Characteristics of Enterocytes

Enterocytes, or absorptive cells, are found in the mucosa of the small and large bowel.
The normal enterocyte lives for a little more than 2 days. They are columnar and are the
principal cells of the villus. Enterocytes absorb a variety of nutrients including Ca, Fe and
H2O.
The primary fuel source of enterocytes is glutamine. Principles and Practice of Surgical
Pathology, 2nd Edition, Vol II, pgs 1121-23

Secretin/Gastrin Relationship
Secretin is produced by specialized cells in the small bowel mucosa and its release is
stimulated by acidification of the duodenum or by contact with bile and perhaps fat. It
stimulates the release of water and bicarbonate from pancreatic ductal cells, which
neutralizes gastric acid. Secretin also acts to stimulate the flow of bile and inhibits gastrin
release and therefore gastric acid secretion and gastrointestinal motility. Schwartz 6th pg.
1128, 1161-62

Activation of Trypsinogen
Trypsinogen is the inactive precursor of trypsin. It is produced by pancreatic acinar cells
along with other inactive proteolytic enzymes, chymotrypsinogen and
procarboxypolypeptidase. These inactivated enzymes are delivered to the duodenum in
an alkaline environment.
Enterokinase, an enzyme secreted by intestinal mucosa, lyses trypsinogen converting it
into the active enzyme. Trypsin is then able to lyse more trypsinogen into trypsin
(autocatalytic activation). Chymotrypsinogen is lysed into its active form chymotrypsin,
and procarboxypolypeptidase - activated form of trypsin also. Trypsinogen is protected
from activation prior to entering the intestinal lumen by trypsin inhibitor. This substance
is also secreted by the same pancreatic acini cells that secrete the proteolytic enzymes.
Guyton, Medical Physiology, pg 779

Physiology of Enteroglucagon
Enteroglucagon is released from the enteroglucagon cells, occurring predominately in the
distal small intestine. This peptide occurs in two forms - one small and one large form.
Release of this hormone is stimulated by carbohydrate and long-chain fatty acid. Its
primary action is to inhibit intestinal motility. Sabiston, Textbook of Surgery, 14th ed.,
pg. 834

Stimulation of Duodenal Secretin Release

Secretin is a gastrointestinal peptide, which is the principal stimulant for pancreatic water
and electrolyte secretion. It is synthesized and stored in mucosal S-cells, in crypts of
Lieberkuhn in the proximal small bowel.
The most important stimulus for secretin release is duodenal acidification; release occurs
when the intraluminal pH falls below 4.5. Fat also stimulates secretin release, but this
occurs only with high luminal fat concentrations. O'Leary, The Physiological Basis of
Surgery, Williams & Wilkins, 1993

Arterial Blood Supply of Duodenum

The main blood supply to the duodenum is from the superior and inferior
pancreaticoduodenal arteries, branches of the gastroduodenal and superior mesenteric
arteries, respectively. The proximal half of the duodenum is supplied by the superior
pancreaticoduodenal artery and the distal half by the inferior pancreaticoduodenal artery.
These vessels anastomose to form anterior and posterior arterial arcades, which lie in the
angle between the duodenum and the pancreas.
The superior part of the duodenum may, in addition, receive blood from:
1. The supraduodenal artery, arising from the common hepatic or gastroduodenal,
2. The right gastric artery,
3. The right gastroepiploic artery, and
4. The gastroduodenal artery.
These vessels often anastomose with each other. Moore, p. 220. Sabiston, p. 871

Characteristics of Migratory Motor Complex of the Small Bowel

Characteristic patterns of motility occur in the small intestine of humans during fasting
and after feeding. During fasting, activity follows a cyclic pattern called the interdigestive
myoelectric complex (IDMEC) or the migrating motor complex (MMC).
Each cycle has four phases.
Phase I has little or no contractile activity or electric spike activity.
Phase II has intermittent spike activity and thus intermittent contractile activity.
Phase III has maximum spike activity superimposed on every slow wave; this is
associated with regular, strong contractile activity.
It is usually followed by a brief period of intermittent spike activity known as Phase IV.
This serves as a transition phase between the phase of regular contractile activity and the
quiescent phase.
The duration of an entire cycle is approximately 90-120 minutes. Each phase appears first
in the distal esophagus, stomach, and duodenum and migrates down the small intestine.
The migration takes about 2 hours. Eating abolishes the interdigestive cycles and in their
place induces a pattern of intermittent contractile activity. The physiologic significance of
the MMC is not completely understood because the complexes are present only in the
fasted state and in most species they have no apparent role in the mixing or propulsion of
ingested meals. These complexes may act as "housekeepers of the small intestine", in the
sense that they may purge the small bowel of residual foods, secretions, and desquamated
cells during the interdigestive state. The MMC may also serve to limit the overgrowth of
bacteria in the distal small bowel. The development of Phase III of the MMC is
associated with increased secretion of pepsin and hydrochloric acid by the stomach and
of amylase and bicarbonate by the pancreas. The association of bile secretion with the
MMC has been suggested by experiments in human subjects that have demonstrated
increasing duodenal output of bile acid and bilirubin during Phase II of the MMC. Miller,
Physiologic Basis of Modern Surgical
Characteristics of Adult Intussusception
Intussusception occurring in children is usually not associated with a mass lesion, which
leads to the intussusception. In adults, however, benign and malignant tumors are often
found at the leading edge or base. A Meckel's diverticulum, although uncommon in
adults, can also be found. Symptoms include partial or total SBO with cramping
abdominal pain and, less often in adults, bloody diarrhea. Sabiston, 14th Ed, Textbook of
Surgery, 1991, p.803

