1. Small Intestine
James Lee

2. Arginine Alanine Glutamine Tyrosine Carnitine
Which of the following is the principal fuel used by the small intestine?
Arginine
Alanine
Glutamine
Tyrosine
Carnitine

3. Glutamine is the principal fuel of the small intestine
Which of the following is the principal fuel used by the small intestine?
Arginine
Alanine
Glutamine
Tyrosine
Carnitine
Glutamine is the principal fuel of the small intestine

4. Epinephrine Serotonin Bradykinin ACTH
A pt. with liver mets related to small bowel carcinoid tumor develops flushing and diarrhea. These symptoms are most likely caused by:
Epinephrine
Serotonin
Bradykinin
ACTH

5. Serotonin is released from carcinoid tumors
A pt. with liver mets related to small bowel carcinoid tumor develops flushing and diarrhea. These symptoms are most likely caused by:
Epinephrine
Serotonin
Bradykinin
ACTH
Serotonin is released from carcinoid tumors
If mets to liver, serotonin not metabolized
Can measure 5-HIAA in urine

6. HIDA scan MIBG scan Octreotide scan MRI
2 years after resection of a small bowel carcinoid with isolated liver mets, the patient develops vague abdominal complaints, but no new lesions are identified on CT scan. What is the best study to look for recurrent carcinoid tumor?
HIDA scan
MIBG scan
Octreotide scan
MRI

7. Octreotide scan is the most sensitive diagnostic test
2 years after resection of a small bowel carcinoid with isolated liver mets, the patient develops vague abdominal complaints, but no new lesions are identified on CT scan. What is the best study to look for recurrent carcinoid tumor?
HIDA scan
MIBG scan
Octreotide scan
MRI
Octreotide scan is the most sensitive diagnostic test
for the detection of a carcinoid tumor not apparent
on CT scan

8. Right hemicolectomy Close observation Post-op radiation Post-op chemo
You perform an appendectomy on a 25 YO man for presumed appendicitis and find a 1 cm tumor at the tip of the appendix. Pathology returns as carcinoid. The most appropriate next step in management is:
Right hemicolectomy
Close observation
Post-op radiation
Post-op chemo

9. Appendectomy is adequate treatment for carcinoid
You perform an appendectomy on a 25 YO man for presumed appendicitis and find a 1 cm tumor at the tip of the appendix. Pathology returns as carcinoid. The most appropriate next step in management is:
Right hemicolectomy
Close observation
Post-op radiation
Post-op chemo
Appendectomy is adequate treatment for carcinoid
tumors localized to the appendix if < 2 cm, not at base,
and no evidence of metastatic disease

10. Right hemicolectomy Close observation Post-op radiation Post-op chemo
You perform an appendectomy on a 25 YO man for presumed appendicitis and find a 2.5 cm tumor at the tip of the appendix. Pathology returns as carcinoid. The most appropriate next step in management is:
Right hemicolectomy
Close observation
Post-op radiation
Post-op chemo

11. If carcinoid is > 2 cm or not at tip, perform Right hemicolectomy
You perform an appendectomy on a 25 YO man for presumed appendicitis and find a 2.5 cm tumor at the tip of the appendix. Pathology returns as carcinoid. The most appropriate next step in management is:
Right hemicolectomy
Close observation
Post-op radiation
Post-op chemo
If carcinoid is > 2 cm or not at tip, perform Right
hemicolectomy

12. B. Tricuspid insufficiency C. Pulmonary stenosis
The most common cardiac valvular lesion associated with carcinoid syndrome is:
A. Tricuspid stenosis
B. Tricuspid insufficiency
C. Pulmonary stenosis
D. Pulmonary insufficiency
E. Mitral stenosis

13. B. Tricuspid insufficiency C. Pulmonary stenosis
The most common cardiac valvular lesion associated with carcinoid syndrome is:
A. Tricuspid stenosis
B. Tricuspid insufficiency
C. Pulmonary stenosis
D. Pulmonary insufficiency
E. Mitral stenosis
Most common valvular disorder is tricuspid insufficiency
Vasoactive substances are released from liver mets and transported to R heart  endocardial damage  thickening/retraction/fixation of valves
Pulmonary valve lesions next most common

