Dehydration and Hypovolemia
All forms of mesenteric ischemia are associated with some degree of hypovolemia, as the ischemic insult produces a marked increase in the permeability of the capillaries and the mucosa itself, with consequent losses of intravascular fluid into the bowel wall and lumen. This fluid loss can be particularly striking in cases of venous thrombosis or intestinal strangulation, in which the venous component dominates the initial occlusive process. Careful hemody-namic monitoring is thus essential,...
Slow Transit Constipation
In slow transit constipation STC , there is a failure to move luminal contents through the proximal colon. This may be associated with dietary factors, such as severe caloric deficiency, with medications that alter motility or with certain neurologic, metabolic, and endocrine disorders. Attention to such factors may lead to improvement in colonic transit. Patients with idiopathic STC who fail to respond to conventional laxatives may have abnormalities of the enteric nerves, such as decreased...
Systemic Anaphylaxis
The most important manifestation of food allergy is systemic anaphylaxis. It is now recognized that food allergy TABLE 57-2. Conditions Associated with Immunologic Reactions to Foods Immediate gastrointestinal hypersensitivity Food protein induced proctocolitis or proctitis is the major cause of anaphylactic reactions in industrialized societies including the United States, Australia, and Europe. The prevalence of peanut allergy 0.5 to 7 of adults in the United States and the United Kingdom and...
Cvid
Both prospective and retrospective studies have shown a high rate of GI symptoms in CVID patients. Forty to 60 of patients experience chronic diarrhea, which may be accompanied by steatorrhea or other signs of malabsorption So and Mayer, 1997 . Common causes of GI symptoms are infectious, predominantly bacterial pathogens Salmonella, Campylobacter, and Clostridium difficile from antibiotic use or the parasite Giardia lamblia. However, inflammatory and malignant disorders of the GI tract also...
Fistula in Ano
Fistulas are classified as intersphincteric, transsphincteric, extrasphincteric, and suprasphincteric. Treatment is generally surgical, except in patients with CD with active proximal intestinal disease. The goal of treatment is to cure the fistula, avoid recurrence, and preserve continence. Therefore, identification of the primary opening and side tracts and division of the least amount of muscle are the key factors for surgical success. External sphincter Internal sphincter FIGURE 91-1....
Management of PCS
Management of PCS has to address the specific cause. Irritable bowel syndrome see Chapter 39, Irritable Bowel Syndrome , peptic ulcer disease see Chapter 25, Peptic Ulcer Disease , cholelithiasis see Chapter 132, Cholelithiasis , and chronic pancreatitis see Chapter 139, Chronic Pancreatitis are important diagnostic considerations in the management of this syndrome. However, in this chapter we will focus on SOD.One study that systematically examined patients after cholecystectomy found that IBS...
Chlamydia trachomatis
Chlamydia infection is caused by Chlamydia trachomatis. The organism can cause proctitis similar to that of CD. Untreated disease may become ulcerated causing fistulas, abscesses, or rectal stricture, which may be misdiagnosed as adenocarcinoma. Diagnosis is usually made by serology. Treatment consists of oral tetracycline or erythromycin, 500 mg 4 times a day for 3 weeks. Rectal strictures are primarily treated medically in case of failure, surgical resection with coloanal anastomosis may be...
Psychotropic Medications
The use of psychotropic medications has become popular in the treatment of functional bowel disorders, especially the IBS. Both the tricyclic antidepressant medications TCAs , as well as the selective serotonin reuptake inhibitors SSRIs , can be used in IBS however, the TCA medications have been more extensively evaluated for this purpose and may be more efficacious. There is a separate chapter on the use of psychotropic drugs in patients with functional disorders see Chapter 43, Psychotropic...
Conclusion Pds
The surgical considerations for patients with chronic pancreatitis include procedures to address chronic pain, various complications of the disease, and pancreatic cancer. The decision to operate in any single patient with pain from the disease is complex, and should be based on a variety of factors that include the psychosocial makeup of the patient as well as pancreatic anatomy. If surgery is indicated, the type of operation hinges on the appearance of the pancreatic ducts Figure 137-1 . In...
Radiation Proctocolitis
Patients with a past history of radiation therapy for prostate cancer or gynecologic malignancy can have lower GI bleeding as either an early or late complication of radiation damage. Acute radiation proctocolitis usually presents as transient diarrhea, tenesmus, and mucoid or bloody discharge per rectum. These signs and symptoms are usually resolved within days or weeks without specific therapy. Chronic radiation injury is an ischemic process, usually beginning 2 to 3 months after treatment...