Complications of Ileal Resection

1. Short bowel syndrome is the fear of patients undergoing bowel resection. Length of
bowel loss leading to this syndrome varies according to whether or not the terminal ileum
and ileocecal valve is resected.
A. Resection of 70% of the small bowel may or may not result in malabsorption.
B. If the terminal ileum and ileocecal valve are included in the resection, even 50% loss
can result in severe malabsorption.
2. The terminal ileum is responsible for the absorption of many substances. The most
important is bile salt.
A. Loss of the active transport site for bile salts in the distal ileum results in bile salt
depletion.
B. The colon and jejunum have a limited capacity to passively absorb bile salts.
C. The liver has a fixed capacity to compensate for losses with increased synthesis.
D. Passage of bile salts and free fatty acids into the colon accentuate the diarrhea
problem.
E. Reduced concentrations of bile salts in bile allows cholesterol to precipitate and the
formation of gallstones.
3. Vitamin B12 is absorbed in the ileum. Chronic loss of this vitamin can result in loss of
body stores after several years.
4. Bacterial overgrowth in the small bowel may result from ileocecal valve loss. Reflux
of colonic contents into the small intestine with the resultant bacterial overgrowth can
lead to deconjugation of bile acids, bile salts malabsorption, and bacterial metabolism of
vitamin B12.
A. It is also postulated that toxic substances may be elaborated by bacteria in the small
intestine. These substances may adversely affect intestinal motility and adaptation.
Shackelford's, Surgery of the Alimentary Tract, 3rd edition. W.B. Saunders Co., 1991

Treatment of Small Bowel Obstruction (SBO)

Obstruction occurs when there is a physical barrier or functional failure, an ileus, to the
normal transit of intestinal contents. The majority is secondary to post-op adhesion
(64-79%), hernia (15-25%), and tumors (10-15%). Classically, the cardinal symptoms are
crampy abdominal pain, obstipation, vomiting and abdominal distention. In addition,
there may be tenderness, fever, leukocytosis, and tachycardia. These additional findings
are suggestive of infection or infarction - complications of small bowel obstruction. Early
radiographic studies are the most important diagnostic maneuver. The presence of
air/fluid levels and its pattern helps the surgeon distinguish between a partial or complete
obstruction and ileus. Partial SBO are frequently resolved without surgical intervention.
The management of bowel obstruction is individualized but the common principles are:
correction of metabolic abnormalities, gastrointestinal decompression by a nasogastric
tube, intravenous hydration and perioperative antibiotic coverage.
If there is a complete obstruction, proper and timely surgery is essential. This may
involve lysis of adhesions, resection and/or bypass of an obstructing lesion, an
enterotomy to remove a foreign object, or the formation of an ileostomy/colostomy
proximal to the obstruction. Schwartz, 6th Edition, pp 1028-1031