14. Corticosteroids Antihistamine Octreotide Abort operation Dantrolene
A 46-year-old woman is about to undergo hepaticresection for a metastatic carcinoid tumor. During induction, SBP falls to 80 mm Hg and heart rate increases to 110 beats/min. Her entire body appears flushed. Her temperature is normal as is end-tidal CO2. Management consists of:
Corticosteroids
Antihistamine
Octreotide
Abort operation
Dantrolene

15. The pt. has carcinoid crisis
A 46-year-old woman is about to undergo hepaticresection for a metastatic carcinoid tumor. During induction, SBP falls to 80 mm Hg and heart rate increases to 110 beats/min. Her entire body appears flushed. Her temperature is normal as is end-tidal CO2. Management consists of:
Corticosteroids
Antihistamine
Octreotide
Abort operation
Dantrolene
The pt. has carcinoid crisis
Carcinoid crisis characterized by hypotension, bronchospasm,
flushing, and tachycardia
Primary treatment is IV octreotide administered as a bolus of pg

16. Appendectomy Close observation Place a drain Ileal resection
You perform laparoscopy on a 25 YO M for presumed appendicitis and find non obstructing terminal ileitis not involving the cecal area. The most appropriate next step in management is:
Appendectomy
Close observation
Place a drain
Ileal resection

17. If cecum involved leave appendix b/c high risk for leak
You perform laparoscopy on a 25 YO M for presumed appendicitis and find non obstructing terminal ileitis not involving the cecal area. The most appropriate next step in management is:
Appendectomy
Close observation
Place a drain
Ileal resection
If cecum not involved perform appendectomy so that confusion of ileitis with appendicitis will not occur in the future
If cecum involved leave appendix b/c high risk for leak

18. Concerning short gut syndrome, all of the following are true except:
This is a clinical diagnosis of inability to absorb enough water and nutritional elements to be off TPN
The length of bowel in general needs to be at least 75 cm if there is no ileocecal valve
The length of bowel in general needs to be at least 50 cm if there ileocecal valve present
The length of bowel needs to be at least 150 cm if there is no ileocecal valve

19. Concerning short gut syndrome, all of the following are true except:
This is a clinical diagnosis of inability to absorb enough water and nutritional elements to be off TPN
The length of bowel in general needs to be at least 75 cm if there is no iliocecal valve
The length of bowel in general needs to be at least 50 cm if there iliocecal valve present
The length of bowel needs to be at least 150 cm if there is no iliocecal valve
In general the length of bowel needs to be at least 50 cm with iliocecal valve and at least 75 cm w/o iliocecal valve to avoid TPN

20. A 75 YO M on NSAIDs for arthritis presents with a 6 hr h/o abdominal pain and is found to have an acute abdomen with pneumoperitoneum. His vital signs stabilize after 2 L crystalloid. What should be the next step in management?
Operation
EGD
UGI
Antisecretory drugs, antibiotics for H. pylori, and operation if he fails to improve in 6 hrs

21. A 75 YO M on NSAIDs for arthritis presents with a 6 hr h/o abdominal pain and is found to have an acute abdomen with pneumoperitoneum. His vital signs stabilize after 2 L crystalloid. What should be the next step in management?
Operation
EGD
UGI
Antisecretory drugs, antibiotics for H. pylori, and operation if he fails to improve in 6 hrs
Preferred treatment of perforated duodenal ulcer is resuscitation and prompt operation
Non op management is reserved for old contained perforations or terminally ill pts. who cannot undergo surgery

22. Suture closure of the perforation Omental patch of perforation
What operation would you perform on the 75 YO M on NSAIDs for arthritis pt. with a perforated duodenal ulcer?
Suture closure of the perforation
Omental patch of perforation
Repair of perforation and highly selective vagotomy
Repair of perforation and truncal vagotomy
Repair of perforation and gastric resection

23. Suture closure of the perforation Omental patch of perforation
What operation would you perform on the 75 YO M on NSAIDs for arthritis pt. with a perforated duodenal ulcer?
Suture closure of the perforation
Omental patch of perforation
Repair of perforation and highly selective vagotomy
Repair of perforation and truncal vagotomy
Repair of perforation and gastric resection
Closure of the perforation is best accomplished with a Graham patch: 1/3 no recurrence; 1/3 recurrence amenable to medical management; 1/3 recurrence requiring surgery
Definitive operations should only be performed on stable patients
Hold ulcerogenic drugs and treat H. pylori following surgery

