Small Bowel and Appendix

Question 1

Tumors of the appendix

Answer 1

About 1/2= carcinoid (neuroendocrine tumor), mets to liver can produce serotonin syndrome (episodic flushing, diarrhea, wheezing and right sided valvular heart disease)
-Mets rare if tumor pseudomyxoma peritonei charac by diffuse collections of gelatinous material thru the abdomen

Question 2

Appendicitis

Answer 2

• mid abdominal pain that migrates to the RLQ
• Nausea and vomiting -High fever, WBC count and severe pain suggest perforation.
• IV fluids, IV antibiotics and surgical resection are the treatment.

Question 3

Plicae circulares

Answer 3

more in prox jejunum, absent terminal ileum

ileum empties into cecum of LI

Question 4

absorption and transport of fluids

Answer 4

9L secreted/ingested
8.9 L absorbed
100 ml excreted

Question 5

Malabsorption/maldigestion

Answer 5

• inadequate absorp of nutrients
• Clinical signs: weight loss, diarrhea, steatorrhea, vitamin deficiencies
• Pale, bulky, malodorous stool: float, hard to flush, oily residue

Question 6

Causes of malabsorption

Answer 6

Surgery:
-gastric bypass
-small bowel resection
Bacterial overgrowth
Meds:
cholestyramine-ADEK
phenytoin, folate
Pancreatic insufficiency
Liver disease
Intestinal inflammation/villous flattening (celiac sprue, Whipple's disease, tropical sprue)
Ulceration
Ischemia
Infiltration (amyloidosis)

Question 7

What test might you use to dx fat malabsorption?

Answer 7

Sudan fat stain

Question 8

Pancreatic insufficiency

Answer 8

90% burned out
Lipid (first) then protein then rarely carb malabsorption
-chronic pancreatitis
-CF

Question 9

Liver disease

Answer 9

bile needed for absorption of lipids

• Cirrhosis (decreased func of hepatocytes, decreased bile formation)
• Biliary obstruction

Question 10

Gastric Bypass

Answer 10

B-II, Roux-en Y

inadequate mixing of food with biliary and pancreatic secretions

Question 11

Gastric Bypass Vitamin Deficiencies

Answer 11

B12, Fe, Ca, Vit D deficiencies are the most common
-Vit C, Cu rare
Prevention: multivitamin
Monitoring recommended

Question 12

Small Bowel Bacterial Overgrowth

Answer 12

Normal:

Question 13

Vitamin levels with bacterial overgrowth and

Dx

Answer 13

fat soluble vitamins and B12 deficiency (bacteria deconjugate bile salts, bacteria consume B12)

Folate: normal to high (bacterial production)

Dx: 
-Aspiration of duodenum w/ culture
-Glucose-hydrogen breath test
-empiric treatment with antibiotics
Treatment: antibiotics (eg Ciprofloxacin)

Question 14

Sx of Vit A def

Answer 14

night blindness

xerophthalmia

Question 15

Sx of Vit D def

Answer 15

Osteomalacia

-bone mineralization defects

Question 16

Sx of Vit E def

Answer 16

rare in adults

hemolytic anemia

Question 17

sx of vit K def

Answer 17

clotting dysfunction

-PT

Question 18

Celiac Sprue

Answer 18

• gluten sensitive enteropathy (wheat, barley, rye)
• inflammatory disease of small intestine
• loss of villi, crypt hyperplasia, lymphocytes
• 80% asx (0.5-1% of US pop)
• incidence increases with age

Question 19

Signs/sx of celiac sprue

Answer 19

Abdominal distension
Abdominal pain
Anorexia
Bulky, sticky, pale stools
-Steatorrhea
Diarrhea
Flatulence
Failure to thrive
-Weight loss
-Fatigue
Vomiting

Question 20

Atypical signs/sx of celiac sprue

Answer 20

Iron deficiency Anemia
Dermatitis Herpetiformis
Liver function tests
-AST, ALT elevations
Cerebellar ataxia
Osteoporosis
Oral apthous ulcers

Question 21

Celiac pathogenesis

Answer 21

-assoc w/ autoimmune diseases: thyroiditis, Type-I DM
-HLA-DQ2, HLA-DQ8 (40% US)
APC MHC II present gluten peptides

CD4+ Tcell response
All have ab to tissue transglutaminase (TTG)

Question 22

Dx of Celiac sprue

Answer 22

Dx:

• finding on SI biopsy
• Serologic tests: anti-TTG, anti-endomysial antibodies, anti-gliadin IgA and IgG

Tx: gluten free diet

Question 23

Findings on endoscopy for celiac

Answer 23

scalloped duodenal folds

Question 24

Tropical sprue

Answer 24

• residents/visitors of tropics
• Cause: bacterial toxins or colonization of aerobic coliform bacteria

