maintaining remission |
|
Definition
|
|
Term
| Role of prednisone in treating Crohn Dz and drawbacks |
|
Definition
# treatment of acute flares (induces remission in 75%)
# adrenal suppression and side effects. |
|
|
Term
| Role of budesonide in treating Crohn Dz, MOA, and drawbacks |
|
Definition
# Treatment of acute flares
# synthetic corticosteroid with less systemic absorption than prednisone, hence less side effects
# adrenal suppression |
|
|
Term
| Role of Remicade (infliximab) in treating Crohn Dz, MOA and drawbacks |
|
Definition
# treatment of acute flaree, maintaining remission and healing complex fistulas
# monoclonal Ab that targets TNFalpha;
# increases risk of opportunistic infectsion (Tb and aspergilosis), activation of latent MS, demyelinating CNS disorders and worsening CHF |
|
|
Term
| Role azathioprine in treating Crohn Dz and MOA |
|
Definition
# maintains remission from acute flares
# inhibitor of DNA synthesis thereby suprressing T cells and NK cells |
|
|
Term
| Role 6-MP in treating Crohn Dz and MOA |
|
Definition
# maintains remission from acute flares
# inhibitor of DNA synthesis thereby suprressing T cells and NK cells |
|
|
Term
| Role of Methotrexate in treating Crohn Dz |
|
Definition
| second line agent in maintaining remission of acute flares |
|
|
Term
| Cells implicated in as the cells of origin of GISTs |
|
Definition
|
|
Term
|
Definition
| Regulates peristalsis (intestinal pacemaker cell) |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Secretes lysozyme, TNFalpha and cryptidins (all assist in host defense) |
|
|
Term
| Function of enteroendocrine cells |
|
Definition
| Secrete various gut hormones |
|
|
Term
| Structure from which Meckels form |
|
Definition
| Remnant of vitelline duct |
|
|
Term
|
Definition
| 60 cm or 2 ft for Ileocecal valve |
|
|
Term
| MC presentation of a Meckel in adults |
|
Definition
| Obstruction from a volvulus around the fibrous band that may connect the Meckel to the umbilicus, intussuception, incarceration of the Meckel in a hernia |
|
|
Term
| Mc presentation of a Meckel in children |
|
Definition
|
|
Term
| MC location of and management of duodenal diverticula |
|
Definition
# Periampulary region
# if found incidentaly at surgery, do nothing; if causing biliary sx- tx endoscopically; can do open diverticulectomy if endo fails |
|
|
Term
| MC cause of lower GIB in children |
|
Definition
|
|
Term
| Pathogenesis of GIB 2/2 Meckel diverticulum |
|
Definition
| Heterotopic gastric tissue produces acid and creats an ulcer in the ileum |
|
|
Term
| Method of diagnosis of chylous ascites |
|
Definition
| Aanlysis of fluid for TG; usually > 200 or 110 is diagnostic |
|
|
Term
Distension s n/v, TTP 2 wks s/p open AAA; CT shows only ascites; Paracentesis shows high TG level and lymphocytes
# DX
# Managmenet |
|
Definition
# Chylous ascites
# High protein diet, low-fat diet with medium-chain TGs; if this fails- NPO, TPN and octreotide; if this fails, lymposcintigraphy to localize leak or obstruction and operative repair |
|
|
Term
| Surgery MC a/w with post-operative chylous ascites |
|
Definition
| Open AAA repairs, retroperitoneal lymph node dissection, IVC surgery and liver transplantation because of proximity to RP lymphatics |
|
|
Term
| Pathogenesis of chylous ascities |
|
Definition
| Exudation from obstructed cisterna chyli or dilated RP vessels, or direct leakage through a lymphoperitoneal fistula |
|
|
Term
| Anatomic structures that allow better tolerance of short bowel syndrome if in tact |
|
Definition
| Ileocecal valve and colon |
|
|
Term
| Technical definition of short bowel syndrome |
|
Definition
| less than 180 cm (in adults) of residual/functional small bowel |
|
|
Term
MC etiologies of small bowel syndrome in:
# adults
# children |
|
Definition
# acute mesenteric ischemia, malignancy, Crohn Dz
# intestinal atresia, midgut volvulus, necrotising enterocolitis |
|
|
Term
| Small bowel section which is better tolerated |
|
Definition
| jejunum because B12 and bile salts are reabsorbed in the ileum |
|
|
Term
| management of short bowel syndrome |
|
Definition
# slow transit time with narcotics (codeine and diphenoxylate) and anti-motility agents (loperamide and Lomotil)
# Hypergastrin state after massive small bowel resection- PPI or H2 blockers
# TPN
# Enteral feeding as soon as ileus resolves
# Diarrhea from unabsorbed bile salts- cholestyramine |
|