24. It is a more common complication of duodenal ulcer than perforation
With regard to duodenal ulcer complicated by hemorrhage which of the following statements are true?
It is a more common complication of duodenal ulcer than perforation
Endoscopic treatment before operation decreases mortality
Endoscopic treatment decreases the need for operation
Operative management is indicated only if endoscopic treatment fails
Operative management should include an acid-reducing procedure

25. It is a more common complication of duodenal ulcer than perforation
With regard to duodenal ulcer complicated by hemorrhage which of the following statements are true?
It is a more common complication of duodenal ulcer than perforation
Endoscopic treatment before operation decreases mortality
Endoscopic treatment decreases the need for operation
Operative management is indicated only if endoscopic treatment fails
Operative management should include an acid-reducing procedure
Hemorrhage is the most common complication of duodenal ulcer
Most important endoscopic predictor of persistent/recurrent bleeding is active arterial spurting; presence of visibile vessel implies high risk of recurrent bleeding
A definitive antiulcer operation should be performed b/c high risk of recurrent bleeding:
If in shock/ill - truncal vagotomy/pyloroplasty
Otherwise parietal cell vagotomy or truncal vagotomy and antrectomy

26. Adenoma of Brunner’s glands Nodular hyperplasia of Brunner’s glands
Which of the following conditions is/are associated with an increased risk of duodenal adenocarcinoma?
Heterotopic pancreas
Adenoma of Brunner’s glands
Nodular hyperplasia of Brunner’s glands
Gardner’s syndrome
Familial polyposis coli

27. Adenoma of Brunner’s glands Nodular hyperplasia of Brunner’s glands
Which of the following conditions is/are associated with an increased risk of duodenal adenocarcinoma?
Heterotopic pancreas
Adenoma of Brunner’s glands
Nodular hyperplasia of Brunner’s glands
Gardner’s syndrome
Familial polyposis coli
Adenocarcinoma is the most common malignant duodenal neoplasm
A/W adenomatous polyps, villous adenomas, familial polyposis coli, Gardner’s syndrome, von Recklinghausen’s disease

28. Familial adenomatous polyposis PJS
Which of the following conditions is not associated with an increased risk of small bowel malignancy?
Celiac disease
Crohn’s disease
Scleroderma
Familial adenomatous polyposis
PJS

29. Familial adenomatous polyposis PJS
Which of the following conditions is not associated with an increased risk of small bowel malignancy?
Celiac disease
Crohn’s disease
Scleroderma
Familial adenomatous polyposis
PJS
↑ lymphoma, esophageal CA, small bowel adenocarcinoma in celiac disease
↑ risk factors in Crohn’s for adenocarcinoma
↑ adenomas in FAP
↑ hamartomatous polyps in PJS

30. What is the most common primary surgical disease of the small bowel?

31. What is the most common primary surgical disease of the small bowel?
Crohn’s disease

32. What is the most common reason to operate on a patient with Crohn’s disease?

33. Small bowel obstruction
What is the most common reason to operate on a patient with Crohn’s disease?
Small bowel obstruction

34. What is the most important hormone in migrating motor complex?

35. What is the most important hormone in migrating motor complex?
Motilin

36. In regards to MMC, what happens during:
Phase I: Phase II: Phase III: Phase IV:
Rest
Acceleration and Gall bladder contraction
Peristalsis
Deceleration

37. What is the most common cause of a small bowel obstruction in a patient without previous surgery?

38. What is the most common cause of a small bowel obstruction in a patient without previous surgery?
Hernia

39. What is the #1 cause of SBO in children?

40. What is the #1 cause of SBO in children?
Hernia

41. What is the #1 cause of SBO in the world?

42. What is the #1 cause of SBO in the world?
Hernia

43. What is the most common cause of a small bowel obstruction in a patient that has had previous surgery?

44. What is the most common cause of a small bowel obstruction in a patient that has had previous surgery?
Adhesions

45. A hernia sac containing a Meckel diverticulum is known as?

46. A hernia sac containing a Meckel diverticulum is known as?
Littre hernia

47. What syndrome is characterized by vascular compression of the duodenum?

48. Wilkie’s syndrome (SMA syndrome)
What syndrome is characterized by vascular compression of the duodenum?
Wilkie’s syndrome (SMA syndrome)

