Small Intestine Disorders (PEARLS)

The NCCPA™ Gastroenterology and Nutrition PANCE Content Blueprint covers five topics under the category diseases of the small intestine

Appendicitis (ReelDx)	ReelDx Virtual Rounds (Appendicitis ) Appendicitis You are called to see a 7-year-old with acute abdominal pain Patient Gender: male Age: 7 years Weight: 60 lb/27.2 kg Height: 49 in/124 cm Vitals Temperature: 98 F/36.7 C Blood Pressure: 125/79 Heart Rate: 112 Respiratory Rate: 28 Pulse Oximetry: 96% RA Signs and Symptoms 2d RLQ abdominal pain; 103 F fever; nausea/vomiting Click here to work through this patient case simulation. Patient will present as → a 14-year-old boy with nausea, vomiting, constipation, and periumbilical pain that has settled in the lower right quadrant. The patient’s mom gave him a piece of toast and some water about 5 hours ago but he vomited 30 minutes after eating. On physical exam, he has tenderness and guarding in the lower right quadrant, pain upon flexion and internal rotation of right lower extremity, RLQ pain with right hip extension, and RLQ pain with palpation of the LLQ. Blood tests reveal leukocytosis with a shift to the left. Appendicitis is the inflammation of the appendix, typically due to obstruction of the appendiceal lumen, leading to infection and possible perforation The first symptom is crampy or "colicky" pain around the navel (periumbilical) → then pain over McBurney’s point (RLQ) There is usually a marked reduction in or total absence of appetite, often associated with nausea, and, occasionally, vomiting and low-grade fever Most common etiology ⇒ fecalith (a stone made of feces) - called appendicolith when it occurs in the appendix As the inflammation increases, the abdominal pain tends to move downward - begins in epigastrium → umbilicus → RLQ Right lower quadrant= "McBurney's point." This "rebound tenderness" suggests inflammation has spread to the peritoneum Signs: Rovsing – RLQ pain with palpation of LLQ Obturator sign – RLQ pain with internal rotation of the hip Psoas sign - RLQ pain with hip extension while laying on the left side Alternatively, the patient lies on their back, and the examiner asks the patient to actively flex the right hip against the examiner's hand DX: Clinical diagnosis: Imaging if atypical presentation - appy ultrasound or abdominal CT scan CBC - neutrophilia supports the diagnosis TX: surgical appendectomy CT scan of the abdomen showing an enlarged appendix, suggestive of acute appendicitis.
Celiac disease and gluten intolerance	*Patient will present as →* a 34-year-old male presents to the clinic with a six-month history of chronic diarrhea, weight loss, and generalized weakness. He reports frequent abdominal pain and bloating after meals. He has also noticed a blistering, itchy rash on his elbows and knees. His medical history is significant for iron deficiency anemia. Physical examination reveals pallor, a distended abdomen, and a rash consistent with dermatitis herpetiformis. Laboratory tests show low hemoglobin and hematocrit levels, elevated transaminases, and a positive tissue transglutaminase (tTG) IgA antibody. Given his clinical presentation and positive serologic test for celiac disease, the patient is diagnosed with celiac disease. Upper endoscopy with a biopsy of the small intestine is scheduled to confirm villous atrophy. He is started on a strict gluten-free diet and referred to a dietitian for comprehensive dietary education and management. He is also advised to avoid foods that may contain hidden sources of gluten and to be aware of cross-contamination. Follow-up is planned to monitor his response to the gluten-free diet, check for improvement in symptoms, and reassess his nutritional status. Celiac Disease is an autoimmune disorder triggered by gluten ingestion, leading to inflammation and damage of the small intestine Gluten exposure causes immune-mediated damage to the intestinal villi, resulting in malabsorption Common symptoms include diarrhea, bloating, weight loss, fatigue, and steatorrhea; iron deficiency anemia, osteoporosis, and dermatitis herpetiformis (pruritic rash) are extraintestinal manifestations Risk factors include a family history, autoimmune diseases (e.g., type 1 diabetes), and Down syndrome DX: Serologic testing – Elevated anti-tissue transglutaminase (anti-tTG) antibodies and anti-endomysial antibodies (EMA) Small bowel biopsy of duodenum (GOLD STANDARD) (showing villous atrophy and crypt hyperplasia) TX: A strict lifelong gluten-free diet (avoiding wheat, barley, rye) Nutritional supplementation (iron, calcium, vitamin D, folate) to correct deficiencies Monitor antibody levels to assess compliance and response to dietary changes Complications include refractory celiac disease, small bowel lymphoma, and osteoporosis if untreated Prognosis: Excellent with adherence to a gluten-free diet, with symptom resolution and intestinal healing over time Non-Celiac Gluten Sensitivity (NCGS): A condition causing symptoms similar to celiac disease, such as bloating and abdominal pain, WITHOUT the autoimmune intestinal damage. Diagnosed by ruling out celiac disease and wheat allergy, and observing symptom improvement on a gluten-free diet. Gluten sensitivity levels vary, and some individuals may tolerate minimal gluten. NCGS does not involve autoimmune damage to the intestine Normal serum biomarkers – NCGS is diagnosed by ruling out celiac disease and wheat allergy and observing symptom improvement on a gluten-free diet. Individuals with NCGS may have varying levels of sensitivity and may be able to tolerate small amounts of gluten.
