Diverticular Disease Of The Colon
48 DIVERTICULAR DISEASE OF THE COLON
Gregory P. Victorino M.D., Jyoti Arya M.D., Lawrence W. Norton M.D.
1. What is a colonic diverticulum?
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A protrusion of mucosa and submucosa through the muscular layers of the bowel wall. It has no muscular covering. Because diverticula do not involve all layers of the bowel wall, they are really “false” diverticula. Diverticulum formation may be related either to weakness of the bowel wall at the sites of vessel perforation or to increased intraluminal pressure caused by low dietary fiber and constipation.
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Intestinal Ischemia. Controversies
CONTROVERSIES
30. What is celiac compression syndrome (Dunbar’s syndrome)?
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Celiac compression is a rare and controversial disorder most commonly described in women (female-to-male ratio = 4:1) between the ages of 20 and 50 years. Patients appear to suffer from chronic mesenteric ischemia without angiographic evidence of atherosclerotic disease. The mechanical compression is believed to be caused by the left crus of the diaphragm (i.e., marginal arcuate ligament), and diagnosis occasionally is confirmed by demonstrating transient celiac compression during expiration. The associated pain is the result of a complicated and still heavily debated redirection of flow (foregut steal) away from the SMA. Effective treatment has required not only release of the compression but also bypass to improve the likelihood of pain resolution.
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Intestinal Ischemia
47 INTESTINAL ISCHEMIA
Thomas F. Rehring M.D.
1. What is the arterial supply to the gut?
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The foregut (stomach and duodenum) receives its blood supply from the celiac artery, the midgut (jejunum to the proximal descending colon) from the superior mesenteric artery (SMA), and the hindgut (the remainder of the intraperitoneal gut) from the inferior mesenteric artery (IMA).
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Small Bowel Obstruction
46 SMALL BOWEL OBSTRUCTION
Joyce A. Majure M.D.
1. Name three mechanisms of bowel obstruction, and give examples and incidence of each type.
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1. Extrinsic compression: adhesions (60%), malignancy (20%), hernias (10%), volvulus, and others (5%)
2. Internal blockage of the lumen by abnormal materials (obturation): bezoars, gallstone, worms, or foreign body (usually obstructs at the ileocecal valve)
3. Mural disease encroaching on the lumen (inflammatory bowel disease [5%]), fibrous stricture secondary to trauma, ischemia, or radiation, intussusception)
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Acid Peptic Ulcer Disease. Gastric Ulcer Disease
GASTRIC ULCER DISEASE
41. What is the most important factor in managing gastric ulcers?
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All gastric ulcers must be evaluated for malignancy. The incidence of malignancy is about 10%.
42. How is gastric ulcer evaluated?
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Biopsy is mandatory. Esophagogastroduodenoscopy (EGD) with multiple biopsies (typically, six) of the ulcer crater is the best method. Upper GI series may be helpful, but biopsy is not possible. The CLO test can be performed at the time of the EGD to detect H. pylori. Benign ulcers usually heal by 12 weeks. Intractability should arouse suspicion for malignancy.
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Acid Peptic Ulcer Disease. Duodenal Ulcer Disease
45 ACID-PEPTIC ULCER DISEASE
Frank H. Chae M.D.
DUODENAL ULCER DISEASE
1. What is the risk of duodenal ulcer disease?
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The lifetime risk for duodenal ulcer is about 1 in 14. It usually occurs between ages 20 and 60 years, with peak incidence in the fourth decade of life. It is more common in males. Hemorrhage is the most common cause of hospital admission. The annual number of deaths in the United States is about 10,000 deaths caused by duodenal ulcers.
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Esophageal Cancer
44 ESOPHAGEAL CANCER
Casey M. Calkins M.D.
1. What are the risk factors for developing esophageal cancer?
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Both alcohol and tobacco increase the risk of carcinoma of the esophagus by a factor of 10. Additional risk factors include Barrett’s esophagus with dysplasia, carcinogen exposures (e.g., nitrosamines in the Eastern world), vitamin and trace element deficiencies, and Plummer-Vinson syndrome.
