1.

The most common site of adenocarcinoma of the small intestine is the:

A. Duodenum.
B. Jejunum.
C. Ileum.
Answer: A

2. The most common benign tumor of the small intestine is:

A. Adenoma.
B. Hemangioma.
C. Leiomyoma.
Answer: C

3. Vigorous bleeding from a small bowel lesion is most likely caused by:
A. Adenocarcinoma.
B. Arteriovenous malformation.
C. Leiomyoma.
Answer: C

4. The lamina propria between the intestinal epithelium and the muscularis
mucosae contains:
A. Blood and lymph vessels.
B. Undifferentiated epithelial cells.
C. Nerve fibers.
D. Enterochromaffin cells.
E. Macrophages.
F. Connective tissue.
Answer: ACEF

DISCUSSION: The mucosa of the small intestine encompasses the epithelium, the
lamina propria, and the muscularis mucosae. The lamina propria between the
epithelium and the muscularis mucosae contains blood and lymph vessels, nerve
fibers, smooth muscle fibers, fibroblasts, macrophages, plasma cells,
lymphocytes, eosinophils, and mast cells, as well as connective tissue elements.

5. The intestinal epithelial cells, 22 to 26 mm. tall, exhibit a striated luminal

border (brush border). The brush border microvilli:
A. Produce the brush border appearance.
B. Contain amylase.
C. Contain dissacharidases.
D. Increase absorptive area.
E. Play an important role in digestion.
F. Contain trypsinogen.
Answer: ACDE
DISCUSSION: The columnar epithelial cells are responsible for absorption. These
cells exhibit a striated luminal border or brush border. The microvilli account for
the appearance of the brush border. The microvilli greatly increase the absorption
surface of the epithelial cell. The brush border contains disaccharidase in high
concentrations. In addition to increasing surface area the microvilli perform an
important digestive function.

6. Which of the following statements about carbohydrate digestion are true?

A. Amylopectin has 1-4 straight chains and 1-6 side chains.
B. Amylase has 1-4 straight chains and 1-6 side chains.
C. Amylase breaks 1-4 glucose linkages.
D. Amylase breaks 1-6 side chains.
E. An adult may ingest about 350 gm. of carbohydrate daily.
F. Dietary starch contains two glucose polymers, amylopectin and amylase.
Answer: ACEF

DISCUSSION: Amylopectin, the most abundant constituent of starch, is a 1-4–

linked straight chain of glucose molecules. In addition, amylopectin possesses a 1-
6 branching side chain at approximately every 25 glucose units along the straight
chain. Amylase has only 1-4 linkages of glucose molecules. Pancreatic and salivary
amylase break the interior 1-4 glucose linkages.

7. Which of these statements about the digestion of fat are true?

A. Micellar solution provides an optimal environment for the action of pancreatic
lipase.
B. Decreasing the pH below 5.5 increases the effectiveness of pancreatic lipase in
hydrolyzing fat.
C. Co-lipase blocks triglyceride hydrolysis.
D. Lipase catalyzes the hydrolysis of dietary triglyceride into 2-monoglyceride and
fatty acids.
E. Fatty acids and 2-monoglyceride are held in micellar solutions.
F. Fatty acid and 2-monoglyceride enter the intestinal cell by active transport.
Answer: ADE

DISCUSSION: Micellar solution provides an optimal environment for the action of

pancreatic lipase. Pro-co-lipase is converted to co-lipase by trypsin. Co-lipase
binds to triglyceride, then lipase complexes with co-lipase, and triglyceride
hydrolysis access. Pancreatic lipase hydrolyzes triglyceride into 2-monoglyceride
and fatty acids. The 2-monoglyceride and fatty acid enter the micellae. An
alkaline pH allows lipase to function optimally. Micellar fatty acids and 2-
monoglyceride pass into the epithelial cell by diffusion.
8. Complete mechanical small bowel obstruction can cause dehydration by:
A. Interfering with oral intake of water.
B. Inducing vomiting.
C. Decreasing intestinal absorption of water.
D. Causing secretion of water into the intestinal lumen.
E. Causing edema of the intestinal wall.
Answer: ABCDE

DISCUSSION: One of the most important events during simple mechanical small
bowel obstruction, loss of water and electrolytes from the body, is caused mainly
by intestinal distention. Distention may produce reflex vomiting. Distention
causes intestinal secretion. Distention causes decreased absorption.

9. History and physical examination permit the diagnosis of intestinal obstruction

in most cases. Which of the following are important for the clinical diagnosis of
small bowel obstruction?
A. Crampy abdominal pain.
B. Fever.
C. Vomiting.
D. Abdominal distention.
E. Leukocyte count above 12,000.
F. Abdominal tenderness.
Answer: ABCDF

DISCUSSION: History and physical examination permit the diagnosis of intestinal

obstruction. Any patient having crampy abdominal pain, vomiting, obstipation,
abdominal distention, abdominal tenderness, and peristaltic rushes should be
managed for intestinal obstruction until the diagnosis can confidently be
excluded.

10. Patients with established, complete, simple, distal small bowel obstruction
usually have the following findings on plain and upright abdominal radiographs:
A. Distended small bowel identifiable by the valvulae conniventes.
B. Multiple air-fluid levels.
C. Modest amount of gas in the pelvis.
D. Peripheral, rather than central, distribution of gas.
E. Prominent haustral markings.
F. Free air.
Answer: AB

DISCUSSION: Abdominal x-ray examination of patients with intestinal obstruction

usually reveals abnormally large quantities of gas in the bowel. One can usually
identify distended small intestine or colon. Gas in the small bowel outlines the
valvulae conniventes, which usually occupy the entire transverse diameter of the
bowel image. Colonic haustral markings occupy only a portion of the transverse
diameter of the bowel.
Typically, the small bowel pattern occupies the more central portion of the
abdomen, whereas the colon shadow is on the periphery of the abdominal files or
in the pelvis. Patients with mechanical small intestinal obstruction usually have
minimal colonic gas, if any.

11. All of the following statements about the embryology of Meckel's diverticulum
are true except:
A. Meckel's diverticulum usually arises from the ileum within 90 cm. of the
ileocecal valve.
B. Meckel's diverticulum results from the failure of the vitelline duct to
obliterate.
C. The incidence of Meckel's diverticulum in the general population is 5%.
D. Meckel's diverticulum is a true diverticulum possessing all layers of the
intestinal wall.
E. Gastric mucosa is the most common ectopic tissue found within a Meckel's
diverticulum.
Answer: C

DISCUSSION: Meckel's diverticulum is a true diverticulum containing all layers of

the intestinal wall, usually arising from the antimesenteric border of the ileum
45–90 cm. proximal to the ileocecal valve. It is a vestige of the
omphalomesenteric or vitelline duct, which usually undergoes complete
obliteration during the seventh week of gestation. Autopsy studies have estimated
the incidence of Meckel's diverticulum to be 1% to 2% with men being more
commonly affected than women by a ratio of 2:1. Gastric mucosa is present in
50% of all Meckel's diverticula, but in over 75% of symptomatic individuals.

12. Meckel's diverticulum most commonly presents as:

A. Gastrointestinal bleeding.
B. Obstruction.
C. Diverticulitis.
D. Intermittent abdominal pain.
Answer: A

DISCUSSION: It is estimated that only 4% of patients who possess a Meckel's

diverticulum will become symptomatic during their lifetimes. The most common
clinical presentation is incidental identification during abdominal exploration.
Symptomatic presentations are secondary to hemorrhage, small bowel
obstruction, diverticulitis, perforation, associated umbilical abnormalities, and
tumors. Over half of patients presenting with symptoms are under the age of 2.
The most common clinical problem associated with Meckel's diverticulum is
gastrointestinal bleeding presenting as bright red blood per rectum. The usual
source of the bleeding is a chronic acid-induced ileal ulcer in the ileum adjacent
to a Meckel's diverticulum that contains gastric mucosa. Another common
symptom associated with a Meckel's diverticulum is intestinal obstruction. The
cause of this obstruction may be volvulus of the small bowel around a
diverticulum associated with a fibrotic band attached to the abdominal wall,
intussusception, or rarely, incarceration of the diverticulum in an inguinal hernia
(Littre's hernia). Volvulus is usually an acute event and if allowed to progress,
may result in strangulation of the involved bowel. In intussusception, a broad-
based diverticulum invaginates and then is carried forward by peristalsis.