Conclusions Abb
GI complaints among patients with AN and BN are the rule rather than the exception, and range from the benign bloating and dyspepsia to the life threatening acute gastric dis-tention, ipecac cardiotoxicity, and the refeeding syndrome . Gastroenterologists are frequently the first physicians to encounter these patients, and because of inherent ambivalence about weight gain that spurs patients to avoid treatment, it may fall to the gastroenterologist to educate the patient about her diagnosis and...
Complications of Ascites Ascitic Fluid Infection
Categories and Diagnosis of Ascitic Fluid Infection Ascitic fluid infection can be classified into three categories based on ascitic fluid PMN count, culture, and the presence or absence of a surgical source. These include spontaneous ascitic fluid infection, secondary bacterial peritonitis, and polymicrobial bacterascites. The spontaneous ascitic fluid infection is further divided into three subcategories, including 1 SBP, 2 monomicrobial non-neutrocytic bacterascites MNB , and 3...
Upf Liver Disease
Laboratory data in patients with biliary tree obstruction usually demonstrate obstructive pattern in liver function tests, including elevated total and direct bilirubin and alkaline phosphatase. The degree of blood bilirubin and alkaline phosphatase elevation usually correlates with the degree and duration of obstruction of the biliary ducts. Patients with incomplete ductal occlusion may have isolated elevation of alkaline phosphatase with a normal level of bilirubin. Infection in obstructed...
Empiric Antibiotic Use
Use of empiric antibiotics must be weighed against potentially harmful consequences, including increases in antimicrobial resistant infections, eradication of commensal flora, cost, and side effects. As a general rule, empiric therapy is used in the following three patient populations 1 patients with acute invasive diarrhea, 2 patients with travelers' diarrhea, and 3 patients with presumed giardiasis. These recommendations are supported by practice guidelines of the American College of...
Complications Spasm
The changes in the wall of the colon seen with diverticu-losis can result in a syndrome of intermittent abdominal pain and spasm that mimics IBS. Symptoms are generally mild and are not associated with fever or signs of sepsis. Treatment is usually conservative and includes measures such as a high fiber diet and pharmacologic agents aimed at decreasing colon spasm, such as hyoscyamine. Symptoms are usually self-limited but may recur with some degree of regularity. Many patients with presumed...
Summary Nki
Palliative therapy of rectal cancer is a highly individualized process for each patient involving a multidisciplinary care team. The goal is to enhance the quality of life by minimizing symptoms, maintaining normal function, and helping the patient and their support network to maintain realistic expectations without eliminating hope. Studies should be limited and be used to assist in decisions regarding palliative therapy. Both invasive and noninvasive therapy modalities exist to palliate...
Paraesophageal Hernia
Paraesophageal hernias are a type of hiatal hernia in which a portion of the stomach generally fundus herniates into the mediastinum with the gastroesophageal junction either below the diaphragm type 2 hernia or above the diaphragm type 3 hernia . Traditionally, surgeons considered the presence of a paraesophageal hernia a surgical emergency urgency. This dogma resulted from two papers published in the late 1960s and early 1970s by Skinner and colleagues 1967 and by Hill 1973 . They observed a...
Fistulas
The surgical treatment of perianal fistulas in CD is based on the fistula type low or high and, more importantly, the presence of active proctitis. For those with low fistula in ano, fistulotomy still has a role. The data to date support the conclusion that, for low fistulas with no active disease, surgery for CD patients is as effective as in non-IBD patients Figure 82-4 . Interestingly, a University of Minnesota series of41 fistulas in 33 patients without active proctocolitis showed a 93...
Wce
WCE using the M2A Given Imaging, Yoqneam, Israel capsule endoscope is a monumental development that allows noninvasive visualization of the entire small bowel. TABLE 59-3A. Contraindication to Wireless Capsule Endoscopy Known or suspected obstruction stricture fistula extensive CD disease Swallowing disorders Pseudo-obstruction Motility disorders Cardiac pacemakers relative Implanted defibrillators and electromechanical devices Relative Contraindications Pregnancy Long-standing NSAID use Large...
Comparison of WCE to Enteroscopy
WCE detects more distal small bowel lesions in patients with OGIB than does push enteroscopy. Lewis and Swain 2002 reported a yield of 55 11 20 for capsule endoscopy. Ell and colleagues 2002 reported on a heterogeneous group of patients with OGIB and found a diagnostic yield of 66 for capsule endoscopy and 28 for push enteroscopy. Mylonaki and colleagues 2003 reported on 50 patients with OGIB. Using WCE, a bleeding source was discovered in the small bowel in 34 of the 50 patients 68 , whereas...
