CHAPTER 28

Small Intestine

1. Where is the largest number o hormone-producing cells Answer: B

ound in the body? he small intestine is the body’s largest reservoir o hormone-
A. T e pituitary producing cells. Multiple specialized cells within the intestinal
B. T e small intestine mucosa respond to luminal stimuli and secrete over 30 pep-
C. T e pancreas tide hormones which regulate the unctions o the intestine,
D. T e liver other organs in the gastro-entero-pancreato-biliary system,
the heart, and the brain (See Schwartz 10th ed., p. 1145.)

2. Which o the ollowing eatures is characteristic o the Answer: B

ileum, as opposed to the jejunum? he entire small intestine contains valvulae conniventes, also
A. T e presence o valvulae conniventes known as plicae circularis. he jejunum has larger vasa recta,
B. T e presence o Peyer patches a larger diameter, and a less atty mesentery. he ileum con-
C. Larger vasa recta tains prominent lymphoid ollicles called Peyer patches. (See
D. Less atty mesentery Schwartz 10th ed., p. 1138.)

3. Within the intestine, epithelial cells originate rom stem Answer: A

cells, proli erate in the crypts, and migrate up the villus in he high cellular turnover rate o enterocytes makes the small
2 to 5 days. T is process replaces cells that are removed due intestine susceptible to damage by inhibitors o proli eration
to apoptosis or ex oliation. T is rapid turnover makes the such as radiation and cytotoxic chemotherapy. (See Schwartz
small intestine susceptible to 10th ed., p. 1138.)
A. Radiation damage
B. Starvation
C. Exogenous steroids
D. Hypothermia

4. A pocket- or sock-like outpouching on the anti-mesenteric Answer: C

side o the distal ileum, called a Meckel diverticulum, is
caused by
A. Excessive traction on the intestine during childbirth.
B. Increased intraluminal pressure.
C. A persistent vitelline duct.
D. A mutation o the c-Mec gene.
he embryonic gut communicates with the yolk sac by mean
o the vitelline duct. Failure o this structure to obliterate by
the end o gestation can result in a Meckel diverticulum. (See
Schwartz 10th ed., p. 1139.)

5. How much uid normally enters the adult small intestine Answer: D
each day? Eight to nine liters o luid enters the small intestine daily,
A. 2 L o which over 80% is absorbed. his includes 2 L rom oral
B. 4 L intake, 1.5 L o saliva, 2.5 L o gastric juice, 1.5 L o biliopan-
C. 6 L creatic secretions, and 1 L o luid secreted by the small intes-
D. 8 L tine. (See Schwartz 10th ed., p. 1140.)