|
Term
| Recommended diet for short bowel syndrome |
|
Definition
| Hight CHO, low fat rich in glutamine combined with growth hormone |
|
|
Term
| Surgical management of short bowel with remnant < 90 cm in adults and < 30 cm in children which is markedly dilated but not obstructed |
|
Definition
# Serial transverse enteroplasty (linearl staples to mesenteric border and antimesenteric border;
# Bianchi procedure\ |
|
|
Term
| Surgical management of short bowel with remnant > 60 cm, markedly dilated and evidence of stasis and bacterial overgrowth |
|
Definition
|
|
Term
| Indications for a small bowel transplant |
|
Definition
# Short bowel syndrome
# TPN dependent but has had complications of TPN |
|
|
Term
| Complications of TPN dependence |
|
Definition
# Liver damage
# Vena cava thrombosis
# multiple catheter-related infections |
|
|
Term
| MC malignant tumors of the small bowel in order of most to least |
|
Definition
# Carcinoid
# adenocarcinoma
# lymphoma
# Gists |
|
|
Term
| Area of the small bowel MC affected by carcinoids |
|
Definition
|
|
Term
| Area of the small bowel MC affected by lymphomas |
|
Definition
|
|
Term
| Area of the small bowel MC affected by adenocarcinoma |
|
Definition
|
|
Term
| Predisposing factor common in pts with small bowel lymphoma |
|
Definition
| Immunodeficient states: AIDS or transplant recipients |
|
|
Term
| MC intestinal neoplasm in children younger than 10 |
|
Definition
|
|
Term
| Initial diagnostic test of choice for suspected mesenteric ischemia and reason |
|
Definition
| CT angiography; it helps distinguish between the various etiologies |
|
|
Term
| Standard tx for SMA embolus |
|
Definition
|
|
Term
| Standard tx for acute SMA thrombosis |
|
Definition
|
|
Term
| Standard tx for mesenteric venous thrombosis |
|
Definition
| Heparin alone as long as there is no evidence infarcted bowel |
|
|
Term
| Management of non-occlusive mesenteric ischemia |
|
Definition
| Medical optimization to improve CO and selective intra-arterial infusion of vasodilator such as papaverine unless there are signs of peritonitis in which case the tx is emergent laparotomy and resection of infarcted bowel |
|
|
Term
| Gold standard test for detection of carcinoid syndrome |
|
Definition
|
|
Term
| Percenteage of patients with midgut carcinoid tumors who have carcinoid syndrome and why |
|
Definition
| 20% because the vasoactive substances produced by the tumor are released into the portal circulation and metabolized by the liver |
|
|
Term
| Most sensitive screening test for detecting carcinoid tumor |
|
Definition
| Serum chromogranin A test |
|
|
Term
| Test used for prognosis and to measure treatment response in carcinoid tumors |
|
Definition
| Serum chromogranin A test |
|
|
Term
| Medical options for advanced metastatic carcinoid |
|
Definition
| Somatostatin analogs, octreotide and lantreotide and interferon-alpha |
|
|
Term
| surgical options for management of advanced carcinoid |
|
Definition
# tumor debulking
# Hepatic artery emoblization (because metastatic liver tumors receive most of their blood supply from systemic, rather than portal circulation)
# RFA |
|
|
Term
| Most common valvular manifestation of carcinoid syndrome |
|
Definition
| Tri-cuspid insufficiency (lesions more common on R-side) because the vasoactive substances cause endocardial damage) |
|
|
Term
| Principal fuel source for the small bowel |
|
Definition
|
|
Term
|
Definition
|
|
Term
| Types of GISTs from most to least common |
|
Definition
Spindle cell
Epithelioid
Mixed |
|
|
Term
| Positive immunohistochemical stains in GISTs |
|
Definition
| CD34 (human progenitor cell antigen) and CD177 (c-kit proto-oncogene protein) |
|
|
Term
| Boundaries of Petit triangle |
|
Definition
| Inferior lumbar triangle: external oblique, latissimus dorsi muscle and the iliac crest |
|
|
Term
| Boundaries of Grynfeltt triangle |
|
Definition
| Superior lumbar trangle: quadratus lumborum, 12th rib and the internal oblique |
|
|
Term
| Hernia that contains a Meckel diverticulum |
|
Definition
|
|
Term
| Predisposing factors a/w Wilkie Syndrome |
|
Definition
| Profound weight loss (i.e. eating disorders); supine immobilization; body casting |
|
|
Term
| 2 methods of diagnosing Wilkie Syndrome and finding |
|
Definition