Averell H Sherker MD FRCPC
Hepatitis B HB is among the most common chronic viral infections of humans. It is estimated that 350 million people more than 5 of the world's population are chronically infected with hepatitis B virus HBV . Among these, approximately 1.25 million HBV carriers are in the United States. These carriers remain at significant risk for the development of cirrhosis, liver failure, and hepatocellular carcinoma HCC throughout their lives, and 10 to 25 will die as a result of their infection.
Hyperemesis Gravidarum
Nausea and vomiting occur in up to 90 of all pregnancies. Hyperemesis gravidarum HG has a prevalence of 0.35 to 1 , and is characterized by severe, persistent nausea and vomiting during the first trimester. Intractable vomiting requires aggressive support, including, at times, parenteral nutrition. Risk associations include increased body weight, multiple gestations, hyperemesis in a prior pregnancy, and nulliparity. Up to half of women hospitalized for HG have liver enzyme abnormalities,...
Mechanics of Swallow
Oropharyngeal swallowing begins with a voluntary oral phase that is then followed by a pharyngeal phase. The oral phase of swallowing is essentially voluntary and highly variable depending upon stimuli such as taste, environment, hunger, and motivation. Disorders of the oral phase of swallowing occur with many conditions characterized by global neurologic dysfunction, such as head trauma, cerebral tumors, or cerebral vascular accident. Once initiated, the pharyngeal phase of swallowing results...
Epidemiology 1
Despite efforts to reduce the level of gastric acid secretion, there remain a substantial number ofpatients admitted each year with PUD. In a recent study in US veterans it was shown that, although there has been an appreciable reduction in hospitalizations for both gastric and duodenal ulcer disease over the past three to four decades, the level has reached a plateau El-Serag and Sonnenberg, 1998 . Furthermore, there appears to be gt 1 million cases of PUD recurrences in the United States each...
Prokinetic Agents
Whether the underlying process is myopathic or neuropathic in nature, all patients with CIP have disordered GI tract motility. Multiple prokinetic agents have been used in an attempt to promote normal intestinal motility, however there are few investigational studies available to demonstrate the efficacy of any of these agents in CIP. Erythromycin, a macrolide antibiotic that acts as an agonist to the motilin receptor, can be given either orally or IV. Doses in the range of 50 to 200 mg orally,...
Reza ShakerMD and Walter J HoganMD
The treatment paradigm for gastroesophageal reflux disease GERD disorders was well established at the onset of the second millennium. Potent antacid medications and laparoscopic fundoplication surgery were well-accepted treatment modalities effective for the great majority of GERD sufferers. However, there remained a significant minority of GERD patients unable or unwilling to be aided by these conventional therapies. Some patients were unresponsive or did not tolerate medications others were...
Nuclear Bleeding Scans
Technetium Tc99m-labeled RBC scans can detect intestinal bleeding rates as low as 0.1 mL min. After the infusion of radiotracer, patients are imaged for 1 to 2 hours initially. If the initial scan is negative, they can be rescanned without reinjection for up to 24 hours. In patients with lower GI bleeding, only 45 will have a positive tagged RBC scan. The chances of obtaining a positive scan are increased if the patient is actively bleeding, as evidenced by hema-tochezia, at the time of the...
Supplemental Reading Alb
Baer AN, Bayless TM, Yardley JH. Intestinal ulceration and malabsorption syndromes. Gastroenterol 1980 79 754-65. Carroccio A, Iannitto E, Cavataio F, et al. Sideropenic anemia and celiac disease one study, two points of view. Dig Dis Sci 1998 43 673-8. Carroccio A, Iacono G, Montalto G, et al. Pancreatic enzyme therapy in childhood celiac disease. A double-blind prospective randomized study. Dig Dis Sci 1995 40 2555-60. de Francischi ML, Salgado JM, da Costa CP. Immunological analysis of serum...
Clinical Features of HH
Before the advent of genetic testing, the diagnosis of HH was based on the recognition of symptoms and physical examination findings of iron overload. Currently, most patients with HH are detected at a much earlier stage, prior to the development of end-organ damage, as a result of 1 routine health maintenance examinations, which include testing for serum iron, ferritin and liver enzymes, 2 genetic testing of relatives of a HH patient as part of family screening, and 3 population studies of...
PostERCP Pancreatitis
Approximately 1 to 10 of ERCPs may be complicated by acute pancreatitis. This is usually mild, but severe pancreatitis and death may occur. Table 136-5 summarizes risk factors and preventive measures. The judicious use of nonimaging procedures magnetic resonance cholangiopancreatography and EUS to circumvent diagnostic ERCP is important because preventative measures have limited success. Short duration 1 to 2 days pancreatic duct stenting appears to be effective in high risk patients, including...