13. Which of the following statements about the surgical treatment of carcinoid
tumors are true?
A. Carcinoid tumors should be treated by resection, regardless of the presence of
metastases.
B. Appendiceal tumors larger than 1.5 cm. should be treated by ileocolectomy.
C. Local excision with margins is adequate for a rectal carcinoid of any size.
D. Carcinoid tumors are associated with a large percentage of other synchronous
or metachronous neoplasms.
Answer: ABD

DISCUSSION: Carcinoid tumors should be treated by resection, regardless of the

presence of metastases, because growth of the primary neoplasm is slow and
local complications, such as obstruction and intussusception, are frequent. At
clinical discovery a large percentage (as many as 70%) of small-intestinal
carcinoids are metastatic to lymph nodes and/or liver. All tumors should be
managed by wide en bloc resection, regardless of the size of the primary lesion or
the presence of distant metastases. Lesions in the distal ileum require
ileocolectomy. Appendiceal tumors larger than 1.5 cm. should be treated by
ileocolectomy. The incidence of metastases depends on the size and location of
the primary tumor. Appendiceal carcinoid tumors smaller than 1.5 cm. are rarely
malignant and may be treated safely by routine appendectomy. This is not true of
larger tumors. Like carcinoid tumors elsewhere in the gastrointestinal tract, the
malignancy potential of rectal carcinoid tumors is directly proportional to their
size. Tumors smaller than 1 cm. have little or no malignant potential and may be
treated by endoscopic excision. Tumors measuring 1 to 2 cm. should be excised
operatively with margins, but when they are larger than 2 cm. rectal carcinoid
tumors may require anterior resection. In patients with ileal carcinoid tumors,
the evidence of a second tumor has been reported as high as 40%. Thus, the
search for synchronous metachronous and metastatic neoplasms should be
undertaken.

14. Which of the following statements about carcinoid syndrome are true?
A. Carcinoid syndrome occurs only when hepatic metastases are present.
B. Serotonin is thought to be responsible for the diarrhea, cardiac lesions, and
flushing in patients with carcinoid syndrome.
C. Foregut carcinoid tumors cause atypical carcinoid syndrome; hindgut tumors
are rarely, if ever, associated with the syndrome.
D. The long-acting somatostatin analog provides the best symptomatic treatment
for carcinoid syndrome.
Answer: CD

DISCUSSION: Carcinoid syndrome occurs when venous drainage from the tumor
gains access to the systemic circulation, escaping hepatic degradation. Although
hepatic metastases are most often responsible, retroperitoneal metastases and
bronchial, ovarian, and testicular carcinoid tumors can also cause the carcinoid
syndrome. Serotonin is thought to be largely responsible for both the diarrhea and
the fibrosing cardiac lesions associated with the carcinoid syndrome. The
vasomotor changes, however, are mediated by kinins and such vasoactive peptides
as substance P, neuropeptide K, neurokinin A, and neurotensin. Other substances,
such as histamine, vasoactive intestinal peptide (VIP), and prostaglandins, may
also contribute to systemic manifestations in the carcinoid syndrome. Foregut
carcinoid tumors, of which stomach and bronchial tumors are the most common,
can cause atypical carcinoid syndrome. It is thought that these tumors are
deficient in the enzyme dopa-decarboxylase and have impaired conversion of 5-
hydroxytryptophan (5-HTP) into 5-hydroxytryptamine (5-HT), leading to secretion
of 5-HTP into the vascular compartment. Some of the 5-HTP is converted into 5-
HT and 5-hydroxyindoleacetic acid (5-HIAA) in extrarenal sites, and some is
decarboxylated in the kidney and excreted into the urine as 5-HT; but some of the
5-HTP is excreted directly into the urine. Thus, in patients with foregut tumors,
the urine contains relatively little 5-HIAA (but more than normal) but large
amounts of 5-HTP and 5-HT, in contrast to patients with midgut carcinoid tumors
in which large amounts of 5-HIAA are secreted into the urine but relatively little
5-HTP. Carcinoid tumors of the hindgut contain no argentaffin or argyrophil cells,
they have no secretory products, and therefore they are not associated with the
carcinoid syndrome. The long-acting somatostatin analog provides the best
symptomatic therapy, because somatostatin inhibits both release and action of
humoral mediators of the carcinoid syndrome. By contrast, serotonin antagonists
are of little value and the efficacy of interferon therapy has yet to be
established.

15. Simple screening tests for malabsorption include:

A. Microscopic examination.
B. D-xylose absorption.
C. A 72-hour stool collection for fats.
D. Small bowel x-ray series.
Answer: ABD

DISCUSSION: The 72-hour stool collection is quite sensitive and detects even mild
malabsorption. As it requires careful stool collection timed by carmen red
markers and documented dietary fat intake, it is not useful for screening.
Microscopic examination of the stool can detect muscle fibers if protein
malabsorption is present and with Sudan II staining can estimate fat content. D-
Xylose absorption from oral ingestion of 5 gm., detected by a blood sample after
1 hour, is a simple and quite accurate test to identify carbohydrate
malabsorption. Small bowel x-ray series, using barium contrast, can give very
useful information on mucosal abnormalities, enteric fistulas, mechanical
obstructions, and very importantly, intestinal motility and transit time.

16. Extensive resection of the small bowel, leaving only 2 or 3 feet beyond the
ligament of Treitz anastomosed to the transverse colon, can lead to the following
metabolic complications:
A. Gastric hyperacidity and hypersecretion.
B. Hyperoxaluria.
C. Hypermetabolic response.
D. Fat-soluble vitamin deficiency.
Answer: ABD

DISCUSSION: Once the stress of the surgical procedure is over, there is no further
hypermetabolic response, nor does there appear to be any reduced energy
expenditure from loss of the metabolically active small bowel. Energy needs are
unaltered. Gastric secretion and hyperacidity are directly related to the extent of
small bowel resection and is due in part to increased concentrations of gastrin in
the serum. H 2 blockers are effective in reducing acidity and volume of gastric
secretions. Hyperoxaluria develops owing to binding of calcium to fat in the diet
with steatorrhea, leaving less to bind with dietary oxalate. The soluble oxalate is
absorbed by the colon and excreted in the urine. If oxalate is excessive, oxalate
kidney stones can form. With fat malabsorption due to bile salt depletion and
rapid intestinal transit, absorption of the fat-soluble vitamins A, E, K, and D is
reduced. Even with oral supplementation, deficiencies can develop.

17. Which of the following physical factors of irradiation is/are related to the
potential for radiation injury?
A. The dimension of the radiation portals.
B. The number of portals.
C. The number of fractions.
D. The total amount of irradiation.
E. All of the above.
Answer: E

DISCUSSION: These physical factors are interactive. Less energy is delivered

through a small portal than through a large one. Multiple portals permit
concentration of the radiation in the area to be treated and spare skin and
viscera from damage. There is less risk of injury from irradiation of a given
intensity if more fractions are applied.
18. For which of the following consequences of radiation injury of the intestine is
urgent laparotomy required?
A. Small bowel obstruction.
B. Colonic perforation.
C. Rectovaginal fistula.
D. Malabsorption and diarrhea.
E. Rectal stenosis.
Answer: B

DISCUSSION: Patients who have symptoms of vascular compromise or evidence of

perforation require urgent laparotomy. Patients with small bowel obstruction may
require a laparotomy if a complete obstruction persists, but gastrointestinal
decompression and hydration are first steps. Patients with radiation-induced
rectovaginal fistula may require temporary or even permanent colostomy, but the
first steps are evaluation and control of sepsis. Malabsorption and diarrhea can
generally be controlled pharmacologically. Rectal stenosis can usually be managed
without laparotomy.