49. What portion of the duodenum is compressed by the SMA with Wilkie’s syndrome?

50. What portion of the duodenum is compressed by the SMA with Wilkie’s syndrome?
3rd portion of duodenum

51. The SMA (Wilkie) syndrome:
A. Involves the second portion of the
duodenum
B. Is more common in men
C. Is best diagnosed with arteriography
D. Is associated with body casting
E. Is best managed by gastrojejunostomy

52. The SMA (Wilkie) syndrome:
A. Involves the second portion of the
duodenum
B. Is more common in men
C. Is best diagnosed with arteriography
D. Is associated with body casting
E. Is best managed by gastrojejunostomy
SMA syndrome more common in women
Dx can best be made by a CT (decreased aortomesenteric angle and decreased
distance b/t aorta and SMA, and duodenal obstruction)
Predisposing factors include supine immobilization, scoliosis, placement of a
body cast, and eating disorders
Conservative measures tried first

53. Operative treatment of choice for pt
Operative treatment of choice for pt. with Wilkie’s syndrome refractory to conservative management?

54. Operative treatment of choice for pt
Operative treatment of choice for pt. with Wilkie’s syndrome refractory to conservative management?
Duodenojejunostomy

55. What is the strongest layer of the small bowel?

56. What is the strongest layer of the small bowel?
Submucosa

57. B. Massive lower GI bleed C. Diverticulitis with abscess
What is the most common presentation of Meckel’s diverticulum in adults?
A. Occult bleeding
B. Massive lower GI bleed
C. Diverticulitis with abscess
D. Diverticulitis with diffuse peritonitis
E. Obstruction

58. B. Massive lower GI bleed C. Diverticulitis with abscess
What is the most common presentation of Meckel’s diverticulum in adults?
A. Occult bleeding
B. Massive lower GI bleed
C. Diverticulitis with abscess
D. Diverticulitis with diffuse peritonitis
E. Obstruction
Volvulus of small bowel around diverticulum; intussusception; incarceration into hernia

59. Most common presentation for Meckel’s diverticulum in children is?
Intussusception
GI bleeding
Incarceration into a hernia sac
Diverticulitis
Obstruction caused by volvulus

60. Most common presentation for Meckel’s diverticulum in children is?
Intussusception
GI bleeding
Incarceration into a hernia sac
Diverticulitis
Obstruction caused by volvulus
Meckel’s also most common cause of lower GI bleeding in children

61. B. Meckel diverticulectomy C. Small bowel follow-through
A 12-year-old boy presents with a large amount of bright red blood per rectum, combined with melena. He is hemodynamically stable. Subsequent work-up includes lower and upper endoscopies, both of which are negative. A technetium-99m pertechnetate nuclear scan is performed and lights up in the in the right lower quadrant. Further management consists of:
A. Arteriography
B. Meckel diverticulectomy
C. Small bowel follow-through
D. Segmental resection of ileum to include the
Meckel diverticulum
E. CT scan of the abdomen with oral contrast

62. B. Meckel diverticulectomy C. Small bowel follow-through
A 12-year-old boy presents with a large amount of bright red blood per rectum, combined with melena. He is hemodynamically stable. Subsequent work-up includes lower and upper endoscopies, both of which are negative. A technetium-99m pertechnetate nuclear scan is performed and lights up in the in the right lower quadrant. Further management consists of:
A. Arteriography
B. Meckel diverticulectomy
C. Small bowel follow-through
D. Segmental resection of ileum to include the Meckel diverticulum
E. CT scan of the abdomen with oral contrast
The gastric mucosa secretes acid  ulcer formation & bleeding
Usually in adjacent ileum and not in Meckel diverticulum itself
Specimen should be opened to search for ulceration

63. B. Meckel diverticulectomy
A 5-year-old boy presents with symptoms and signsof acute appendicitis. He undergoes an open appendectomy. At surgery, the appendix is acutely inflamed but not perforated. A Meckel diverticulum is incidentally discovered. In addition to performing an appendectomy, further management consists of:
A. Observation
B. Meckel diverticulectomy
C. Meckel diverticulectomy only if ectopic mucosa is palpated in the diverticulum
D. Meckel diverticulectomy only if an adhesive band to the umbilicus is present
E. Meckel diverticulectomy only if previous signs of inflammation are present