Intussusception (ReelDx)	ReelDx Virtual Rounds (Intussusception) Intussusception You are called to see a 12-month-old with episodic abdominal pain and vomiting. Patient Gender: Female Age: 12 months Height: Not Available Weight: 16.3 lb/7.4 kg Vitals Temperature: 99.4 F/37.4 C Blood Pressure: 102/60 Heart Rate: 130 Respiratory Rate: 36 Pulse Oximetry: 99% RA Signs and Symptoms Episodic abdominal pain and vomiting Click here to work through this patient case simulation. *Patient will present as →* a young mother who brings her 12-month-old daughter to your office, reporting that she has had recurrent “belly aches” for the past two weeks. The child experiences sudden, colicky abdominal pain that recurs every 15 to 20 minutes, often with vomiting. These episodes are interspersed with periods of no complaints. The mother also reports that she has seen her squatting with her knees to her chest, which seems to relieve her of her symptoms. She describes her stool as bloody with mucus, almost as though it were a currant jelly. On physical examination, you note abdominal distention and tenderness along with a sausage-shaped abdominal mass in the RUQ. Ultrasound shows a target sign, confirming intussusception. Management includes fluid resuscitation and air enema reduction, with surgical intervention if nonoperative reduction fails. Intussusception is the telescoping of one segment of the intestine into another, leading to bowel obstruction and compromised blood flow The most common cause of intestinal obstruction in children aged 6 months to 3 years Typically idiopathic in children, but may be triggered by viral infections or hypertrophied Peyer’s patches; in adults, often due to a pathologic lead point (e.g., tumor, polyp) Presents with sudden, severe, intermittent abdominal pain, currant jelly stools (blood and mucus), vomiting, and a palpable sausage-shaped mass in the right abdomen Children may pull their legs to the chest and appear well between episodes of pain DX: Diagnosis is made with abdominal ultrasound, showing the classic “target” or “donut” sign TX: Air or contrast enema is both diagnostic and therapeutic in most pediatric cases Surgical intervention is required if enema reduction fails or if there are signs of perforation, peritonitis, or pathologic lead point Complications include bowel ischemia, necrosis, and perforation if not promptly treated Crescent sign of intussusception (image by Case Reports in Pediatrics CC BY 4.0) An intraoperative ultrasound showing the classic target sign appearance of intussusception (image by open access)
Small bowel obstruction	ReelDx Virtual Rounds (Small bowel obstruction) Small bowel obstruction You are called to see a 61 y/o with acute onset severe abdominal pain and vomiting Patient Gender: Female Age: 61 Vitals Temperature: 99.4ºF/37.4ºC Heart Rate: 67 Respiratory Rate: 16 Pulse Oximetry: 99% on RA Blood Pressure: 130/79 Signs and Symptoms Acute onset severe abdominal pain and vomiting Click here to work through this patient case simulation. Patient with small bowel obstruction will present as → a 55-year-old male presents to the emergency department with a two-day history of severe abdominal pain, vomiting, and inability to pass stool or gas. He describes the pain as crampy and worsening, localized initially around the umbilicus but now diffused across the abdomen. His medical history is significant for an open appendectomy 20 years ago. On examination, his abdomen is distended and tender with high-pitched, tinkling bowel sounds. He is afebrile, but his heart rate is elevated. An abdominal X-ray reveals dilated loops of small bowel with air-fluid levels. You note valvulae conniventes across the full width of the bowel suggestive of a small bowel obstruction. A CT scan of the abdomen confirms the diagnosis, showing a transition point with no evidence of strangulation. The patient is admitted for nasogastric decompression, intravenous fluids, and bowel rest. Surgery is consulted for potential operative