19. In addition to its absorptive and digestive roles, the small bowel also plays a
significant role in the body’s immune system. Gut-associated lymphoid tissue
(GALT) represents a major division of the immune system. Which of the following
statement(s) is/are true concerning the immunologic functions of the small
intestine?

a. The B lymphocytes of the small intestine do not produce immunoglobulin A

(IgA)
b. Peyer’s patches, an example of an aggregated cellular portion of the gut-
associated lymphoid system tissue, are large collections of lymphoid follicles
found on the antimesenteric border of the ileum
c. The major immunoglobulin of the intestinal immune system is IgM
d. IgA produced by the intestinal immune system produces the classic Fc-
mediated inflammatory reactions to antigen stimulus
Answer: b

Gut-associated lymphoid tissue (GALT) represent a major division of the immune

system and is made up of aggregated (Peyer’s patches, lymphoid follicles,
mesenteric lymph nodes) and nonaggregated cellular components. The lamina
propria of the small intestine contains a wide array of nonaggregated lymphoid
tissue including B cells, T cells, macrophages, eosinophils, and mast cells. Some
80% to 99% of B cells are active producers of immunoglobulin A (IgA). In
comparison, only 2% to 5% of B cells found in other lymphoid tissues of the body
secrete IgA. IgA is the major immunoglobulin of the intestinal immune system.
The functional characteristics of IgA are unlike those of other antibodies. Unlike
IgG or IgM, secretory IgA does not induce Fc-mediated inflammatory reactions.
Antigen-IgA complexes do not activate the classic or alternate complement
systems, nor does IgA promote the phagocytosis of bacteria by opsonization. Most
of the protective effect of IgA derives from its ability to bind the threatening
antigen efficiently, while resisting enzymatic degradation by gut enzymes.

20. During the fasting state, a well-defined pattern of small bowel electrical
activity occurs which is known as the interdigestive myoelectric complex or the
migrating motor complex (MMC). Which of the following statement(s) is/are true
concerning the MMC?

a. This complex consists of a cyclic pattern of spike bursts and muscular

contractions that migrate from the duodenum to the terminal ileum and can be
divided into four phases
b. The major activity during the MMC occurs during phase I
c. In humans the MMC usually lasts less than one hour
d. Blood levels of the GI peptide, motilin, correlate closely with MMC activity and
exogenous motilin can induce the MMC front
Answer: a, d

The migrating motor complex (MMC) is a cyclic pattern of spike bursts and
muscular contractions that migrate from the duodenum to the terminal ileum.
The MMC is divided into four phases: phase I-the period of quiescence with no
activity; phase II-accelerating irregular spike activity; phase III-the activity front
with a series of high-amplitude, rapid spikes corresponding to strong, rhythmic
gut contractions; and phase IV-subsiding activity. In humans the cycle lasts about
90 to 120 minutes. Each phase passes in sequence along the bowel, and when the
terminal ileum is reached, the process resumes in the proximal gut. This
interdigestive cycle is interrupted and replaced by rapid spiking activity (similar
to phase II) when the gut receives a food bolus. The duration of the interruption
depends on the volume and nature of the food stuffs with fats causing the largest
duration of rapid spiking. Blood levels of the GI hormone, motilin, correlate
closely with MMC activity and exogenous motilin can induce the MMC front. Other
hormones whose serum levels parallel MMC activity are pancreatic polypeptide
and somatostatin. Drugs that can initiate the MMC front include histamine,
metoclopramide, and morphine.

21. Which of the following statement(s) is/are true concerning the anatomy of
the small intestine?

a. The second (descending), third (transverse) and fourth (ascending) portions of

the duodenum lie in the retroperitoneum and are mobilized for surgical
procedures via the Kocher maneuver
b. The identification of the superior mesenteric vein and artery can be facilitated
by an extensive Kocher maneuver mobilizing the transverse portion of the
duodenum and exposing the vessels as they course over the duodenum and under
the neck of the pancreas
c. In only the minority of patients can the accessory pancreatic duct (the duct of
Santorini) be seen on endoscopic exam entering the duodenum
d. The ileum is the widest portion of the small intestine, with the diameter of the
small bowel progressively increasing as the ileocecal valve is approached
Answer: a, b

The duodenum is divided into four parts-the bulb, followed by the second
(descending), third (transverse), and fourth (ascending) portion. The duodenal
bulb begins at the pylorus and extends for the next 5 cm as the duodenum
assumes a retroperitoneal position for the second, third, and fourth portion. The
third and fourth portion of the duodenum complete the duodenal sweep.
Mobilization of the duodenum from the retroperitoneum for a multitude of
abdominal procedures can be facilitated by the Kocher maneuver where the
retroperitoneal attachment is divided and the duodenum and head of the
pancreas can be brought out of its retroperitoneal position. Endoscopically, the
major papilla of the duodenum can be seen entering at the mid-point of the
second portion of the duodenum. The papilla (ampulla of Vater) appears
anatomically as a hooded fold, marking the confluence of the common bile duct
and the main pancreatic duct (duct of Wirsung) and is surrounded by the muscular
sphincter of Oddi. In some 50% to 60% of patients, an accessory pancreatic duct
(the duct of Santorini) can be seen entering the duodenum proximal to the
ampulla of Vater. Endoscopically, this lesser, or minor, papilla appears as a one-to-
three mm sessile polyp. The jejunum is the portion of the small bowel that
courses from the ligament of Treitz to an arbitrary point approximately two-fifths
of the distance to the ileocecal valve. The length of the jejunum has been
estimated at 100 cm although this distance can vary dramatically depending on
the status of the small intestine. The jejunum is the widest portion of the small
intestine, and the diameter progressively decreases as the ileocecal valve is
approached. The ileum makes up the distal three-fifths of the combined
jejunal/ileal length.

22. Historically, the small intestine was presumed to have only digestive and
absorptive function. However, in the last decade the small intestine has become
recognized as the body’s largest endocrine organ, producing a number of
hormones, neurotransmitters, and paracrine substances. Which of the following
statement(s) is/are true concerning small bowel hormones?

a. Cholecystokinin (CCK) is produced from cells in the mucosa of the duodenum

and jejunum and is released in response to luminal fats and proteins
b. Secretin is released in response to rising intraduodenal pH, resulting in
inhibition of pancreatic secretion
c. Motilin is a 22-amino acid peptide released during the fasting state with
increased levels corresponding with the onset of the migrating motor complex
(MMC)
d. Neurotensin is produced primarily in the duodenal mucosa and its release is
stimulated primarily by carbohydrates and proteins
Answer: a, c

The endocrine functions of the small intestine are diverse with an ever increasing
number of hormones, peptides, neurotransmitters, and paracrine substances
identified. Cholecystokinin (CCK) is produced by cells located primarily in the
mucosa of the duodenum and jejunum and released in response to luminal fats
and proteins. After CCK release from the duodenum and jejunum, the gallbladder
contracts and the sphincter of Oddi relaxes, emptying bile into the duodenum.
Secretin is found in the S cells of the duodenum and jejunum. Secretin, a true
hormone, is released in response to acid in the duodenum when luminal pH falls
below 4.5. Intraduodenal secretion of pancreatic bicarbonate neutralizes
duodenal pH and results in diminished release of secretin. CCK acts in a
synergistic fashion with secretin to stimulate pancreatic exocrine function.
Motilin is a 22-amino acid peptide localized in the enterochromaffin cells of the
mucosa of the upper small intestine. Motilin likely has a physiologic role in the
regulation of the migrating motor complex (MMC). Motilin is released during the
fasting state, and increased levels correspond with the onset of the MMC.
Neurotensin is a 13-amino acid neurotransmitter found in the central nervous
system and in the gut. Specific endocrine cells that contain neurotensin are found
in the ileal mucosa with smaller quantities found in the jejunum, stomach,
duodenum, and colonic mucosa. Neurotensin is released by a mixed meal and
fats, with carbohydrates and protein releasing much smaller increments. It has
been proposed that neurotensin has a physiologic role in fat-initiated changes in
gastric acid secretion, gastric emptying, pancreatic secretion, and intestinal
motility.