Procedure for Prolase and Hemorroids
Recently, an alternative technique has been developed and tested that is associated with markedly reduced postoperative pain Sutherland et al, 2002 . The procedure for prolapse and hemorrhoids PPH , or stapled hemorrhoidectomy, employs a circular stapler with a hollow head to excise a cuff of tissue at the most superior aspect of hemorrhoidal complexes and create a superficial end-to-end anastomosis Figure 92-2 . During this procedure, a submucosal purses-tring is placed 4 cm above the dentate...
Presentation Hps
The main presenting symptoms in patients with benign and malignant biliary strictures are abdominal pain, fever, chills, cholangitis, and obstructive jaundice. Abdominal pain is usually localized in the right upper quadrant or epigastric area. Usually the pain starts gradually and has a constant not crampy character. Infection in the obstructed portion of the biliary tree manifests with low grade fever and chills or with overt cholangitis high fever, pain, jaundice, and changed mental state ....
Arden M Morris MD MPH and Robert D MadoffMD
Fecal incontinence is the inability to control discharge of anal contents, which may be gas, liquid, or solid. Episodes of incontinence vary in frequency and often have a profoundly negative impact on both physical and psychological well-being. Patients with fecal incontinence may limit their social interaction, change or reduce activities of daily living, and experience grave health side effects. Given the associated social stigma, patients are often reluctant to discuss symptoms of fecal...
Ischemic Colitis
Colonic ischemia may result from any of the aforementioned circumstances the colon may even be involved in an intestinal strangulation due to cecal or sigmoid volvulus. Perhaps the most common cause of severe colonic ischemia is the liga-tion of the IMA during abdominal aortic surgery. It is also important to note that two common forms of infectious colitis, from Clostridium difficille and enteropathogenic Escherichia coli are manifestations of toxin-induced tissue ischemia. The principles of...
Recurrent or Chronic Pouchitis
Defective function of the pouch is probably the commonest reason for excessive bowel frequency in IPAA patients. Pouch inflammation, from pouchitis, unrecognized CD, or infectious causes, often is the cause of a true diarrhea, ie, passage of an abnormally high volume of feces . Ten to 20 of IPAA patients experience recurrent episodes of acute pou-chitis. Although it is important to confirm the diagnosis of pouchitis with endoscopy and biopsy to exclude other explanations for symptoms, many...
Hypolipidemic Agents
NASH has been associated with circulating hyperlipidemia, specifically hypercholesterolemia and hypertriglyceridemia. One relatively unsuccessful treatment approach has been to correct this circulatory abnormality with the hope that decreased circulating lipids would decrease the uptake of lipids by the liver and decrease the amount of fat in the liver. In reality, little circulating triglyceride is destined for the liver and most of the triglyceride in very low density lipoprotein is used as...
Cure Of Diseases
The primary goal of HBV treatment is to convert active replicative infection to the inactive nonreplicative state. If this state is achieved and sustained, the risk of liver-related morbidity and mortality is significantly reduced. The following three treatments are currently FDA-approved therapies for HBV 1 interferon-a, 2 lamivudine, and 3 adefovir dip-ivoxil. Several other agents are in late-stage clinical study. Interferons are both antiviral and immunostimulatory. It is believed that the...
Focal Biliary FibrosisCirrhosis
This is a description of the pathology in the liver of CF patients. The scarring around the biliary tree is not generalized, but patchy, and likely occurs to some degree in most patients, although clearly some patients are more affected and go on to an extensive lesion with cirrhosis and consequent portal hypertension. The fibrosis alone does not produce symptoms. Biochemical tests of liver enzymes aspartate aminotransferase, alanine aminotransferase, GGT, alkaline phosphatase may, however, be...
Cowden Syndrome
Cowden syndrome CS , also called multiple hamartoma syndrome, is a syndrome characterized by cutaneous findings, in addition to polyposis, and a significant risk for development of extra-intestinal malignancy. The disease is associated with a mutation in the PTEN MMAC1 gene on chromosome 10 that is found in about 80 of patients FIGURE 95-3. Atypical polyp in juvenile polyposis characterized by a white exudate on the polyp surface. FIGURE 95-3. Atypical polyp in juvenile polyposis characterized...
Dios
Previously known as meconium ileus equivalent, DIOS is obstruction of the distal small bowel with inspissated stool and mucous. This occurs more frequently in the older child adolescent or adult, and may present acutely, or have a prodrome of weeks or even months of nonspecific crampy abdominal pain. The patient presents with a partial or, less commonly, complete distal small bowel obstruction with crampy abdominal pain, vomiting, abdominal distension, and decreased stooling. Although the...