Classic presentation: Megaloblastic anemia from B12 and folate deficiency

Diagnosis: intestinal biopsy with villous flattening and travel history

Treatment: Antibiotics, B12, and folate

Question 25

Whipple's Disease

Answer 25

RARE (

Question 26

Mesenteric Ischemia

Answer 26

Atherosclerosis, Clot, Radiation Chronic: 2 of 3 major vessels occluded post-prandial abdominal pain, weight loss, sitophobia, malabsorption Acute: embolus, severe abdominal pain

Question 27

Malabsorption diagnostic tests

Answer 27

``` Focused testing-clinical scenario Fecal Fat Vitamin levels CBC, albumin CT-small bowel, liver, pancreas, bile ducts Endoscopy ```

Question 28

Small Intestinal Tumors

Answer 28

RARE primary tumors (

Question 29

Two main causes of diarrhea

Answer 29

decreased fluid/elec absorption increased secretion -occurs when colonic water load exceeds absorptive capacity

Question 30

Diarrhea classification

Answer 30

Fatty - malabsorption - maldigestion Watery - osmotic - secretory Inflammatory/exudative Functional

Question 31

Watery diarrhea-- osmotic

Answer 31

Carb malabsorption: lactose sorbitol (gum) fructose (non-diet drinks and many commercial foods) Osmotic laxatives: - Magnesium containing - Phosphate, sulfate (colonoscopy bowel preps) Osmotic diarrhea: presence of OSMOLAR GAP *ie presence of poorly absorbed luminal osmols

Question 32

Osmotic vs secretory diarrhea

Answer 32

Osm gap= 290-2(stool sodium + potassium) diff >50mOsm, diarrhea is osmotic

Question 33

Lactose intolerance

Answer 33

>50% of world down-regulates lactase after weaning -->diarrhea (osmotic), flatulence (colonic bacteria)

Question 34

Secretory watery diarrhea

Answer 34

``` Bacterial toxins -V. cholerae, E. coli enterotoxins Neuroendocrine tumors -gastrinoma, VIPoma, carcinoids, calcitonin Ileal bile salt malabsorption Stimulant laxatives Disordered motility/regulation -Diabetic neuropathy, postvagotomy, irritable bowel syndrome ```

Question 35

Bile acid induced diarrhea

Answer 35

- from ileal dysfunction (only site of ACTIVE bile acid absorption - increased bile acid into colon--> colonic secretion of fluid/elec--> diarrhea

Question 36

Fatty diarrhea

Answer 36

Malabsorption syndromes -Mucosal diseases (Celiac disease, Whipple’s disease) -Short-bowel syndrome -Small bowel bacterial overgrowth Maldigestion/Malabsorption -Pancreatic insufficiency -Inadequate luminal bile salt concentration (chronic liver disease, biliary obstruction)

Question 37

Inflammatory diarrhea

Answer 37

Infection Inflammatory Bowel Disease - Crohn’s Disease - Ulcerative Colitis Ischemia

Question 38

Fecal leukocytes in intestinal infections

Answer 38

Present: Shigella Campylobacter Enterohemorrhagic, enteroinvasis E. coli Variable: Salmonella Yersinia Clostridium difficile (pseudomembranous colitis) Absent: V. cholerae Enterotoxigenic E. coli Giardia lamblia

Question 39

Inflammatory diarrhea dx

Answer 39

Infection: Usually Stool Culture Endoscopy Ischemia: CT scan Endoscopy-colon Inflammatory Bowel Disease: Endoscopy

Question 40

IBS

Answer 40

Abdominal Pain and altered bowel habits in the absence of an organic cause: Pain improved with defecation Pain onset with change in stool frequency Pain onset with change in stool appearance Constipation and/or Diarrhea 10-15% of the population North America ``` Possible mechanisms: Visceral hypersensitivity Carbohydrate malabsorption -FODMAPS fermentable oligo-, di-, and monosaccharides and polyols (Fructose, fructans (wheat polymers e.g.inulin) sorbitol, lactose,) Low grade inflammation ```

Question 41

When to be concerned about IBS

Answer 41

``` Weight Loss Rectal bleeding Anemia Nocturnal symptoms Electrolyte abnormalities Elevated inflammatory markers ```

Question 42

What could be the result of longstanding Celiac?

Answer 42

T cell lymphoma

Question 43

Arterial supply to SI, LI

Answer 43

SMA: part of duodenum, entire SI, half of colon IMA: left colon and rectum Collateral circ bt SMA and IMA via marginal arteries and Arc of Riolan