intervention, given his history of previous abdominal surgery and the likelihood of adhesive disease. The patient is closely monitored for signs of bowel ischemia or perforation. What are the 4 cardinal signs of strangulated bowel? The 4 cardinal signs of strangulated bowel: fever, tachycardia, leukocytosis, and localized abdominal tenderness. Small bowel obstruction MCC: Postoperative adhesions (MC cause in adults) or hernias, cancer, IBD, volvulus, and intussusception (MC cause in children) Obstruction is typically in the ileum or jejunum History of prior abdominal surgery Symptoms include colicky abdominal pain, nausea, bilious vomiting, abdominal distention, and diarrhea High-pitched hyperactive bowel sounds (early) progressing to silent bowel sounds (hypoactive bowel sounds -late) Dehydration + electrolyte imbalances DX: Obtain plain radiographs to quickly confirm a diagnosis of bowel obstruction, and, provided the films do not have findings that indicate the need for immediate intervention, then use computed tomography (CT) of the abdomen and pelvis to further characterize the nature, severity, and potential etiologies of the obstruction KUB shows dilated small bowel loops (< 3 cm), air-fluid levels in the small bowel with valvulae conniventes visible across the full width of the bowel, string of pearls (multiple air-fluid levels), and paucity of gas in the colon TX: Treat with decompression with an NGT, bowel rest, surgery if a mechanical obstruction is suspected Hyperactive bowel sounds, as heard in SBO SBO vs. LBO On the physical exam: In small bowel obstruction, vomiting is more common, and the pain tends to be periumbilical, cramping, and intermittent – with bouts that last for a few minutes at a time In large bowel obstruction, vomiting is less common, and the pain is lower in the abdomen and the bouts of pain are less frequent but last a bit longer On the abdominal x-ray (KUB): Large bowel obstruction presents with haustra (small pouches caused by sacculation, which give the colon its segmented appearance) that do not transverse bowel Small bowel obstruction presents with valvulae conniventes (white lines passing across the full width of the bowel) that are only found in the small bowel
Polyps of small bowel	Patient will present as → a 45-year-old woman presents with intermittent, crampy abdominal pain and iron-deficiency anemia. She experiences occasional nausea but no vomiting, weight loss, or bowel habit changes. Her medical history and physical examination, including a soft, non-distended abdomen, are unremarkable. Despite normal upper endoscopy and colonoscopy results, persistent symptoms and anemia lead to a capsule endoscopy, revealing a 2 cm jejunal polyp. A double-balloon enteroscopy confirms it as a benign hamartomatous polyp. She undergoes successful endoscopic polypectomy, resolving her symptoms and anemia, with planned follow-up for symptom monitoring. Small bowel polyps are abnormal growths of tissue protruding from the lining of the small intestine Small bowel polyps are relatively uncommon, accounting for only about 3% of gastrointestinal tumors Most small bowel polyps do not cause any symptoms. However, some people may experience abdominal pain, bloating, diarrhea, or bleeding (anemia) DX: Small bowel polyps are often found incidentally during endoscopy, surgery, or imaging for other indications Capsule endoscopy and device-assisted enteroscopy (double balloon or spiral) allow direct visualization of the small bowel CT and MRI enterography Biopsy during endoscopy provides definitive diagnosis based on histopathology TX: Most small hyperplastic polyps can just be followed without intervention Pedunculated or large adenomas should be removed via polypectomy during enteroscopy For multiple polyps, consider surgical resection if accessible Surveillance endoscopy is recommended after polypectomy due to risk of metachronous polyps Malignant polyps require oncologic resection with lymph node dissection and possible chemotherapy