Ulcerogenic Potential of NSAIDs
Although all NSAIDs can cause GI injury, some NSAIDs are more ulcerogenic than others. In general, the ulcerogenic potential of an NSAID correlates with its antiinflammatory activity. NSAIDs with a high analgesic effect at doses with low anti-inflammatory activity, such as ibupro-fen,are less ulcerogenic than NSAIDs that achieve acceptable analgesic effects only at doses with high anti-inflammatory activity eg, piroxicam . Clinically, the ulcer risk observed with various NSAIDs is in part a...
Specific Etiologies and Treatments
The small bowel is an unusual but important source of GI blood loss. In patients with negative repeat endoscopy and colonoscopy, the small bowel should become the focus of further investigation. The overwhelming majority of small bowel bleeding originates from vascular lesions ie, arteriovenous malformations AVM and small bowel tumors. Other less common sources include drug-induced ulcerations, Crohn's disease CD , Dieulafoy's malformation, and metastatic tumors to the small bowel. The likely...
Stool Softeners
Docusates Colace, Surfak work by lowering the surface tension of stool and allowing water to move easily into the fecal mass. These agents have marginal value in treating chronic constipation. Mineral oil also softens stool as a result of its emollient effect. It is particularly effective in enemas to soften hard impactions. However, aspiration with lipoid pneumonia is a major hazard associated with oral administration, especially in patients with impaired swallowing or severe reflux disease....
Antiemetic Therapy
It is important to remember that nausea will often persist for some time after the initiation of prokinetic therapy that is aimed at restoring gastric motility. The patient's perception of symptom relief starts with nausea and vomiting and this must be immediately addressed while the prokinetics are started. Prokinetics coordinate the motility of the stomach and proximal gut and this effect requires a little longer to work and decrease symptoms than antiemetics which can be effective almost...
Supplemental Reading Xvn
Borruel N, Carol M, Casellas F, et al. Increased mucosal tumour necrosis factor alpha production in Crohn's disease can be down-regulated ex vivo by probiotic bacteria. Gut 2002 51 659-64. Brant SR, Picco MF, Achhar JP, Bayless TM, et al. Defining complex contributions ofNODz CARD15 gene mutations, age at onset and tobacco use in Crohn's Disease phenotypes. Inflamm Bowel Dis 2003 9 281-9. Crandall WV, Mackner LM. Infusion reactions to infliximab in children and adolescents frequency, outcome...
Setons
The use of a noncutting Seton is the most common and effective treatment modality in use for CD patients with complex fistula in ano Scott and Northover, 1996 Takesue et al, 2002 Koganei et al, 1995 . A Seton is a nonabsorbable suture or vessel loop that is placed through the fistula tract Figure 82-5 . Passing it through the cutaneous opening of the fistula and out of the associated anal canal opening allows the two ends to be tied loosely together. Although sometimes these draining setons are...
Conclution Of Liver Disease
The diagnosis and management of abdominal pain, particularly when chronic, is one of the most challenging clinical problems that a gastroenterologist encounters. Significant progress has been made in our understanding of the pathogenesis of somatic sensitization and it is hoped that this will lead to similar advances in visceral pain. Although there is a clear role for pharmacotherapy, the successful management of pain requires an intensely engaged physician who can interpret this symptom along...
Anal Stenosis 1
The treatment of anal stenosis depends on its position in the anal canal and the severity of the stenosis. High anal strictures that are entirely covered by mucosa are more difficult to treat than low anal strictures at the level of the anoderm. Mild stenosis with minimal symptoms can usually be managed with dietary modifications and bulking agents, with the intention of naturally dilating the anal canal. Self-dilation using a Hegar's dilator may result in hematoma formation and further...
Wells Rectopexy
The Ivalon sponge procedure is similar to the Ripstein procedure, but the mesh is placed partially around the bowel instead of circumferentially. This technique was popularized because of concerns over sling obstruction with a circumferential mesh. The technique was described by Wells in 1959. Wells based his procedure on the use of a polyvinyl alcohol sponge Ivalon with its tendency to create a reactive fibrotic response. It is, however, unclear whether this reactive response is needed, as...
Natural History Ehx
Varices are common in patients with cirrhosis. At the time of diagnosis, approximately 40 of those with compensated cirrhosis and 60 of those with decompensated cirrhosis will have varices. Varices do not develop, however, until an HVPG of 10 to 12 mm Hg has been reached. Overall, varices will develop in 50 to 60 of cirrhotics. In those without varices at the time of diagnosis, the incidence of variceal development is 5 per year, with the severity of liver disease having the greatest influence...