23. The enterohepatic circulation refers to the circular flow of bile through the
small intestine and liver. Which of the following statement(s) concerning the
absorption of bile salts is/are correct?

a. The enterohepatic circulation is highly efficient with 80% to 90% of secreted

bile salts reabsorbed and returned to the liver through the portal circulation
b. The reabsorption of bile is entirely an active process
c. The small amount of bile escaping in the colon is deconjugated by bacteria,
promoting lipid solubility and passive colonic absorption
d. Ileal resection results in presenting high concentrations of bile salts to the
colon which promotes diarrhea by bacterial overgrowth
Answer: a, c

Some 80% to 90% of bile salts secreted into the small intestine as micelles are
reabsorbed and returned to the liver through the portal circulation. This circular
flow of bile is termed the enterohepatic circulation. In the liver, bile salts are
resecreted and stored in the gallbladder in preparation for the next meal. The
reabsorption process of bile is both passive and active. Passive absorption occurs
along the entire length of the small bowel and depends on the lipid solubility of
the bile salt. Glycine bile conjugates are more soluble than taurine conjugates. As
much as 50% of bile is passively reabsorbed. Active absorption of bile occurs only
in the terminal ileum. A small amount of bile escapes into the colon, where it is
deconjugated by bacteria, promoting lipid solubility and further passive
absorption. High colonic concentration of bile salts promote diarrhea by inhibiting
sodium and water absorption. This commonly occurs in patients with ileal
resection and can be treated with the bile-binding resin, cholestyramine.

24. The most obvious function of the GI tract is digestion and absorption of food
for continued growth and survival of the organism. Which of the following
statement(s) is/are true concerning small bowel absorption?

a. The jejunum is the site of maximum absorption for most ingested materials
with almost all jejunal absorption performed via active transfer mechanisms
b. Eighty percent of water presented to the gastrointestinal system is reabsorbed
by the small bowel
c. The absorption of carbohydrates requires digestion of large starch molecules by
salivary and pancreatic amylase, therefore presenting smaller oligosaccharides to
the brush border of the jejunum to complete the digestion and absorptive process
d. Dietary fiber represents poorly digestible carbohydrates which can absorb
organic materials such as bile salts and lipids
Answer: b, c, d

The jejunum is the site of maximum absorption of all ingested materials expect
for vitamin B12. Although its mucosa contains numerous specific transport
processes, the presence of large intercellular pores produces a permeable
membrane and allows for rapid passive transfer or solutes and water. The ileum is
less permeable and makes greater use of active-transport mechanisms. Normally
about 1 to 1.5 liters of water is ingested each day with another 5 to 10 liters
secreted by the GI tract in some form. About 80% of this fluid is absorbed by the
small bowel. Because of this large bidirectional movement of water, a small
alteration in bowel permeability or transport can rapidly result in net secretion
and diarrheal disease states. A major source of caloric nutrition comes in the
form of carbohydrate. In the Western diet, this is made up primarily of starch
(about 60%), sucrose (30%), and lactose (10%). The digestive process for starch
begins with digestion of the polysaccharide first by salivary amylase and continues
with pancreatic amylase yielding smaller oligosaccharides which along with
sucrose and lactose are then presented to the brush border of the jejunum to
complete the digestion and absorptive processes. Dietary fiber consists of
nondigestible carbohydrate, such as cellulose. Fiber is found commonly in all-bran
cereals, beans, partially cooked vegetables, and raw pulpy fruits. High fiber diets
retain water within the bowel lumen and significantly shorten bowel transit time.
Dietary fiber can absorb organic materials such as bile salts and lipids and
inorganic materials such as zinc, calcium, magnesium and iron.

25. Which of the following statement(s) is/are true concerning the

pathophysiology of small bowel obstruction?

a. Most of gas seen on plane abdominal radiographs is produced by gas forming

microorganisms
b. Elevation of luminal pressure contributes to fluid accumulation in the small
bowel in closed loop but not open loop small bowel obstructions
c. Intestinal blood flow initially increases to the bowel wall in early bowel
obstruction
d. In the face of obstruction, myoelectrical activity of the bowel is consistently
increased
Answer: b, c

When a loop of bowel is obstructed, intestinal gas and fluid accumulate.

Approximately 80% of the gas seen on plane abdominal radiographs is attributable
to swallowed air. In the setting of acute pain and anxiety, patients with intestinal
obstruction may swallow excessive amounts of air. Fluid accumulates
intraluminally with open-or closed-loop small intestinal obstruction due to a
number of factors. Experimental studies and clinical investigations demonstrate
that elevation of luminal pressures above 20 cm H2O inhibits absorption and
stimulates secretion of salt and water into the lumen proximal to an obstruction.
In closed-loop obstruction, luminal pressures may exceed 50 cm H2O and may
account for a substantial proportion of a luminal fluid accumulation. In simple,
open-loop obstruction, distention of the lumen by gas rarely leads to a luminal
pressure higher than 8–12 cm H2O. Thus, in open-loop obstruction, the
contributions of high luminal pressures to hypersecretion may not be important.
In response to heightened luminal pressure, total blood flow to the bowel may
initially increase. Subsequently, however, blood flow to the bowel is compromised
as luminal pressures increase, bacteria invade, and inflammation leads to edema
within the bowel wall. Accumulation of gas and fluid in the obstructed lumen also
leads to changes in myoelectrical function in the gut, proximal and distal to the
obstructed segment. In response to distension, the obstructed segment itself may
dilate, a process known as “receptive relaxation.” At sites proximal and distal to
the obstruction, changes in myoelectrical activity are time-dependent. Initially,
there may be intense periods of activity and peristalsis. Subsequently,
myoelectrical activity is diminished and interdigestive migrating myoelectrical
complex (MMC) is replaced by ineffectual and seemingly disorganized clusters of
contractions.

26. A 45-year-old man with a history of previous right hemicolectomy for colon
cancer presents with colicky abdominal pain which has become constant over the
last few hours. He has marked abdominal distension and has had only minimal
vomiting of a feculent material. His abdomen is diffusely tender. Abdominal x-ray
shows multiple air fluid levels with dilatation of some loops to greater than 3 cm
in diameter. The most likely diagnosis is:

a. Proximal small bowel obstruction

b. Distal small bowel obstruction
c. Acute appendicitis
d. Closed-loop small bowel obstruction
Answer: b

Distinguishing the various types of bowel obstruction can be difficult based on

history, physical findings, and radiographic studies. The patient described has
intermittent to constant pain with low volume feculent vomiting. Distension is
marked and progressive, and tenderness is diffuse. This scenario most likely fits
with an open-loop distal small bowel obstruction. The feculent vomiting suggests
a more distal rather than proximal obstruction. The lack of severe pain and signs
of peritoneal irritation suggests that a closed-loop obstruction is unlikely. A colon
obstruction with an incompetent ileocecal valve would be another alternative to
consider if gas in the colon had been seen on x-ray.

27. In the patient described above, the following statement(s) is/are true
concerning the possible etiology of bowel obstruction.

a. Simple obstruction secondary to an adhesion is most likely to resolve

nonoperatively
b. It is most likely that the patient’s obstruction is secondary to recurrent
malignancy
c. A history of colon cancer makes carcinomatosis the most likely diagnosis
d. Lower abdominal procedures are more likely to result in obstructive adhesions
than are upper abdominal procedures
Answer: a, d

Peritoneal adhesions account for more than half of small bowel obstruction cases.
Lower abdominal procedures such as appendectomy, hysterectomy, and abdominal
perineal resection are common precursor operations to account for obstruction
although adhesions may follow any abdominal procedure including
cholecystectomy, gastrectomy, and abdominal vascular procedures. Simple
adhesive obstruction is distinguished from other forms of obstruction by the
capacity to resolve without surgical intervention. In recent surveys, as many as
80% of episodes of small bowel obstruction due to adhesions may resolve
nonoperatively. The likelihood that an obstruction is due to recurrent malignancy
relates to several factors including the origin of the primary malignancy, the stage
of the primary malignancy, and the designation of original surgery as curative or
palliative. Gastric and pancreatic cancers often present with, or are subsequently
complicated by peritoneal carcinomatosis and subsequent obstruction. With
respect to colon and rectal carcinomas, as many as 50% of cases presenting with
obstruction after resection of the primary may be due to adhesions and not
recurrent malignancy.

