SSmall bowel

Question 1

NET staging ileum/ jejunum

Answer 1

T1: <1cm and confined to lamina propria or submucosa
T2: >1cm or invades into muscularis propria
T3: Invades into without penetration of serosa
T4: Invades beyond serosa into other organs or adjacent structures

N1: Regional mets to < 12 nodes
N2: Large mesenteric mass > 2cm and/or > 12nodes involved or extensive nodal deposits that encase the mesenteric vessels

M1 - distant mets
M1a: Liver mets
M1b: at least 1 extra-hepatic site
M1c: both hepatic and extrahepatic mets

Stage 1 disease - 95% 10 year survival
Stage 4 disease 42% 10 year survival

Question 2

Duodenal/ ampullary NET staging

Answer 2

T1: <1cm and confined to mucosa or submucosa or SOD (ampullary)
T2: >1cm and invades muscularis propria (duodenal) or invades beyond sphincter into duodenal submucosa or muscularis (ampullary)
T3: Invades pancreas or peripancreatic tissue
T4: Invades serosa/ peritoneum or other organs

N1 - regional nodes

M1 - distant mets
M1a: Mets in liver only
M1b: Mets in at least 1 extrahepatic site
M1c: Hepatic and extrahepatic mets

Question 3

Grading for SB NET

Answer 3

Grade 1:
low grade, Ki67 <3%, <2 mitoses

Grade 2:
Intermediate grade, Ki67 3-20%, 2-20 mitoses

Grade 3:
High grade, Ki67 > 20%, >20 mitoses

Question 4

Factors affecting intestinal function in short gut

Answer 4

• Length of SB
• Loss of ileum or ICV (decreased absorption, vit B12, bile salts, slowing gut transit)
• Loss of colon (reabsorption of fluid, Na and fermented carbs)
• Continuity of intestines
• Other factors (altered GI motility, bacterial overgrowth, gastric hypersecretion, mucosal disease in remaining bowel)

Question 5

Phases of intestinal failure from short gut

Answer 5

1. Acute phase - hypersecretion.
   - LAsts 3-4 weeks
   - Fluid and electrolyte loss due to acute lack of functional bowel

Management
- IV fluids and electrolytes
- Acid suppression
TPN
Enteral feeding ASAP to facilitate adaptation

2. Adaptation phase
   - Occurs over 1-2 years
   - Ileum best at adapting. Adaption better in kids
   - Structural and functional bowel changes.
   Structural changes (Bowel dilatation and elongaiton, Increased number of villi, increased depth of crypts, increased protein and DNA content.)
   Functional changes (increased brush border enzyme activity, slowed gut transit, increased carrier-mediated transport)

Management
- Oral diet (complex carbs, fibre, moderate fat restriction, minise oxalate if colon present)
- Isotonic fluids (avoid water, coffee, tea, hypertonic juice)
- Loperamide
- Acid suppression
- Consider ABx for SIBO
- Micronutrient supplements prn