64. B. Meckel diverticulectomy
A 5-year-old boy presents with symptoms and signsof acute appendicitis. He undergoes an open appendectomy. At surgery, the appendix is acutely inflamed but not perforated. A Meckel diverticulum is incidentally discovered. In addition to performing an appendectomy, further management consists of:
A. Observation
B. Meckel diverticulectomy
C. Meckel diverticulectomy only if ectopic mucosa is palpated in the diverticulum
D. Meckel diverticulectomy only if an adhesive band to the umbilicus is present
E. Meckel diverticulectomy only if previous signs of inflammation are present
Most surgeons recommend removal in children when discovered incidentally at
surgery
Guidelines in adults:
Age < 50 years
Presence of palpable heterotopic tissue
Diverticulum length > 2 cm
Presence of a mesodiverticular band
Signs of previous diverticulitis.

65. Extensive stricturing of the small bowel
An intraoperative finding that is virtually pathognomic for Crohn’s disease is:
Extensive stricturing of the small bowel
Multiple interloop small bowel abscesses
Multiple EC fistulas
Terminal ileitis
Extensive mesenteric fat wrapping

66. Extensive stricturing of the small bowel
An intraoperative finding that is virtually pathognomic for Crohn’s disease is:
Extensive stricturing of the small bowel
Multiple interloop small bowel abscesses
Multiple EC fistulas
Terminal ileitis
Extensive mesenteric fat wrapping

67. Optimal margin is at least 4 cm beyond grossly visible disease
Which of the following is true regarding the principles of the operative management of the small bowel in Crohn’s disease?
Optimal margin is at least 4 cm beyond grossly visible disease
Frozen section should be obtained to confirm the absence of active disease in at least 1 margin
Duodenal disease is best managed by resection
A 10 cm strictured segment of jejunum can be managed by a Heineke-Mikulicz strictureplasty rather than resection
Strictures longer than 10 cm are best managed by resection

68. Optimal margin is at least 4 cm beyond grossly visible disease
Which of the following is true regarding the principles of the operative management of the small bowel in Crohn’s disease?
Optimal margin is at least 4 cm beyond grossly visible disease
Frozen section should be obtained to confirm the absence of active disease in at least 1 margin
Duodenal disease is best managed by resection
A 10 cm strictured segment of jejunum can be managed by a Heineke-Mikulicz strictureplasty rather than resection
Strictures longer than 10 cm are best managed by resection
H-M strictureplasty for ≤ 12 cm stricture
Finney strictureplasty for ≤ 25 cm stricture
Don’t forget to biopsy intraluminal ulcerations

69. The earliest lesion characteristic of Crohn’s is?
Apthous ulcer
Caseating granuloma
Noncaseating granuloma
Cobblestone mucosa
Serosal thickening

70. The earliest lesion characteristic of Crohn’s is?
Apthous ulcer
Caseating granuloma
Noncaseating granuloma
Cobblestone mucosa
Serosal thickening
Superficial mucosal ulcers form from submucosal lymphoid follicle expansion

71. Sulfasalazine Prednisone Budesonide Metronidazole Infliximab
Which of the following is the best therapeutic option for mild active Crohn’s disease?
Sulfasalazine
Prednisone
Budesonide
Metronidazole
Infliximab

72. Most commonly used drug for mild active disease is sulfasalazine
Which of the following is the best therapeutic option for mild active Crohn’s disease?
Sulfasalazine
Prednisone
Budesonide
Metronidazole
Infliximab
Most commonly used drug for mild active disease is sulfasalazine
Prednisone is treatment of choice for acute flare-ups
Infliximab is used to maintain remission

73. All of the following are true regarding stromal tumors of the small bowel EXCEPT:
A. They can be treated with tyrosine kinase
inhibitors
B. They stain positive for CD34
C. They typically present as large bulky
tumors
D. Surgical resection is the management
procedure of choice
E. Malignancy is primarily determined by
evidence of local invasion

74. All of the following are true regarding stromal tumors of the small bowel EXCEPT:
A. They can be treated with tyrosine kinase
inhibitors
B. They stain positive for CD34
C. They typically present as large bulky
tumors
D. Surgical resection is the management
procedure of choice
E. Malignancy is primarily determined by
evidence of local invasion

75. The most useful indicators of survival/risk of mets are size of the tumor at
presentation, mitotic index, and evidence of tumor invasion into the lamina propria
Adjuvant treatment includes Gleevec (imatinib), a tyrosine kinase
Inhibitor (unresectable/metastatic/recurrent)
GISTs stain positive for CD34 (human progenitor cell antigen) and CD177 (c-kit
proto-oncogene protein)
Small bowel GISTs that present with symptoms tend to be very large and bulky
Standard treatment is surgical resection with negative margins