28. Which of the following statement(s) is/are true concerning laboratory tests
which might be obtained in the patient discussed above?

a. The presence of a white blood cell count > 15,000 would be highly suggestive
of a closed-loop obstruction
b. Metabolic acidosis mandates emergency exploration
c. An elevation of BUN would suggest underlying renal dysfunction
d. There is no rapidly available test to distinguish tissue necrosis from simple
bowel obstruction
Answer: d

There have been multiple attempts to use common clinical laboratory test
criteria to identify the likelihood that obstruction is associated with
strangulation. In most cases of simple obstruction, laboratory studies do not play
a direct role in diagnosis but are helpful in understanding the extent of
complications such as dehydration and fluid and electrolyte abnormalities. An
elevation of the white blood cell count along with fever, tachycardia, and
localized abdominal tenderness is one of the “cardinal signs” for risk for
strangulation. However, such an elevation is nonspecific. Similarly, metabolic
acidosis may be associated with intestinal ischemia as well as evidence of
dehydration and fluid loss. Elevation of BUN and other electrolyte abnormalities
also represent fluid loss and dehydration. Therefore, at present there is no non-
invasive rapid laboratory tests that can provide information to suggest that tissue
necrosis is eminent.

29. The patient discussed above was admitted to the hospital and after 24 hours
remained distended with no evidence of resolution. Which of the following
radiographic studies would be considered appropriate at this time?

a. Contrast enema
b. Enteroclysis study with dilute barium
c. CT scan with dilute barium oral contrast
d. None of the above
Answer: a, b, c, d

Contrast studies such as those listed above may provide specific localization at
the point of obstruction and the nature of the underlying lesion. When
obstruction of the small intestine is not progressively resolving, a small bowel
follow-through is indicated to confirm the presence and location of the
obstruction. The history of a previous right hemicolectomy in this patient may
also allow reflux through the colon to define the ileocolonic anastomosis and be
able to define the site of obstruction in a retrograde fashion. The potential
benefits for a CT scan include not only defining the obstruction and perhaps the
nature of the lesion, but also in defining any other evidence of abdominal
pathology such as metastases, ascites, or parenchymal liver abnormalities which
might be present in a patient with a previous neoplasm. Although none of these
tests would be contraindicated, failure of this patient to improve will likely
mandate an operation and make contrast studies unnecessary. There would
appear to be no evidence of strangulation or perforation therefore there are no
contraindications to these studies.

30. A 75-year-old woman is hospitalized after a fall in which she has experienced
a hip fracture. Several days after her surgical procedure, progressive painless
abdominal distension is noted. Which of the following statement(s) is/are true
concerning her diagnosis and management?

a. Colon distension with a cecal diameter in excess of 12 cm should indicate the

need for urgent operation
b. Endoscopic decompression may be attempted but seldom is successful
c. After successful colonoscopic decompression, recurrence is unlikely
d. A rectal tube as the primary treatment is generally not successful
Answer: d

Acute pseudo-obstruction of the colon, known as Ogilvie’s syndrome, is a paralytic

ileus of the large bowel characterized by rapidly progressive abdominal distension
often without associated pain. Plane radiographs of the abdomen may reveal air
in the small bowel and distension of discrete segments of the colon (cecum or
transverse colon) or the entire abdominal colon. Distension can become
impressive, oftentimes in chronic cases distension in excess of 15 cm can be
observed without evidence of colon perforation or wall ischemia. Major risk
factors for the development of Ogilvie’s syndrome include severe blunt trauma,
orthopedic trauma or procedures, acute cardiac events or coronary bypass
surgery, acute neurologic events or neurosurgical procedures, and acute
metabolic derangements. Initial management includes resuscitation and
correction of the underlying metabolic and electrolyte abnormalities. A
nasogastric tube is indicated if the patient is vomiting and will prevent swallowed
air from passing distally. If distension is painless and the patient shows no signs of
toxicity or bowel ischemia, expectant management can be successful in about 50%
of cases. If distension worsens so that the cecal diameter increases beyond 10–12
cm or if it persists for more than 48 hours, colonoscopy is recommended.
Endoscopic decompression is successful in 60–90% of cases, but colonic distension
may recur in up to 40% of cases. Rectal tubes are ineffective in managing
distension of the proximal colon, however, such tubes may be useful after
colonoscopy.
31. Which of the following statement(s) is/are true concerning the etiology of
intestinal obstruction?

a. In the United States, peritoneal adhesions account for over half of the cases of
small bowel obstruction
b. A leading cause of bowel obstruction is early postoperative adhesions
c. Bowel obstruction cannot occur with a Richter’s hernia
d. Ninety percent of adult cases of intussusception are associated with a
pathologic process, most commonly a tumor
Answer: a, d

Peritoneal adhesions account for more than half of the cases of small bowel
obstruction in the United States. Obstruction in the immediate postoperative
period following abdominal surgery, however, is uncommon, occurring in only 1%
of patients in the four weeks following laparotomy. Hernias of all types are
second only to adhesions as the most frequent cause of obstruction. External
hernias such as inguinal or femoral hernias may present with symptoms of
obstruction. Femoral hernias are particularly prone to incarceration and bowel
necrosis, due to the small size of the hernia inlet. One important consideration is
the Richter’s hernia. In this variant, only a portion of the bowel wall is
incarcerated. These most frequently occur in association with femoral or inguinal
hernias. Complete obstruction can occur if more than half to two-thirds of the
bowel circumference is incarcerated. About 5% of intussusception cases occur as
adults. Intussusception occurs when one segment of bowel telescopes into an
adjacent segment, resulting in obstruction and ischemic injury to the
intussuscepting segment. Ninety percent of adult cases are associated with
pathological processes. Tumors, benign and malignant, can act as a lead point
against the sussesception in over 65% of adult cases.

32. Which of the following statement(s) is/are true concerning postoperative

ileus?

a. The use of intravenous patient-controlled analgesia has no effect on return of

small bowel motor activity
b. The presence of peritonitis at the time of the original operation delays the
return of normal bowel function
c. The routine use of metoclopramide will hasten the return of small intestinal
motor activity
d. Contrast radiographic studies have no role in distinguishing early postoperative
bowel obstruction from normal ileus
Answer: b

The term ileus reflects the underlying alterations in motility of the

gastrointestinal tract, leading to functional obstruction. From a practical
standpoint, ileus represents the interval between abdominal exploration and the
reappearance of flatus and bowel movements. Distinguishing a normal
postoperative ileus and the prolonged course of a “paralytic” ileus is based
primarily on the time since operation and the clinical circumstances. Besides the
location of the previous operation (upper abdominal, lower abdominal, pelvic.,
the nature of the previous operation and the findings may also contribute.
Peritonitis or spillage of noxious material leads to an increase in the delay of
return of normal bowel function. Distinguishing a paralytic ileus from mechanical
obstruction can oftentimes be difficult. Abdominal x-rays in a postoperative ileus
should reveal gas in segments of both the small and large bowel. Upper GI
contrast or CT scan may also be helpful. Early postoperative obstruction is
uncommon and is particularly rare for upper abdominal surgery, with most cases
occurring after surgery of the colon, particularly abdominal perineal resection.
There has been little success in the use of prokinetic agents to shorten recovery
times after lower abdominal procedures. The use of intravenous patient
controlled analgesia may delay the recovery of postoperative ileus when
compared to the IM route of narcotic administration.

33. The initial management of this patient should consist of:

a. Fluid resuscitation with D5 half normal saline with 40 mEq of potassium

chloride/liter
b. Placement of an indwelling urinary catheter
c. Nasogastric decompression with a nasogastric tube
d. Immediate surgery
e. The patient should be begun on broad spectrum antibiotics at the time of
admission
Answer: b, c

The principles of management of a patient with small bowel obstruction include

initial fluid resuscitation and restricting oral intake. The optimal fluid for
resuscitation in this patient with a distal small bowel obstruction would likely be
Ringer’s lactate or normal saline. Since gastric secretion is a small component of
the fluid loss, potassium replacement is likely not particularly important. An
indwelling urinary catheter should be placed to monitor the urine output to
reflect the fluid status. Invasive hemodynamic monitoring with a central line is
likely unnecessary unless concerns are raised about cardiac status. Nasogastric
decompression is indicated in all but mild cases. The nasogastric tube serves to
prevent distal passage of swallowed air and minimizes discomfort of reflux of
intestinal contents and eliminates vomiting. There appears to be no clinical
evidence suggesting the need for urgent operation and therefore resuscitation
prior to surgery is of optimal importance in this patient.
It has been well established that perioperatively-administered antibiotics reduce
wound infection and abdominal sepsis rates in patients undergoing operation to
relieve intestinal obstruction, simple or strangulated. Once the decision has been
made to proceed with surgery, broad spectrum antibiotics, covering gram-
negative aerobes and anaerobes should be given. The use of antibiotics in
patients who have not been committed to operation has not been evaluated
systematically. Giving antibiotics to patients who are being observed can obscure
the underlying process and, in the end, delay optimal therapy.