# CT- decreased aortomesenteric angleand decreased distance b/w the aorto and the SMA and obstruction of duodenum
# Barium UGI- abrupt cessation of contrast from the duodenum to the jejunum |
|
|
Term
| Management of Wilkie Syndrome |
|
Definition
# initial, non-op management is weight gain
# surgical is duodenojejunostomy |
|
|
Term
| Pathogenesis of radiation enteritis |
|
Definition
| obliterative arteritis of the submucosal vessels leading to fibrosis and stricture formation |
|
|
Term
| Factors a/w with increased risk of radiation enteritis |
|
Definition
# whether or not the pt received CTx
# diabetis
# underlying vascular dz |
|
|
Term
| Management of acute radiation enteritis |
|
Definition
Symptomatic tx:
# antispasmodic agents
# analgesics
# anti-diarrheals |
|
|
Term
| Sequelae of chronic radiation enteritis and management |
|
Definition
# stricture or fistula
# resection or bypass (not stricturoplasty) |
|
|
Term
| Etiologies of acute ileitis |
|
Definition
# Early Chron Dz (not as common as other causes)
# infection: yersinia (enterocolitica and pseudotuberculosis), Mycobacterium, CMV (AIDS), Salmonella, Campylobacter, Shigella |
|
|
Term
| Management of an incidentally found Meckel in children |
|
Definition
|
|
Term
| Management of an incidentally found Meckel in adults |
|
Definition
Diverticulectomy if:
# < 50 yo
# presence of palpable heterotopic tissue
# diverticulum length > 2 cm
# presence of a mesodiverticular band
# signs of previous diverticulitis |
|
|
Term
| Characteristics of carcinoid crisis |
|
Definition
| Tachycardia, hypotension, flushing and bronchospasm |
|
|
Term
| Treatment for carcinoid crisis |
|
Definition
|
|
Term
| Sx of blind loop syndrome |
|
Definition
| Diarrhea, steatorrhea, megaloblastic anemia, weight loss, abdominal pain and deficiencies in fat-soluble vitamins |
|
|
Term
| Method of diagnosis of blind loop syndrome |
|
Definition
| Barium study to define the anatomical anomaly and D-xylose test to confirm (elevated etCO2 |
|
|
Term
| Mechanism of Schilling test and way to differentiate b/w blind loop syndrome and pernicious anemia |
|
Definition
# step 1: administer oral radiolabled B12 and unlabled B12 parenterally. The parenteral B12 saturates the liver receptors and if oral absorption of B12 is normal, all of the radio-labeled B12 should end up in the urine
# administer intrinsic factor: this will increase B12 absorption in pernicious anemia and thus increase urinary excretion of radiolabled B12. In blind loop, no increase in urinary B12 after IF administration. |
|
|
Term
| management of blind loop syndrome |
|
Definition
# broad spectrum abx: flagyl and tetracycline
# Parenteral B12
# Dietary modification: medium-chain TGs and lactose free |
|
|
Term
| Main features of Peutz-Jeghers syndrome |
|
Definition
| mucocutaneous melanotic lesions (around mouth/face, in mouth, forearms, palms, soles, digits and perianal area); hamartomas of jejunum and ileum |
|
|
Term
| Most common GI presentation of Peutz-Jeghers |
|
Definition
| Colicky abd pain or obstruction from a hamartoma or intussception of a hamartoma |
|
|
Term
| Types of cancers Peutz-Jeghers pre-disposes to |
|
Definition
GI tract: esophagus, stomach, colon, pancreas
Extraintestinal: testis, breast, ovaries, uterus |
|
|
Term
| Definition of and MCC of obscure GIB in adults |
|
Definition
# Persistant or recurrent bleeding with out a source found on EGD or colonoscopy
# 75% are caused by angiodysplasias in the small bowel |
|
|
Term
| Bloody diarrhea, fever, abdominal pain and free air after recent travel to South America with a single perforation mesenteric lymphadenopathy and splenomegalyat surgery |
|
Definition
# Typhoid enteritis caused by Salmonella typhosa
# causes hyperplasia of reticuloendothelial system including Peyer patches which may ulcerate and perforate |
|
|
Term
| Management of perforation in typhoid enteritis |
|
Definition
| usually solitary and can be repaired primarily |
|
|
Term
| Most important factor in reducing mortality from a small bowel fistula and other management principles |
|
Definition
# most important: control of sepsis- requires CT scan to ascertain presence of abscesses
# skin protection, TPN, fluid and electrolyte resuscitation
# majority close spontaneously in 3-6 weeks with above steps
# surgery should always be delayed at least 6 weeks if indicated |
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