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6. How are the digestion products o carbohydrates, such as
glucose, galactose, and ructose, absorbed through the
intestine?
A. By passive di usion across enterocyte plasma membranes.
B. By acilitated di usion via speci c transporters such as
sodium-glucose cotransporter 1 (SGL 1), glucose trans-
porter 2 (GLU 2), and glucose transporter 5 (GLU 5).
C. By endocytosis o enterocytes on the villus.
D. By acilitated di usion through tight junctions between
enterocytes.
7. What does the “enterohepatic circulation” re er to?
A. T e superior mesenteric-portal venous circuit.
B. T e secretion o cholesterol in the bile and its reabsorp-
tion in the distal ileum.
C. T e secretion o bile acids by the liver and their reab-
sorption in the distal ileum.
D. T e secretion o cholecystokinin by the jejunum and its
stimulation o bile ow.
8. T e secretin-glucagon amily o gut hormones includes all
o the ollowing structurally related peptides EXCEP
A. Somatostatin (SS )
B. Glucose-dependent insulinotropic polypeptide (GIP)
C. Glucagon-like peptide-1 (GLP-1)
D. Vasoactive intestinal polypeptide (VIP)
9. T e most common cause o small bowel obstruction is
A. Incarcerated hernia
B. Crohn’s disease
C. Malignancy
D. Postoperative adhesions
10. A closed-loop obstruction is particularly dangerous
because
A. Intraluminal pressure rises high enough to cause
ischemia and necrosis.
B. T e obstruction is painless.
C. Bacterial overgrowth results in sepsis.
D. T e obstructive segment is not apparent on imaging
studies.
Answer: B
he three terminal products o carbohydrate digestion are
transported through the enterocyte brush border membrane
via acilitative transporter proteins such as the sodium-glucose
cotransporter 1 (SGL 1), glucose transporter 2 (GLU 2), and
glucose transporter 5 (GLU 5). here is evidence o overex-
pression o these transporters, particularly SGL 1, in diabetes
and obesity, and new therapeutic approaches or these condi-
tions are designed to inhibit these transporters. (See Schwartz
10th ed., p. 1141.)
Answer: C
Bile acids act as detergents which increase the solubility o lipid
micelles which are taken up by the brush border membrane o
the jejunum, where over 90% o at is absorbed. he bile acids
themselves remain in the intestinal lumen and are reabsorbed
in the distal ileum where they enter the portal venous circula-
tion and are re-secreted in the bile. (See Schwartz 10th ed.,
p. 1143.)
Answer: A
Peptide hormones produced by enteroendocrine cells o
the intestine are grouped into amilies based on their amino
acid structural similarity. he secretin-glucagon amily o
hormones includes glucose-dependent insulinotropic poly-
peptide (GIP), glucagon-like peptide-1 (GLP-1), vasoactive
intestinal polypeptide (VIP), peptide histidine isoleucine
(PHI), growth hormone-releasing hormone (GHRH), and
pituitary adenylyl cyclase-activating peptide (PACAP). (See
Schwartz 10th ed., p. 1145.)
Answer: D
Intra-abdominal adhesions related to prior abdominal sur-
gery accounts or 75% o cases o small bowel obstruction.
Cancer-related small bowel obstruction is almost always due
to extrinsic compression or entrapment o the bowel by a pri-
mary or metastatic tumor; primary small bowel malignancies
are rare. (See Schwartz 10th ed., p. 1146.)
Answer: A
A closed-loop obstruction, in which an intestinal segment is
obstructed both proximally and distally, as in a volvulus, is
particularly dangerous because intraluminal pressure rises
quickly and can cause venous congestion and arterial obstruc-
tion which leads to necrosis o the intestinal wall and per o-
ration. It classically presents with “pain out o proportion to
the physical exam,” and is usually apparent on C scan which
requently shows a U-shaped or C-shaped dilated bowel loop
associated with a radial distribution o mesenteric vessels
converging toward a torsion point. (See Schwartz 10th ed.,
p. 1147.)