34. An 82-year-old female nursing home resident is admitted with massive

abdominal distension and constant abdominal pain with diffuse tenderness.
Abdominal x-ray shows a massively distended loop of colon with a characteristic
“bent inner tube” appearance. The management of this patient should include:

a. Urgent laparotomy because of the massive colon distension

b. An attempt at endoscopic decompression with a flexible sigmoidoscope
c. Elective laparotomy and sigmoid resection should follow if endoscopic
decompression is successful
d. If at urgent laparotomy resected bowel is present, colon resection with primary
anastomosis is in order
Answer: b, c

The most common site of volvulus is the sigmoid colon, accounting for 65% of
cases. The preferred method and management involves endoscopic
decompression. This conservative approach resolves the volvulus in 85% to 90% of
cases, and elective resection of the redundant segment can then be planned.
Following endoscopic decompression, recurrence of the volvulus is higher than
60% if sigmoid resection is not performed. If the patient presents with peritoneal
findings, sepsis, and shock, rapid resuscitation followed by urgent resection and
colostomy is warranted.

35. A common manifestation of Crohn’s disease is perianal disease, including anal

fistulas with extension to adjacent organs and soft tissue regions, fissures, and
perirectal abscesses. Which of the following statement(s) is/are true concerning
perianal disease with Crohn’s disease?

a. Perianal disease is the initial mode of presentation in the majority of patients

b. The prevalence of perianal disease is increased in patients with either
ileocolitis or isolated colonic involvement
c. Metronidazole has been shown to be effective in the treatment of perianal
disease secondary to Crohn’s
d. An aggressive surgical approach is appropriate in most cases due to the
frequent rapid progression of perianal disease
Answer: b, c

A common manifestation of Crohn’s disease is perianal disease, including anal

fistulas with extension into the adjacent organs and soft tissue regions, fissures,
and perirectal abscesses. The prevalence of perianal disease approaches 25% for
patients with ileitis, 50% for ileocolitis, and 40% for those with isolated colonic
involvement. Perianal disease is one of the initial signs of presentation in one-
third of patients. Although broad spectrum antibiotics are clearly indicated for
septic complications of Crohn’s disease, their use as a primary treatment has
generally been met without success. Metronidazole has been used effectively in
the treatment of perianal disease. In general, a conservative surgical approach to
perianal disease is usually prudent. Many patients who have indolent anal fistulas
can live comfortably with their disease for years. Although the development of an
abscess requires conventional drainage depending on the state of Crohn’s
involvement of the rectum, standard surgical procedures can be applied to most
forms of perirectal and perianal disease. Proctectomy may be indicated for
patients with advanced perianal disease in direct continuity with active rectal
involvement.

36. Nongastrointestinal complications of Crohn’s disease include:

a. Renal calculi
b. Cholelithiasis
c. Arthritis
d. Anemia
Answer: a, b, c, d

Although Crohn’s disease is primarily a disease involving the alimentary tract,

involvement of extraintestinal tissues (joints, skin, and eyes) is common and
indicates that Crohn’s disease is a systemic disorder rather than a localized
intestinal disease. In addition to specific processes, secondary consequences of
impaired intestinal absorption and resulting malnutrition include anemia due to
specific deficits in vitamins, trace elements, and bile acids and electrolytes.
Growth retardation and delayed bone maturation are present in 10–40% of
children and adolescents with this disease. Patients with terminal ileal disease
are also prone to develop renal urate or oxalate stones. Furthermore, as the
result of altered bile salt metabolism and the development of lithogenic bile,
patients with ileal disease and ileal resections are also at risk for cholelithiasis.

37. Which of the following points is/are true concerning the diagnosis of Crohn’s
disease?

a. Recurrent disease on contrast radiographs frequently lags behind the

development of clinical signs and symptoms
b. In 10% of cases, Crohn’s disease cannot be distinguished from chronic
ulcerative colitis based on clinical, radiologic, and pathologic criteria
c. Although no specific laboratory tests exist for Crohn’s disease, the erythrocyte
sedimentation rate has evolved as a useful measure of disease activity
d. Specific endoscopic features encountered in Crohn’s disease which allow
differentiation from ulcerative colitis include aphthous ulcers, cobblestoning, and
skip areas
Answer: b, c, d

A number of laboratory and radiographic studies as well as the role of endoscopy

and biopsy are useful in the diagnosis and assessment of Crohn’s disease. Although
no specific laboratory test exists for Crohn’s disease, acute-phase protein levels
and erythrocyte sedimentation rate have evolved as measures of disease activity
and severity. Endoscopic examination of the colon and rectum is often performed
early in the diagnostic workup. In the presence of colorectal involvement,
specific endoscopic features encountered which allow differentiation from
ulcerative colitis include: aphthous ulcers, linear ulcers, cobblestoning, and
asymmetric and discontinuous involvement. The radiologic examination is
essential for differential diagnosis in delineating the extent or the severity of the
disease primarily involving the small bowel. Barium contrast studies will disclose
a number of specific features in patients with Crohn’s disease. A correlation,
however, between the extent of the disease seen radiographically and clinical
symptoms does not exist. Recurrent disease after surgical resection is often
apparent radiologically before the development of clinical signs and symptoms.
The most important differential diagnosis is between Crohn’s disease and chronic
ulcerative colitis, especially when the information is limited to the colon and
rectum. Despite extensive clinical, radiologic, and pathologic evaluation, 5% to
10% of patients will be defined as having indeterminant colitis without clear-cut
evidence of either condition.

38. The following statement(s) is/are true concerning the surgical management of
Crohn’s disease.

a. Strictureplasty, although offering short-term benefits, is associated with a

higher rate of recurrence when compared to resection
b. Frozen section examination of the margin of resection is essential to prevent
both recurrent disease and early anastomotic complications
c. Conservative margins of resection are appropriate, resecting only grossly
involved segments of bowel
d. Patients with Crohn’s disease confined to the colon may be treated with total
proctocolectomy with construction of an ileal-anal pouch anastomosis
Answer: c

Surgical therapy for Crohn’s disease is curative not palliative, therefore is

reserved for complications of the disease or failure of or debilitation, secondary
to medical therapy. The lines of bowel resection should be chosen conservatively
with only a few centimeters proximally and distally to the site of visible changes
of Crohn’s disease. Microscopic evidence of Crohn’s disease at the resection
margins does not compromise safe anastomosis and therefore frozen section
examination of resection margins is not necessary. In patients with multiple
strictures of the small bowel, resection may involve excessive resection of bowel.
Therefore, strictureplasty is an appropriate surgical therapy. Long-term results
using this approach indicate that recurrence rates are not substantially increased
with strictureplasty, even though inflamed intestinal tissue is left in situ. In
patients with diffuse disease of the colon or rectum, proctocolectomy with
ileostomy is the treatment of choice. Both the risk of ileal involvement and
transmural involvement of the rectum precludes the technique of ileal pouch-anal
reconstruction in patients with Crohn’s disease.

39. The etiology of Crohn’s disease is unknown, although two major hypotheses
have evolved: an infectious and an immunologic theory. The following
statement(s) is/are true concerning the possible etiology of Crohn’s disease.

a. The leading infectious agent thus far suggested is infection with a

Mycobacterium species
b. Strong evidence linking viral pathogens to Crohn’s disease has been developed
c. Although many alterations in cellular and immune functions in patients with
Crohn’s disease have been observed, no primary defect in the immune system has
yet been identified
d. The identification of antibodies to enterocytes provides strong support for the
theory that Crohn’s disease is an autoimmune process
Answer: a, c

Investigations for the last 60 years have tried to determine the etiology of Crohn’s
disease. Although a number of theories have evolved and evidence is available
supporting numerous theories, there is no conclusive evidence to support any
etiologic theory for its development. Given the characteristic histologic findings
of granuloma formation, early investigations focused on bacterial causes of
Crohn’s disease, most notably infection with Mycobacterium species. Several
reports have isolated Mycobacteria from mesenteric lymph nodes and intestine
involved in Crohn’s disease but have not proven the Mycobacterial cause.
Similarly, research in viral causes has been inconclusive, and although viral
pathogens have been isolated from tissue extractions with Crohn’s disease,
linkage to induction and persistence of the disease has not been convincing.
Similar difficulties exist in theories concerning immunogenetic causes of Crohn’s
disease, and although many alterations in cellular and immune functions
associated with Crohn’s disease have been observed, no primary defect, either
systemic or mucosal, humoral or cellular has been identified. A number of reports
have described antibodies and lymphocyte reactivity to enterocytes, however the
presence of antibody cannot be correlated with disease activity and furthermore
antibodies have been found in patients with other diseases and in healthy
volunteers.