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Gastroesophageal Reflux Disease. Controversies
CONTROVERSIES
15. Is GERD better treated in the long term by PPI therapy or Nissen fundoplication?
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PPIs really work in resolving esophagitis and eliminating symptoms of GERD, but the long-term side effects are not fully known. Fundoplication potentially frees the patient from daily medicine (this has been challenged recently) and may cause morbidity in ≤ 10% of patients.
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Gastroesophageal Reflux Disease
43 GASTROESOPHAGEAL REFLUX DISEASE
Michael E. Fenoglio M.D., Lawrence W. Norton M.D.
1. What symptoms suggest gastroesophageal reflux disease (GERD)?
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Substernal burning after meals or at night, associated occasionally with regurgitation of gastric juices, is one symptom. Discomfort is relieved by standing or sitting. Dysphagia, a late complication of GERD, is caused by mucosal edema or stricture of the distal esophagus. However, no symptom is specific for GERD, and therapeutic decisions should not be made on symptoms alone.
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Portal Hypertension & Esophageal Varices. Controversy
CONTROVERSY
32. How should a patient with known esophageal varices be treated to prevent an initial variceal bleed?
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The combination of beta blocker and nitrate is used for primary prophylaxis, but endoscopic band ligation is at least equivalent to pharmacotherapy without the side effects (one third of patients cannot tolerate beta-blockers because of fatigue or bronchospasm, and 20% cannot tolerate nitrates secondary to pounding headaches). These treatments reduce the incidence of an initial bleed from 30% to < 10% and the mortality from 30% to 20%. Endoscopic band ligation was previously suggested for prophylaxis only in class C disease, but mounting evidence suggests that EBL is more effective than pharmacotherapy in all patients. The effect of combined EBL and beta blockade in primary prophylaxis remains to be established but makes great intuitive sense.
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Portal Hypertension & Esophageal Varices
42 PORTAL HYPERTENSION AND ESOPHAGEAL VARICES
Ramin Jamshidi B.S., B.S., Gregory V. Stiegmann M.D.
1. Describe the blood supply to the liver.
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Total hepatic blood flow is roughly 1500 mL/min, or 25% of cardiac output. The hepatic artery normally supplies about 30% of blood flow, and the portal vein contributes 70%. The hepatic artery and portal vein each supply 50% of the liver’s oxygen, however. With portal hypertension, portal flow decreases and the relative contribution of the hepatic artery necessarily increases.
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Diagnosis & Therapy of Chronic Pancreatitis
41 DIAGNOSIS AND THERAPY OF CHRONIC PANCREATITIS
Clay Cothren M.D., Jon M. Burch M.D.
1. What is chronic pancreatitis?
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The classic syndrome consists of smoldering abdominal pain and evidence of pancreatic insufficiency. Histologically, chronic inflammation results in destruction of the functioning endocrine and exocrine pancreatic cells.
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Acute Pancreatitis
40 ACUTE PANCREATITIS
Clay Cothren M.D., Jon M. Burch M.D.
1. What are the common causes of acute pancreatitis?
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Gallstones (45%), alcohol (35%), and other (20%).
2. What are the uncommon causes?
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Hyperlipidemia, hypercalcemia (hyperparathyroidism, multiple myeloma), iatrogenic factors (endoscopic retrograde cholangiopancreatography), drugs (didanosine, thiazide diuretics, H2 blockers, tetracycline, azathioprine), infections (mumps, coxsackievirus), pancreas divisum, and scorpion bites (favorite pimp question on rounds). Approximately 10% of cases are considered truly idiopathic.
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Pancreatic Cancer
39 PANCREATIC CANCER
Nathan W. Pearlman M.D.
1. What are the general features of pancreatic cancer?
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There are about 30,000 new cases per year in the United States, and more than 29,000 deaths, so it is a highly lethal disease. In most cases, histology is adenocarcinoma. About 80% arise in the head of the gland, and 20% arise in the body and tail. About 20% of patients have localized (potentially curable) disease at diagnosis; the remainder are inoperable either because of regional spread (portal vein, superior mesenteric artery) or widespread metastases (liver, peritoneum). Read more
Gallbladder Disease
38 GALLBLADDER DISEASE
Jeff Cross M.D.
1. What is the prevalence of gallstones in Western society for women and men 60 years of age?
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Women, 50%; men, 15%, although there is formidable ethnic predilection with gallstones endemic in Native Americans.
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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