76. Early postoperative small bowel obstruction:
A. Is best managed nonoperatively in the
majority of patients
B. Is more frequent with upper intestinal than
lower intestinal surgery
C. Does not seem to occur after open
transperitoneal aortic surgery
D. Has a higher rate of strangulation than
delayed small bowel obstruction
E. Is associated with high morbidity and
mortality rates

77. Early postoperative small bowel obstruction:
A. Is best managed nonoperatively in the
majority of patients
B. Is more frequent with upper intestinal than
lower intestinal surgery
C. Does not seem to occur after open
transperitoneal aortic surgery
D. Has a higher rate of strangulation than
delayed small bowel obstruction
E. Is associated with high morbidity and
mortality rates
SBO seems to be more frequent with lower abdominal surgery
Majority of pts. can be managed nonop
Morbidity and mortality rates are very low

78. All of the following are true regarding Crohn disease EXCEPT:
A. It is more common in individuals of low
socioeconomic status
B. It is the most common primary surgical
disease of the small bowel
C. It has a bimodal distribution
D. It is more prevalent in smokers

79. All of the following are true regarding Crohn disease EXCEPT:
A. It is more common in individuals of low
socioeconomic status
B. It is the most common primary surgical
disease of the small bowel
C. It has a bimodal distribution
D. It is more prevalent in smokers
Bimodal distribution (2nd-3rd and 6th decades of life)
Risk factors include living in northern latitudes, Ashkenazi Jews,
smoking, and familial inheritance
Relative risk among 1st-degree relatives of patients with Crohn
disease 14-15X greater than general population.
More common in urban areas/high socioeconomic status

80. C. Enteroendocrine cells D. Paneth cells E. Absorptive enterocytes
Which intestinal cells have been implicated in the formation of gastrointestinal stromal tumors
A. Goblet cells
B. Cajal cells
C. Enteroendocrine cells
D. Paneth cells
E. Absorptive enterocytes

81. Goblet cells secrete mucus
Which intestinal cells have been implicated in the formation of gastrointestinal stromal tumors
A. Goblet cells
B. Cajal cells
C. Enteroendocrine cells
D. Paneth cells
E. Absorptive enterocytes
Goblet cells secrete mucus
Paneth cells secrete lysozyme, tumor necrosis factor, and cryptidins
Enteroendocrine cells secrete various gut hormones

82. Which of the following is true regarding duodenal diverticula?
A. They tend to occur on the antimesenteric side
of the bowel
B. They are usually true diverticula
C. Treatment with endoscopic interventions is
contraindicated
D. They are most commonly located in the
periampullary region
E. When discovered incidentally at surgery, they
should be left alone

83. Which of the following is true regarding duodenal diverticula?
A. They tend to occur on the antimesenteric side
of the bowel
B. They are usually true diverticula
C. Treatment with endoscopic interventions is
contraindicated
D. They are most commonly located in the 1st portion of the duodenum
E. When discovered incidentally at surgery, they
should be left alone
Most commonly (75%) located adjacent to the ampulla of Vater
False diverticula that arise on the mesenteric border in areas of
weakness in the bowel wall where blood vessels penetrate
Asymptomatic in majority of pts, and surgery not recommended
if incidentally discovered

84. Small intestinal lymphoma:
A. Is most often the Hodgkin type B. Is associated with acquired immunodeficiency syndrome C. Most commonly occurs in the duodenum D. Is the most common small bowel malignancy E. Is primarily treated by chemotherapy

85. Small intestinal lymphoma:
Is most often the Hodgkin type
B. Is associated with acquired immunodeficiency syndrome
C. Most commonly occurs in the duodenum
D. Is the most common small bowel malignancy
E. Is primarily treated by chemotherapy
Predominantly non-Hodgkin type
Small bowel lymphomas are a/w pts. w/ AIDS and transplant recipients
Small bowel lymphomas most commonly involve
the ileum (carcinoids) vs. adenocarcinomas in duodenum vs.
GISTs evenly distributed throughout small bowel
Primary treatment of small bowel lymphoma (as well as all other small
bowel malignancies) is surgical resection including affected
mesentery