40. Crohn’s disease is an incurable disease, therefore recurrence after surgical

resection is likely. Which of the following statement(s) regarding the recurrence
of Crohn’s disease is/are accurate?

a. Endoscopic evidence of recurrence is present in less than 50% of patients at

five years
b. Radiographic or endoscopic evidence of recurrence is frequently not
accompanied by symptoms
c. Clinical recurrence of Crohn’s disease is seen in 20% of patients at two years,
and 40–50% at four years after surgery
d. Reoperation for Crohn’s disease is necessary in the majority of patients by five
years
e. No solid evidence demonstrating prolongation of remission can be seen with
corticosteroids, sulfasalazine, or antibiotics
Answer: b, c, e

The majority of patients with Crohn’s disease will recur. If recurrence is defined
as alterations detected endoscopically, then 70% will recur within one year of
surgery, and 85% within three years. However, in most of these patients clinical
symptoms will not accompany the endoscopic or radiographic evidence of disease.
A clinical recurrence (return of symptoms) confirmed as Crohn’s disease
radiologically, endoscopically, or surgically, affects 20% of patients at two years,
and 40–50% at four years after surgery. Reoperation becomes necessary in about
30% of the patients by five years. These statistics give impetus to maintain
remission and prevent recurrence. Although it is common practice to stem
recurrence with sulfsalazine, 5-ASA preparations, antibiotics, and possibly
azathioprine, none of these (possibly excepting azathioprine) have definitely been
proven effective.

41. Which of the following statement(s) is/are true concerning drug therapy for
Crohn’s disease?

a. Corticosteroids have been demonstrated to effectively treat acute

exacerbations and to prolong remission in patients with Crohn’s disease
b. Sulfasalazine is indicated primarily for the treatment of patients with acute
exacerbations of Crohn’s disease involving the small bowel
c. Azathioprine, an immunosuppressant, has been shown to be effective in
maintaining remission of Crohn’s disease
d. Low dose cyclosporine has significant therapeutic benefit for patients with
both low and high disease activity
Answer: c

Systemic corticosteroids have been used to treat Crohn’s disease since the 1940s.
Although the exact mechanism of action is not clear, nonspecific
immunosuppression is the likely effect. Several well designed trials have
demonstrated that Prednisone (or its equivalent) is effective in the treatment of
acute exacerbations. Patients with quiescent disease, or patients who have
received remission through medical or surgical therapy, however, do not benefit
from long-term continued corticosteroids. Sulfasalazine consisting of a
sulfonamide linked to an aspirin analogue (5-ASA) is more effective than placebo
in the treatment of acute disease. This agent, however, is most effective in
patients with predominantly colonic disease and is less effective than
corticosteroids in treating patients with small bowel disease. Asymptomatic
patients do not appear to benefit from prophylactic treatment. The
immunosuppressive agent azathioprine, which acts to inhibit nucleic acid
metabolism, has been demonstrated to be highly effective in long-term use. The
use of azathioprine has a steroid-sparing effect with reduction of steroid dose or
discontinuation of therapy. In chronic treatment, azathioprine is effective in
decreasing disease activity, steroid requirements, and complications leading to
surgery, therefore, in contrast to corticosteroids and sulfasalazine, azathioprine
appears effective in maintaining remission. Side-effects, however, can be
significant including bone marrow suppression and acute pancreatitis. Finally,
cyclosporine, an immunosuppressant, has undergone extensive review with the
conclusion that low-dose oral cyclosporine treatment confers no therapeutic
benefit for patients with low or high disease activity and in no reduction in the
need for other forms of therapy.

42. Which of the following are predominant histologic features of Crohn’s disease?

a. The presence of granulomas involving the bowel wall and mesenteric lymph
nodes
b. Transmural inflammation
c. Fissures and ulceration extending into the muscularis propria
d. Chronic fibrotic changes
Answer: a, b, c, d

Crohn’s disease can affect any part of the gastrointestinal tract with the most
common site being the ileocecal region. The acute, active phase is marked by
aphthous mucosal ulcerations, lymphoid aggregates, and granulomas present in
both the bowel wall, adjacent lymph nodes, and in other organs. Transmural
inflammation is present with characteristic fissures and ulcers extending deep
into the muscularis propria. The acquiescent or healing phase of Crohn’s disease
is marked by fibrosis with late stricture formation and chronic ulceration.

43. The following statement(s) is/are true concerning the epidemiology of Crohn’s
disease.

a. Crohn’s disease has an age distribution with peaks between the ages of 15 and
30 years and 65 and 75 years
b. There is a definite female predilection for Crohn’s disease
c. The disease is equally prevalent in industrialized versus underdeveloped
countries
d. First and second generation relatives with Crohn’s disease have an increased
prevalence when compared to the general population
Answer: d

Crohn’s disease arises most commonly between the ages of 15 and 30 years, with
a second peak at 55 to 60 years. Men and women are equally affected. The
disease is seen more commonly in urban residents than rural dwellers and is
associated with higher levels of education. The disease is almost exclusively
encountered in industrialized nations like Western Europe and the United States
which suggests that environmental factors are important in the pathogenesis.
Aggregation in families can occur with first-and second-generation relatives of
patients with Crohn’s disease found to have a 10-and 3-fold increase,
respectively, in the prevalence of Crohn’s disease when compared to other non-
related individuals.

44. The management of adenocarcinoma of the small intestine depends primarily

on tumor location. Which of the following statements concerning surgical
management are true?

a. Radical pancreaticoduodenectomy (Whipple resection) is necessary for

resection of most duodenal adenocarcinomas
b. Adenocarcinomas of the jejunum or ileum are managed by limited segmental
resection including resection of the mesentery down to the first vascular arcade
c. Distal ileal carcinomas are best managed by right hemi-colectomy to include
lymph node chains along the ileo-cecal blood supply
d. Small invasive adenocarcinomas of the ampulla and peri-ampullary duodenum
can frequently be managed by local excision
Answer: a, c

Optimal surgical treatment of adenocarcinoma of the small intestine requires

wide, segmental resection, including the draining nodal system. For most
duodenal adenocarcinomas, a radical pancreaticoduodenectomy (Whipple
procedure) is necessary to incorporate pertinent training lymph nodes. Although
local excision of villous adenomas of the periampullary area has been reported,
the presence of invasive carcinoma warrants wider resection as a
pancreaticoduodenectomy. Jejunal and ileal carcinomas are removed with
segmental resections with adequate margins on the bowel and wide resection of
the mesentery with associated lymph nodes down to the superior mesenteric
artery. Distal ileal carcinomas are drained by lymph nodes along the ileocolic
artery and are best managed by right hemicolectomy.

45. The management of carcinoid tumors must be individualized based on the

findings at surgery. Which of the following is/are components of optimal care?
a. Limited segmental resection without lymphadenectomy
b. Careful exploration of the remaining small bowel and colon
c. Non-anatomic resection of small multiple liver metastases
d. Postoperative adjuvant chemotherapy for all carcinoid tumors regardless of
size or level of invasion
Answer: b, c

Operative management of a primary small bowel carcinoid tumor involves

principals similar to those of small bowel carcinomas. Wide en bloc excision
should include as many lymphatic drainage pathways as possible because of their
frequent metastatic involvement. Because of the increased incidence of both
multicentricity and a second unrelated malignancy, a diligent search for other
primary carcinoids of the small bowel and for other synchronous malignancies of
other organs is imperative. When localized hepatic metastasis are amenable to
resection, hepatic resection should be considered to minimize the potential
development of Carcinoid Syndrome. Adjuvant postoperative chemotherapy for
patients with metastatic carcinoid tumor is of modest benefit with response rates
in the 20–30% range with median duration response short-lived. At present,
adjuvant therapy is confined only to those patients with Carcinoid Syndrome.