11. T erapy o a small bowel obstruction usually consists o
prompt surgical correction. In patients with no evidence
o closed-loop obstruction, and in whom there is no ever
or leukocytosis or tachycardia, a period o care ul obser-
vation with nasogastric decompression may be success ul
in all o the ollowing conditions EXCEP
A. Partial small bowel obstruction.
B. Obstruction in the early postoperative period.
C. Obstruction due to Crohn disease.
D. Obstruction due to an internal hernia.
12. Interventions which may reduce the incidence and dura-
tion o postoperative ileus include all o the ollowing
EXCEP
A. Epidural analgesia
B. A m-opioid receptor antagonist
C. Intravenous erythromycin
D. Avoiding excess intra- and postoperative uid
administration
13. Risk actors or the development o Crohn’s disease
include all o the ollowing EXCEP
A. Having a amily member with Crohn’s disease
B. Smoking
C. Having Chinese ancestry
D. Having Ashkenazi Jewish ancestry
14. T e primary genetic de ect associated with Crohn’s dis-
ease is a mutation o the NOD2 gene on chromosome 16.
T is gene encodes or a protein product which
A. Mediates the innate immune response to microbial
pathogens
B. Activates stellate cells to produce collagen
C. Regulates the rate o crypt-to-villus enterocyte migration
D. Mediates the production o enterocyte alkaline
phosphatase
15. In the resection o a stenotic area o intestine in a patient
with Crohn’s disease, the best approach is
A. A resection margin o 2 cm rom gross disease.
B. A resection margin o 12 cm rom gross disease.
C. A resection margin 2 cm rom microscopic disease on
rozen section.
D. A resection margin 12 cm rom microscopic disease
on rozen section.
16. T e ailure o an enterocutaneous stula to heal on a regi-
men o total parenteral nutrition and antisecretory ther-
apy may be due to which o the ollowing?
A. A oreign body in the stula tract.
B. Epithelialization o the stula tract.
C. Downstream obstruction o the stulized segment o
intestine.
D. All o the above.
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Answer: D
Partial small bowel obstruction and early postoperative
obstruction can mimic ileus, and may respond to nonop-
erative therapy. Crohn disease usually responds to medical
therapy, although recurrent obstruction is an indication or
surgical correction. Obstruction due to an internal hernia
requires prompt surgical intervention to avoid strangulation
and necrosis. (See Schwartz 10th ed., p. 1149.)
Answer: C
Epidural analgesia (with reduced systemic narcotic admin-
istration), avoiding excess intra- and postoperative luid
administration, and administration o alvimopan, a mu-
opioid receptor antagonist, have all been associated with
reduced incidence and/or duration o postoperative ileus.
Prokinetic agents such as metoclopramide and erythromycin
are rarely use ul. (See Schwartz 10th ed., p. 1153.)
Answer: C
he risk o having Crohn’s disease is two- to our old higher in
Ashkenazi Jewish amilies, 15 times higher in amily members
o a patient with Crohn’s disease, and is increased in higher
socioeconomic groups, and among smokers. he incidence in
China is 1% o the incidence in the United States, although
this number is increasing. (See Schwartz 10th ed., p. 1153.)
Answer: A
he protein product o the NOD2 gene mediates the innate
immune response to microbial pathogens. A variety o de ects
in immune regulatory mechanisms such as overresponsive-
ness o mucosal cells to enteric lora-derived antigens can
lead to de ective immune tolerance and sustained in lamma-
tion. (See Schwartz 10th ed., p. 1153.)
Answer: A
here are no di erences in the recurrence rates or resection
with a 2-cm margin or a 12-cm margin rom gross disease.
he additional bowel lost may contribute to eventual short
gut syndrome in a patient who requires multiple resections,
so minimizing bowel loss is a priority. here is no bene it to
achieving rozen section negative margins in the resection o
Crohn’s strictures; positive margin resections have the same
recurrence rate as negative margin resections. he e ort to
obtain a rozen section negative margin carries the risk o
removing more intestine than is necessary. (See Schwartz
10th ed., p. 1157.)
Answer: D
Factors which prevent healing o an enterocutaneous istula
include oreign body, epithelialization o the istula tract,
downstream obstruction, radiation enteritis, associated in ec-
tion (abscess or sepsis), malignancy, and a short (<2 cm)
istula tract. (See Schwartz 10th ed., p. 1158.)
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17. Which primary malignancy o the small intestine is most
common?
A. Adenocarcinoma o the duodenum
B. Carcinoid tumor o the ileum
C. Lymphoma o the jejunum
D. Gastrointestinal stromal tumor (GIS ) o the
duodenum
18. Adenocarcinoma o the duodenum is associated with
what hereditary oncologic syndrome?
A. Hereditary nonpolyposis colorectal cancer (HNPCC)
B. Familial adenomatous polyposis (FAP)
C. Peutz-Jeghers syndrome
D. Von Hippel-Lindau (VHL) syndrome
19. Which o the ollowing statements is true regarding
GIS s?
A. Most occur in the small intestine.
B. GIS s are usually metastatic when rst diagnosed.
C. GIS s typically present with GI hemorrhage.
D. GIS s are usually responsive to cytotoxic chemotherapy.
20. Methods to prevent radiation enteritis o the small bowel
during pelvic irradiation or gynecologic or rectal malig-
nancy include which o the ollowing?
A. ilt table positioning in rendelenburg position dur-
ing radiation therapy treatments.
B. Closure (reapproximation) o the pelvic peritoneum
af er primary resection.
C. Placement o an absorbable mesh sling to suspend
small intestine out o the pelvis during postoperative
radiation therapy.
D. All o the above.
21. What ectopic tissue is commonly ound in a Meckel
diverticulum?
A. Gastric mucosa
B. Ectopic pancreas
C. Splenic ollicles
D. Ovarian ollicles
22. A patient with recent onset o ascites af er an episode o
acute pancreatitis undergoes paracentesis, which reveals
cloudy white uid. What therapy is indicated?
A. Surgical exploration
B. Low- at diet
C. otal parenteral nutrition ( PN) and octreotide
D. Octreotide and weekly paracentesis
Answer: A
Adenocarcinomas o the duodenum are the most common
primary small bowel malignancy and account or 35 to 50%
o the total. Lymphoma and gastrointestinal stromal tumors
(GIS s) o the small bowel are the least common and each
accounts or 10 to 15% o the total. (See Schwartz 10th ed.,
p. 1159.)
Answer: B
Duodenal carcinoma is a late mani estation o the amilial
adenomatous polyposis (FAP) syndrome. A ter resolution o
the colonic disease by total colectomy, patients with FAP must
be ollowed with periodic upper gastrointestinal (GI) endos-
copy to maintain surveillance or duodenal tumors. Duodenal
cancer is the leading cause o death among patients with FAP.
(See Schwartz 10th ed., p. 1158.)
Answer: C
GIS s are a orm o sarcoma which occur most commonly
(70%) in the stomach. hey more requently present with GI
hemorrhage than other small bowel malignancies. hey are
usually re ractory to conventional cytotoxic chemotherapy,
but are not usually metastatic on initial diagnosis. A radical
lymphadenectomy is not usually required; a segmental resec-
tion o the involved portion o the small intestine is usually
su icient surgical treatment. (See Schwartz 10th ed., p. 1162.)
Answer: D
In addition to limiting radiation exposure to less than 5000 cGy,
avoiding radiation to the small intestine a ter pelvic surgery
can involve steep rendelenburg positioning during radia-
tion therapy sessions, closure o the pelvic peritoneum at the
level o the sacral promontory to prevent small bowel illing
the pelvis, and creating o an absorbable mesh sling to prevent
the small intestine rom illing the pelvic cavity. (See Schwartz
10th ed., p. 1163.)
Answer: A
Approximately 60% o Meckel diverticula contain ectopic tis-
sue, o which over 60% consists o gastric mucosa. Pancreatic
acini are next most common, ollowed by pancreatic islets,
endometriosis, and hepatobiliary tissues. Gastric mucosa can
ulcerate and bleed, the etiology o which can be hard to deter-
mine unless the Meckel diverticulum is known. (See Schwartz
10th ed., pp. 1163–1164).
Answer: C
Chylous ascites can develop as a complication o operative
procedures or in lammatory conditions such as acute pan-
creatitis. Lymphatic drainage rom damaged lymphatics can
heal when the patient is made NPO, and maintained on PN
and octreotide. Medium-chain triglycerides have been advo-
cated as an oral diet, but temporary cessation o oral eeding
and octreotide comprise the most success ul therapy. (See
Schwartz 10th ed., pp. 1169–1170.)
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23. Short bowel syndrome has been arbitrarily de ned in Answer: B
adults as having a small intestine o less than what length? A unctional de inition, in which insu icient absorptive
A. 300 cm capacity results in diarrhea, dehydration, and malnutrition
B. 200 cm is more appropriate, but a standard de inition o short bowel
C. 100 cm syndrome o 200 cm has been used widely. (See Schwartz
D. 50 cm 10th ed., p. 1171.)