Rx of Complication of Small Bowel Resection

The complications of small bowel resection include short bowel syndrome and
anastomotic leak, which can result in either abscess formation or fistula. The typical
presentation of an anastomotic leak occurs 5-7 days after surgery initially as a wound
infection that begins to drain intestinal contents 2-3 days thereafter - an enterocutaneous
fistula. The principles of treatment include electrolyte correction, control of sepsis, skin
protection with control of fistula drainage, and bowel rest with nutritional support. The
treatment of an enterocutaneous fistula can be expectant if sepsis and peritonitis is not
present; it involves placement of a red rubber catheter through the skin tract to control the
fistula and preserve the skin. Decreasing the fistula output is essential in effecting an
earlier closure than occurs with the natural outcome. This is accomplished by
administering H2-blockers, or proton pump inhibitors, which diminishes gastric output,
somatostatin, and TPN - allowing for bowel rest. Definition of the anatomy is
accomplished via fistulogram after a mature tract has formed and/or via small bowel
followthrough or barium enema.
The highest mortality occurs in the group in which surgical treatment is undertaken 1-6
weeks after formation. Greater likelihood of spontaneous closure occurs in patients with
tracts greater than 2 cm in length, distal in the GI tract, and fistulas in which intestinal
continuity is present. At times an anastomotic leak may present as a single accessible
abscess, which may be treated with CT-guided percutaneous drainage allowing for the
formation of a controlled fistula; however, if an abscess is associated with sepsis or
peritoneal signs, surgical exploration is warranted. Current treatment of short bowel
syndrome involves supportive care until the bowel can adapt. In the initial period, bowel
rest, TPN, motility modulating agents (codeine or loperamide), H2-blockers, or proton
pump inhibitors, and replacement of fluids are essential. After the initial or early phase is
complete, initiation of enteral nutrition, and vitamins is begun. Small bowel transplants
have had only limited success. Other bowel procedures such as reversing intestinal
segments has not been proven beneficial. Schwartz, 6th Ed, pp 425-27, 1184-85

Site of Primary in Carcinoid Syndrome

Carcinoid tumors are most frequently identified in the appendix (46%) followed by the
ileum (28%) and rectum (17%).
A malignant potential is related to (1) location, (2) size, (3) depth of invasion, and (4)
growth pattern.
35% of the ileal carcinoids are associated with metastases, whereas only 3% of
appendiceal carcinoids metastasize. Multiple carcinoids of the small bowel occur in 30%
of the cases. Typically, ileal carcinoids tend to be less than 1 cm. Treatment: Treatment
of patients with small bowel carcinoid tumors less than 1 cm in diameter without
evidence of regional lymph node metastases should be treated with a segmental intestinal
resection. For lesions greater than 1 cm, or patients with multiple tumors, and the
presence of regional lymph nodes, a wide excision of the bowel and mesentery is
required, and may entail a right hemicolectomy. Schwartz, 6th Edition, pp 1176

Characteristics of Carcinoid Tumors

Carcinoids have variable malignant potential and are composed of multipotential cells
with the ability to secrete numerous humoral agents, the most prominent of which are
serotonin and substance P. The carcinoid syndrome, characterized by episodic attacks of
cutaneous flushing, bronchospasm, diarrhea, and vasomotor collapse, occurs in fewer
than 5% of patients with malignant carcinoids. Carcinoids may occur in organs derived
from the foregut, midgut, or the hindgut.
In the GI tract, the appendix is the most commonly involved (46%) followed by the ileum
(28%), and the rectum (17%). The malignant potential appears to be related to the site of
origin and the size of the primary. Only about 3% of appendiceal carcinoids metastasize,
but 35% of ileal carcinoids do. The larger the size, the more the likelihood of metastases.
Carcinoids larger than 2 cm in diameter have 80-90% incidence of malignancy.
Most common symptoms associated with ileal carcinoid are pain, obstruction, diarrhea,
and weight loss.
Primary tumors less than 1 cm without regional nodal metastases are treated with
segmental intestinal resection. For those greater than 1 cm in diameter or with regional
metastases, wide excision of bowel and mesentery is required. Malignant carcinoid
tumors of the duodenum may require radical pancreaticoduodenectomy. Carcinoid
tumors of the appendix are commonly located in the tip, thus a simple appendectomy is
curative providing the tumor is 1 cm or smaller and without evidence of metastases.
Right hemicolectomy is indicated for tumors greater than 2 cm because of the potential
for metastases. Schwartz, 6th Edition, pp 1175-78, 1298