46. An increased evidence of adenocarcinoma of the small intestine has been

established with which of the following conditions?

a. Peutz-Jegher Syndrome
b. Crohn’s disease
c. Simple tubular adenomas of the small intestine
d. Colon carcinoma
Answer: b

The incidence of adenocarcinoma of the small bowel is surprisingly low when

compared to that of colon carcinoma when considering the vast length and
surface area of the small intestine. The relative infrequency of these tumors has
limited our knowledge of pathogenic factors. It appears, however, that the polyp-
to-cancer sequence is not well established for simple tubular adenomas of the
small intestine. Peutz-Jegher Syndrome is an inherited syndrome which is
associated with multiple small intestinal polyps. These polyps are hamartomas
with progression of dysplasia to carcinoma felt not to be a major concern. The
chronic inflammatory changes of Crohn’s disease appears to predispose to the
development of adenocarcinoma, thereby increasing the risk to 100 times that of
the general population. There is no known association of carcinoma of the colon
and small intestine.

47. A 60-year-old male presents with nonspecific symptoms of fatigue, malaise,

weight loss and abdominal pain. Barium small bowel series shows a limited
segment of small intestine with thickened mucosal folds and partial obstruction.
CT scan confirms small intestinal wall thickening and suggests the presence of
bulky mesenteric lymph nodes. Which of the following is/are components of
optimal care?

a. Attempts at percutaneous biopsy of the mesenteric mass

b. Surgical exploration with aggressive resection of the localized disease including
wide, en bloc lymphadenectomy
c. Liver biopsy and sampling of periaortic and mesenteric lymph nodes outside the
field of resection
d. Splenectomy
Answer: b, c

Most patients suspected of having small intestinal lymphoma require operation

with the goals of treatment including diagnosis, staging, relief of obstruction and
perforation, and resection or debulking. Because intraoperative staging affects
postoperative management, liver biopsy and sampling of periaortic and
mesenteric lymph nodes outside the field of resection are important aspects of
the operative management. In contrast there is no role for splenectomy for
primary small bowel lymphoma. For localized disease, aggressive resection with
wide, en bloc lymphadenectomy is important. Percutaneous biopsy has no role in
such cases both because the preoperative diagnosis will not eliminate the need
for surgical intervention, and percutaneous biopsy is frequently inadequate to
determine necessary information for the treatment of lymphoma.

48. Malignant neoplasms of the small bowel tend to have a characteristic

anatomic distribution. Which of the following statements are true?

a. Adenocarcinomas of the small intestine show a distinct polarity with decreasing

frequency from duodenum to ileum
b. Adenocarcinoma of the small intestine associated with Crohn’s disease occurs
primarily in the ileum
c. Lymphomas of the small intestine arise primarily in the jejunum
d. The vast majority of carcinoid tumors of the small intestine occur in the ileum
Answer: a, b, d

Anatomically, adenocarcinomas of the small intestine show a distinct polarity with

a decreasing frequency from duodenum to ileum. Given the difference in length
between the duodenum, jejunum and ileum, the duodenal epithelium shows a
substantially greater propensity towards malignant transformation. Even within
the duodenum, two-thirds of the carcinomas occur in the periampullary region
suggesting that the periampullary mucosa or luminal content (ingested potential
carcinogens) interacts with pancreaticobiliary secretions to induce local
neoplastic changes. Crohn’s disease primarily is a disease involving the terminal
ileum and therefore it is not surprising that most adenocarcinomas developing in
association with Crohn’s disease occur also at this site. Small intestinal
lymphomas arise from lymphoid tissue within the wall of the bowel. Therefore
lymphomas predominate in the ileum, where the greatest concentration of gut
lymphoid tissue occurs. Next to the appendix, which harbors 85% of all carcinoid
tumors, the small intestine is by far the next most common site of origin.
Approximately ninety percent of small intestinal carcinoids are located in the
ileum with 40% found within two feet of the ileocecal junction. Multiple primary
tumors may be present in 30% of patients.

49. Small intestinal carcinoids may present in a multitude of fashions. Which of

the following may be seen as a presentation of carcinoid tumors of the small
intestine?

a. Intestinal obstruction
b. Gastrointestinal bleeding
c. Small intestinal infarction
d. Asymptomatic
Answer: a, b, d

Many small intestinal carcinoids are small and asymptomatic and are found only
incidentally or at autopsy. Clinical symptoms can arise either from the primary
tumor, from sequelae of metastatic disease, or from the Carcinoid Syndrome.
Obstructive symptoms can occur either from intussusception or more commonly
as a submucosal tumor infiltrates the bowel wall and beyond, the bowel
mesentery may become shortened, thickened and fixed by an intense
desmoplastic reaction characteristic of carcinoid tumors. This leads to kinking and
angulation of intestinal loops and may eventually result in mechanical
obstruction. Intestinal ischemia or even infarction can occur secondary to an
unusual type of mesenteric angiopathy characterized by vascular thickening and
sclerosis that accompanies the desmoplastic mesenteric reaction. Although
mucosal ulceration and bleeding can occur, such symptoms are unusual.

50. With regard to benign neoplasms of the small intestine, which of the following
are true statements?

a. Many are asymptomatic and only found as incidental findings

b. Leiomyomas are the most common symptomatic benign neoplasm and may
present with gastrointestinal bleeding
c. Villous adenomas carry a distinct malignant potential and occur most
commonly in the periampullary duodenum
d. Peutz-Jegher Syndrome is associated with multiple adenomatous polyps
throughout the small intestine
Answer: a, b, c
The most common benign small intestinal neoplasms are adenomas, leiomyomas,
and lipomas. Hamartomas, fibromas, angiomas, and neurofibromas may also occur
at a lesser frequency. Three types of adenomas occur, simple tubular adenomas,
villous adenomas, and Brunner gland adenomas. Tubular adenomas have a very
low malignant potential whereas villous adenomas carry a distinct malignant
potential similar to that of colonic villous adenomas. These adenomas occur most
commonly in the duodenum and especially in the periampullary region. Brunner
gland adenomas represent hyperplasia of the exocrine glands within the proximal
duodenal mucosa and have little risk of malignant change. The smooth muscle
tumor, leiomyoma, are the most common symptomatic benign neoplasms. Most
leiomyomas enlarge with an extraluminal orientation and, may reach considerable
size. The tumors eventually may outgrow their blood supply leading to central
necrosis, ulceration and intraluminal bleeding. Rupture of the tumor may also
occur with intraperitoneal bleeding. Differentiation of larger leiomyomas from
their malignant counterpart, leiomyosarcoma, may be difficult on pathologic
review. Peutz-Jegher Syndrome is an inherited syndrome associated with multiple
gastrointestinal polyps throughout the jejunum and ileum. Histologically these
polyps are hamartomas and not adenomas and therefore offer little risk of
malignant transformation.

51. Primary gastrointestinal lymphomas involving the small bowel are uncommon
accounting for less than 5% of all lymphomas. Conditions associated with small
intestinal lymphomas include which of the following?

a. Acquired immune deficiency syndrome (AIDS)

b. Celiac disease
c. Crohn’s disease
d. Rheumatoid arthritis
Answer: a, b, c, d

Although rare, small intestinal lymphomas are associated with several conditions.
The chronic malabsorptive condition, celiac disease, is recognized to be
associated with small intestinal lymphoma. Clinical deterioration in a patient with
previously controlled celiac disease should immediately suggest the diagnosis of
lymphoma. There is also an increased incidence of lymphoma in Crohn’s disease.
Disorders of immunologic function have an increased incidence of extranodal
gastrointestinal lymphoma. These disorders include autoimmune diseases such as
rheumatoid arthritis, Wegener granulomatosis, systemic lupus erythematous, and
congenital immunodeficiencies. Immunosuppressed patients after organ
transplantation and patients with prolonged, high-dose chemotherapy are also at
increased risk. AIDS has been associated with the development of aggressive, non-
Hodgkin’s lymphoma presenting with primary gastrointestinal involvement.
Although this is usually a diffuse systemic disease, extranodal lymphoma of the
small bowel has been frequently recognized.