24. Common causes o short bowel syndrome include all o Answer: D

the ollowing EXCEP In adults, the common etiologies o short bowel syndrome
A. Mesenteric ischemia include mesenteric ischemia, malignancy, and Crohn’s dis-
B. Malignancy ease. In pediatric patients, common causes include intestinal
C. Crohn’s disease atresias, volvulus, and necrotizing enterocolitis. Radiation
D. Radiation enteritis enteritis usually involves isolated segments o small bowel o
less than 50% o total small intestinal length. (See Schwartz
10th ed., p. 1171.)

25. Af er an emergency operation or bowel in arction in Answer: D

which more than hal o the small intestine was removed
and a jejunostomy created, high volume ostomy losses
cause recurrent dehydration. Management o this condi-
tion includes which o the ollowing?
A. Proton pump inhibitors or histamine-2 receptor
antagonists
B. Octreotide
C. Loperamide
D. All o the above
Reducing gastric secretion with proton pump inhibitors or
histamine-2 receptor antagonist, reducing gastroenteropan-
creatic secretions with octreotide, and inhibiting motility
with agents such as loperamide or diphenoxylate, are use ul
approaches to prevent dehydration as the short gut adapts to
its new length. otal parenteral nutrition is also o ten required.
(See Schwartz 10th ed., p. 1171.)