86. A. Intravenous (IV) heparin drip B. Exploratory laparotomy
A 68-year-old woman presents with an exacerbation of congestive heart failure and acute abdominal pain. Physical examination of abdomen is significant for mild diffuse abdominal tenderness but no rebound or guarding. CT arteriography of the abdomen demonstrates diffuse narrowing of the SMA and its branches. Which of the following is the best management option?
A. Intravenous (IV) heparin drip
B. Exploratory laparotomy
C. Observation
D. Intra-arterial papaverine
E. Thrombolytic therapy

87. A. Intravenous (IV) heparin drip B. Exploratory laparotomy
A 68-year-old woman presents with an exacerbation of congestive heart failure and acute abdominal pain. Physical examination of abdomen is significant for mild diffuse abdominal tenderness but no rebound or guarding. CT arteriography of the abdomen demonstrates diffuse narrowing of the SMA and its branches. Which of the following is the best management option?
A. Intravenous (IV) heparin drip
B. Exploratory laparotomy
C. Observation
D. Intra-arterial papaverine
E. Thrombolytic therapy
C/W nonocclusive mesenteric ischemia (20-30%)
Seen in setting of decreased cardiac output (acute MI, CHF exacerbation or after
cardiac surgery)
For nonocclusive mesenteric ischemia, the treatment is medical optimization to
improve cardiac output and selective intra-arterial infusion of a vasodilator
(papaverine) into the SMA

88. A. Platelet serotonin levels B. A 24-hour urinary 5-HIAA test
Which of the following is the best test for prognosis and for monitoring treatment response in carcinoid tumors?
A. Platelet serotonin levels
B. A 24-hour urinary 5-HIAA test
C. Serum chromogranin A levels
D. Serum serotonin levels
E. Neuron-specific enolase

89. A. Platelet serotonin levels B. A 24-hour urinary 5-HIAA test
Which of the following is the best test for prognosis and for monitoring treatment response in carcinoid tumors?
A. Platelet serotonin levels
B. A 24-hour urinary 5-HIAA test
C. Serum chromogranin A levels
D. Serum serotonin levels
E. Neuron-specific enolase
Serum chromogranin A is the most sensitive marker for
detecting neuroendocrine tumors in general
Most useful marker for detecting recurrence and response to
treatment

90. A. Early operative intervention B. Prevention of skin breakdown
The most important factor in reducing mortality from a small bowel fistula is:
A. Early operative intervention
B. Prevention of skin breakdown
C. Waiting at least 6 weeks before operative
intervention
D. Control of sepsis
E. Use of TPN

91. A. Early operative intervention B. Prevention of skin breakdown
The most important factor in reducing mortality from a small bowel fistula is:
A. Early operative intervention
B. Prevention of skin breakdown
C. Waiting at least 6 weeks before operative
intervention
D. Control of sepsis
E. Use of TPN
Primary cause of mortality from small bowel fistula is sepsis
CT essential to ascertain whether fistula is being adequately
captured and to rule out intraperitoneal abscesses
Early management focuses on adequate fluid/electrolyte
repletion, early institution of TPN, and skin protection

92. A. Closure of perforation
A 35-year-old man with recent travel to South America presents with fever, bloody diarrhea, and abdominal pain. On plain radiograph, there is free air under the diaphragm. At surgery, a single perforation is found in the terminal ileum with accompanying mesenteric lymphadenopathy and splenomegaly. Management consists of:
A. Closure of perforation
B. Segmental resection with primary anastomosis
C. Ileocecectomy with ileal ascending colostomy
D. Resection of terminal ileum with ileostomy
and mucous fistula
E. Resection of terminal ileum with right
colectomy and ileotransverse colostomy

93. A. Closure of perforation
A 35-year-old man with recent travel to South America presents with fever, bloody diarrhea, and abdominal pain. On plain radiograph, there is free air under the diaphragm. At surgery, a single perforation is found in the terminal ileum with accompanying mesenteric lymphadenopathy and splenomegaly. Management consists of:
A. Closure of perforation
B. Segmental resection with primary anastomosis
C. Ileocecectomy with ileal ascending colostomy
D. Resection of terminal ileum with ileostomy
and mucous fistula
E. Resection of terminal ileum with right
colectomy and ileotransverse colostomy
C/W typhoid enteritis; Dx confirmed by positive blood or stool
Culture
Infection from Salmonella typhosa
Perforation (peyer’s patches) typically solitary and in terminal ileum ;
managed with simple closure and antibiotics