Care, pp 350-351

Diagnosis of Gastrinoma
Fasting hypergastrinemia (>200 pg/ml) in the face of gastric acid hypersecretion defined
as basal acid output >15mEq/h with intact stomach or >5mEq/h after ulcer surgery. Most
patients with gastrinoma have serum gastrin levels >500 pg/ml. A secretin provocative
test is usually done to confirm diagnosis when serum gastrin is in the range of 200-500
pg/ml.
Secretin Provocative Test:
Following 2 u/kg secretin IV bolus, a rise in serum gastrin level of 200 pg/ml within 15
min or doubling of the fasting gastrin level is diagnostic of gastrinoma.
Additional Studies: Upper GI or endoscopy will show ulcers often in unusual locations,
i.e. 2nd & 3rd portions of duodenum or jejunum. The stomach may have prominent rugal
folds along with excessive luminal secretions. CT scan may show tumor in the pancreas
or paraduodenal areas. Angiography with portal venous sampling may show "hot spots"
of gastrin secretion. Schwartz, 6th ed, pp 1427-28
Duodenal Hematoma
Intramural hematoma of the duodenum is usually due to blunt abdominal trauma. This
causes rupture of intramural duodenal blood vessels with formation of a dark, sausage-
shaped mass in the submucosal layer of the duodenal wall. It can also occur
spontaneously in patients on anticoagulants. The hematoma may cause partial or
complete duodenal obstruction. The patient has signs of a high small bowel obstruction,
with nausea and vomiting associated with upper abdominal pain and tenderness, and
sometimes a suggestion of a right upper quadrant mass on palpation of the abdomen.
Plain films of the abdomen may show an ill-defined right upper quadrant mass and
obliteration of the right psoas shadow. An upper GI is usually diagnostic with filling of
the duodenal lumen and the appearance of a "coiled spring" in the second and third
portions due to crowding of the valvulae conniventes. The serum amylase may be
elevated. Most infants and children may be successfully treated without surgical
intervention. Nonsurgical treatment of these patients consists of cessation of oral intake,
nasogastric suction, and intravenous replacement of fluids and electrolytes. Schwartz, 6th
Edition. O'Leary, 2nd Edition, Physiologic Basis of Surgery

Treatment of Meckel's Diverticulum

The Meckel's diverticulum is the most common true diverticulum of the gastrointestinal
tract. It arises from incomplete closure of the omphalomesenteric or vitelline duct during
early development. It is generally found 18-24 inches from the ileocecal valve and arises
on the antimesenteric border of the ileum. Most are benign but problems arise from
bleeding and perforation secondary to the heterotopic gastric or pancreatic tissue found in
the diverticulum. The majority of these diverticuli are found in young children with the
most common symptom being bleeding. Other complications that occur are obstruction,
bleeding, acute diverticulitis or the presence of a diverticulum in a hernia sac (Littre's
hernia). Treatment is indicted if any of these complications should occur. Incidental
resection is not indicated because there is only a 2% risk of complications with a simple
Meckel's. If bleeding is present, a segmental small bowel resection should be performed
because the bleeding will be from the surrounding ileal mucosa subjected to the irritating
secretions. If there is a persistent connection to the overlying abdominal wall, this too
should be disconnected. Schwartz, 6th ed, pp 1179-80

Diagnostic Study of Gallstone Ileus

Gallstone ileus occurs when a gallstone obstructs the small bowel, which most commonly
occurs at the terminal ileum. Diagnosis of gallstone ileus is determined through a
combination of clinic findings and radiographs. Air fluid levels on the upright or
decubitus abdominal x-rays suggesting a small bowel obstruction and air in the biliary
tree are pathognomonic of gallstone ileus. The history will reveal past symptoms of
cholelithiasis that suddenly resolved or a history of gallstones. The findings on physical
exam supporting gallstone ileus are symptoms of small bowel obstruction: abdominal
pain, obstipation, vomiting, and abdominal distention. The treatment is an enterotomy
removing the stone, palpation of the entire small bowel to eliminate the possibility of a
second gallstone in transit, and if possible a concomitant cholecystectomy with closure of
the duodenal fistula. Schwartz, 6th Edition, pg 1381
Treatment of Acute Ileitis
Acute ileitis is most often associated with an acute flair of Crohn's disease. Surgery for
Crohn's disease is indicated only for complications (fistula, abscess, obstruction) as
recurrence of disease is quite common. Generally, acute Crohn's disease flair up is treated
medically with bowel rest, parenteral nutrition, antiinflammatory medication (steroids),
antibiotics, and drainage of abscesses (percutaneous) where applicable. Emergent
surgical intervention may be needed for certain situations (perforation, intractable
obstruction, sepsis). Elective resection of the diseased bowel segment responsible for the
complication is indicated once the acute process subsides. As a rule, bowel continuity is
reestablished whenever possible; however, if acute inflammation or infection is present at
surgery then temporary stoma may be necessary. Acute ileitis may also be caused by
Yersinia enterocolitica. Nine percent of these patients, if observed for long periods of
time, develop ileocolic Crohn's disease. Schwartz, 6th Ed., pp 1249-1250. Mazier,
Surgery of the Colon & Rectum, pg 956

Diagnostic Test for Adenocarcinoma of Small Intestine

Endoscopy useful for duodenum and proximal jejunum. Small bowel follow-through is
limited by low diagnostic sensitivity. Enteroclysis - superior to small bowel follow-
through for detection of small filling defects and for changes in mucousal pattern. With
diagnostic accuracy approaching 90% it is radiographic "gold standard" for study of
small bowel. Schwartz, 6th ed, pp 1171-72