as given by Dr. Climaco

1. Small Bowel

2. Anatomy
Duodenum
**has Brunners glands alkalinisation
1st portion: bulb; 90% of ulcers. Ulcers here have
little malignant potential
2nd portion: descending. Has Ampulla of Vater.
Retroperitoneal
3rd portion: transverse. Retroperitoneal
4th portion: Ascending
Blood Supply- superior and inferior
pancreaticoduodenal arteries
Jejunum:
100cm – 250cm. Most absorption occurs here
EXCEPT FOR:
Ileum- B12, Folate, Bile
Duodenum- Iron
Blood supply off of SMA
Ileum:
150cm- 300cm. Short vasa recta. Flat.
Peyers patches Lymphoid tissue

3. MotilityandBile
Motility
 Gut motility is regulated via the migrating motor
complex
 Phase I- rest; II- acceleration + gallbladder contraction;
III- peristalsis; IV- deceleration
 Motilin hormone peristalsis
 Bile absorption:
 Terminal ileum (active in terminal ileum via Na/K
ATPase; passive in ileum and colon; conjugated only
absorbed in TI)
 *s/p ileum resection  malabsorption of bile salts 
stone formation

4. LackofMotility
Obstruction:
ABC adhesion, bulge, cancer
N/V, crampy ab pain, obstipation/constipation
Air fluid levels, distended bowel (3,6,9 rule: 3cm small
bowel; 6cm transverse colon; 9cm cecum);
decompressed region (transition point)
NGT, IV fluids, NPO  Surgery
Ileus:
Uniform dilatation w/o decompressed region.
Surgery, electrolyte abnormalities, peritonitis, ischemia,
trauma, meds
Gallstone Ileus:
Gallstone in TI 2/2 fistula between GB and duodenum
TX: stone resection via ex-lap + proximal enterotomy. If
can tolerate long procedure/stable should takedown
fistula + cholecystectomy. Typically leave GB and fistula
if patient is too sick

5. ShortGut
Syndrome
 Steatorrhea, WL, nutrition deficiency
 Sudan red- fecal fat; Schilling- B12 absorption. Give
patient radiolabelled B12 if malabs excrete in
urine
 Need 75cm to survive off of TPN, 50cm if w/ competent
ileocecal valve
 Low fat, Slow gut via Lomotil (diphenoxylate and
atropine)

6. Fistulas
Fistulas:
FRIENDS. Foreign body, radiation, IBD,
epithelization, neoplasm, distal obstruction,
steroids/sepsis
Low output: 200cc/day  likely to close
spontaneously via conservative management
High output: 500cc/day or greater likely proximal.
Unlikely to close spontaneously
Electrolyte abnormalities
NPO, TPN/Nutritional Optimization, Wound
management, octreotide resection

7. Meckel’s
Diverticulum
From failed closure of omphalomesenteric duct
2 ft from IC valve, 2% of pop, first 2yrs of life. TRUE
DIVERTICULUM
Children: Painless lower GI bleed
Adults: Obstruction
MC tissue: Pancreatic tissue
MC symptomatic tissue: Gastric bleeding
DX:
Meckel scan 99 Technicium
TX:
- Nothing unless symptomatic, gastric mucosa suspected
(thicker).
- Diverticulectomy if uncomplicated
- Segmental resection if complicated (perf), neck >1/3
diameter of bowel lumen, involves base

8. Duodenal Diverticuli
and
Intussusception
Diverticuli
Observe unless symptomatic (bleed, obstruction, perf).
More common proximally
TX: Segmental resection if not in 2nd portion
If juxta-ampullary choledochojejunostomy
Intussusception
Target sign
In children hypertrophied peyer patchair contrast
enema. Monitor for 24hrs as 10% recur w/in this time. If
not reducible reduce in DISTAL to PROXIMAL fashion
In adults OR for segmental resection. 70% have
malignant lead point (cecal adenocarcinoma)

9. Neoplasms
Adenoma- duodenum. Can bleed/ cause obstruction
Resect
Peutz-Jegher: Autosomal dominant. STK11/LB1.
Melanotic skin pigmentation and hamartomas
throughout GI tract. High risk of EXTRA-
INTESTINAL MALIGNANCY (breast); low risk for
GI malignancy)
-EGD/Colo every 2 yrs
-screening for reproductive cancers
GIST: typically benign. 7-% in stomach. Spindle cells.
C Kit.
-TX: Resect w/ 1cm margins.

10. Neoplasms2
Carcinoid
From Enterochromaffin/ Kulchintsky cells. Part of amine precursor
uptake decarboxylase system
Carcinoid syndrome liver mets. Typically metabolites are cleared by
the liver
Serotonin- diarrhea
Kallikrein- flushing
Bradykinin- cough, bronchospasm
Right heart valve lesions
DX: Most Sensitive Chromogranin A; For localization octreotide
Locations: Appendix > Ileum > rectum
TX:
Appendix <2cm appendectomy; in appendix >2cm right
hemicolectomy
Small bowel resection + lymphadenectomy
Colon formal partial colectomy + lymphadenectomy
Rectal <2cm wide local excision; Rectal >2cm APR
Streptozocin, 5FU, Octreotide. Txx symptoms as well: albuterol, a-
blockers (for flushing)

11. Neoplasms3
Adenocarcinoma- MC malignant small bowel tumor, but
overall is rare
Typically in duodenum.
Resection w/ lymphadenectomy/ Whipple if 1st or 2nd
portion of duo
+/- FOLFOX
Leiomyosarcoma- Jejunum and ileum. Biopsy 1st.
Extraluminal. >5 mitosis/50HPF, atypia, necrosis
Resection w/o lymphadenectomy

12. Lymphoma
Usually in ileum.
Non Hodgkins is most common. B cell.
Associated with celiac disease
TX:
Wide en bloc resection + Chemo. Chemo XRT if
in 1st/2nd portion of duo
R-CHOP (rituximab, cylophosphamide,
doxorubicin, vincristine, prednisone)
Side effects:
Cyclophosphamide- hemorrhagic cystitis
Doxorubicin (-rubicin)- Cardiomyopathy
Vincristine- Neurotoxicity
Bleomycin- Pulmonary Fibrosis

13. Stricturoplasties
Incise along antimesenteric border
Extend 1-2cm proximal and distal to diseased segment
Heineke-Mikulicz: Short Segment (5-10 cm). Longitudinal incisional and transverse
closure
Finney: Medium length (10-20cm). Fold bowel at stricture site. Bring together
healthy proximal to healthy distal. Open up diseased segment along antimesenteric
border and close side to side
Jaboulay: For when stricture is too narrow to pass

14. Steatorrhea
Steatorrhea:
high acid, low bile salts, low pancreatic enzymes
Fat soluble vitamin deficiency
Sudan Red Stain- fecal fat testing
DX to consider:
Gastrinoma, Pancreatitis, Pancreatic Tumors