94. A. If a stricture is present, it is best managed by strictureplasty
45 YO F with a h/o laparotomy and 5000 cGy of abdominal and pelvic irradiation for ovarian cancer 10 years ago presents with an acute bowel obstruction. CT scan shows a complete SBO at the level of the mid jejunum with no evidence of any masses. Which of the following is true about this condition?
A. If a stricture is present, it is best managed by strictureplasty
B. The patient should undergo a complete lysis of adhesions
C. Chronic radiation enteritis is due to an obliterative arteritis
D. A trial of corticosteroids is indicated
E. The degree of radiation damage is not affected by whether the patient received chemotherapy

95. A. If a stricture is present, it is best managed by strictureplasty
45 YO F with a h/o laparotomy and 5000 cGy of abdominal and pelvic irradiation for ovarian cancer 10 years ago presents with an acute bowel obstruction. CT scan shows a complete SBO at the level of the mid jejunum with no evidence of any masses. Which of the following is true about this condition?
A. If a stricture is present, it is best managed by strictureplasty
B. The patient should undergo a complete lysis of adhesions
C. Chronic radiation enteritis is due to an obliterative arteritis
D. A trial of corticosteroids is indicated
E. The degree of radiation damage is not affected by whether the patient received chemotherapy
Chronic radiation enteritis results from an obliterative arteritis of the submucosal
vessels  submucosal fibrosis/stricture formation
Strictureplasty not recommended b/c high risk of tissue breakdown
Extensive LOA risks enterotomy and subsequent fistula formation
Risk of radiation damage increases if pt. received chemo, has
underlying vascular disease or diabetes

96. The most common cause of obscure GI bleeding in adults is:
A. Small intestine angiodysplasia
B. Meckel diverticulum
C. Crohn disease
D. Infectious enteritis
E. Vasculitis

97. A. Small intestine angiodysplasia B. Meckel diverticulum
The most common cause of obscure (not seen on upper GI/ colonscopy) GI bleeding in adults is:
A. Small intestine angiodysplasia
B. Meckel diverticulum
C. Crohn disease
D. Infectious enteritis
E. Vasculitis
Small intestine angiodysplasia accounts for 75% of obscure GI bleeding in adults

98. All of the following are true regarding Peutz-Jeghers syndrome EXCEPT:
A. The typical small bowel lesion is an adenomatous polyp
B. It is autosomal dominant
C. Bowel obstruction is the most common
Presentation
D. There is an increased risk of small intestine
cancer
E. There is an increased risk of breast cancer

99. All of the following are true regarding Peutz-Jeghers syndrome EXCEPT:
A. The typical small bowel lesion is an adenomatous polyp
B. It is autosomal dominant
C. Bowel obstruction is the most common
Presentation
D. There is an increased risk of small intestine
cancer
E. There is an increased risk of breast cancer
Features include mucocutaneous melanotic pigmentation and hamartomatous
polyps (not adenomatous) of the small intestine
Autosomal dominant inherited syndrome
Most common symptom is recurrent colicky abdominal pain at significantly increased risk for development Gl tract cancers and extraintestinal cancers (testis, breast, uterus, ovary)

100. B. It can lead to a nonsurgical pneumoperitoneum
All of the following are true regarding pneumatosis intestinalis EXCEPT:
A. In neonates, it is most often associated with necrotizing entercolitis
B. It can lead to a nonsurgical pneumoperitoneum
C. In adults, it is commonly a/w COPD
D. Primary pneumatosis usually requires surgical intervention
E. The diagnosis is readily made with plain radiography

101. B. It can lead to a nonsurgical pneumoperitoneum
All of the following are true regarding pneumatosis intestinalis EXCEPT:
A. In neonates, it is most often associated with necrotizing entercolitis
B. It can lead to a nonsurgical pneumoperitoneum
C. In adults, it is commonly a/w COPD
D. Primary pneumatosis usually requires surgical intervention
E. The diagnosis is readily made with plain radiography
Pneumatosis intestinalis is a radiographic finding and not a disease
Divided into primary and secondary
No specific treatment for primary
Pneumoperitoneum can result from a benign case of pneumatosis intestinalis because the air-filled cysts are thin walled and can burst

102. THE END….