Treatment of Hemochromatosis

Therapy for HH is relatively simple and quite effective. Phlebotomy has been shown to effectively remove excess iron stores without significant side effects. If therapeutic phlebotomy is started before the development of cirrhosis, morbidity and mortality are significantly reduced. Some clinical features of iron overload respond better to phlebotomy than others. Malaise, fatigue, abdominal pain, skin pigmentation, and insulin requirements in diabetic patients tend to improve, whereas...

Medical Therapy Oral Bile Acid Dissolution Therapy

Dissolution of cholesterol gallstones with oral bile acid supplementation is appropriate in selected candidates. The two bile acids which have been studied are chenodeoxycholic acid and UDCA.However, UDCA (ACTIGAL) has very few side effects, and has become the preferred bile acid for this indication. UDCA works by decreasing biliary cholesterol secretion and thus inducing the secretion of undersatu-rated bile. This favors the dissolution of cholesterol stones. To be considered for this therapy,...

Micronutrients

The essential micronutrients are present in minute or trace amounts within the body, sometimes in quantities of less than 100 g. Although trace elements are present in very small amounts, they often have dramatic effects. Deficiencies TABLE 54-1. Estimated Calorie and Protein Needs Mild physiologic stress Moderate physiologic stress Severe physiologic stress 25 to 28 kcal kg d 28 to 32 cal kg d 32 to 35 cal kg d 0.8 to 1.0 g kg d 1.0 to 1.2 g kg d 1.5 to 2.0 g kg d TABLE 54-2. Mineral and...

Pancreatic Resection

Patients with a normal diameter or narrowed duct may be candidates for pancreatic resection. This is especially true when the pancreatic head is enlarged and contains multiple cysts and calcifications. Pancreaticoduodenectomy (Whipple resection) or pylorus-preserving pancreatico-duodenectomy are performed most commonly, and we prefer the latter. Pylorus preservation is felt by many to allow for better postoperative nutrition and weight gain, but little objective data support this. The operative...

Venous Thrombosis

The less common condition of mensenteric venous thrombosis occurs in the face of a predisposing factor, such as severe, especially acute, portal hypertension, polycythemia vera, severe dehydration, and other hypercoagulable states, including, occasionally, pregnancy. In recent years, subclinical coagulopathies due to deficiencies in protein A, protein C, and factor V Leiden have been identified in many of these patients. Frequently, there is a history of (even minor) abdominal trauma. The...

Irritable Pouch Syndrome

A small minority of IPAA patients will experience symptoms suggestive of pouchitis, but investigations reveal little inflammation and the absence of pouch outlet or other problems. These patients respond poorly to antibiotic therapy and are best considered as having irritable pouches (Schmidt et al, 1995). Empiric use of antidiarrheals or antispasmidics and fiber supplements is the most prudent approach. Editor's Note If the dose of metronidazole is less than 1g d, peripheral neuropathy is...

Nematodes Roundworms

Angiostrongyliasis costaricensis (Anisakiasis) Angiostrongyliasis costaricensis causes an eosinophilic ileo-colitis. Infection occurs following ingestion of larva in the intermediate host (slug, snails) or from food contaminated by larvae from slug or snail mucus. Clinically, it can present as fever, right lower quadrant pain, abdominal mass, leukocytosis, and eosinophilia. Complications such as perforation, bleeding, intestinal obstruction, or infarction can occur. There is no specific...

SOS Hepatic Veno Occlusive Disease

SOS results from occlusion of the sinusoids by necrotic cells (hepatocytes, red blood cells, sinusoidal epithelial cells, and lymphocytes). The initial toxic injury to the sinusoidal epithelial cells extends to involve the adjacent hepatocytes. These necrotic cells initially fill the spaces of Disse, but they then spill into the sinusoids and eventually block the sinusoidal outflow channel. Occasionally, sinusoidal obstruction may be complicated by thrombosis extending into the hepatic venules....

Pathogen Specific Therapy Bacterial Pathogens

Nontyphoidal species of Salmonella cause approximately 1.4 million cases of gastroenteritis and diarrhea annually. Contaminated meat, poultry, and eggs are common sources of infection, although bean sprouts, tomatoes, and orange juice have also been linked to outbreaks of salmonellosis. Other than diarrhea, clinical features may include abdominal pain, fever, and chills. Grossly bloody diarrhea is uncommon. Patients may carry Salmonella in their stools for weeks after symptoms resolve and 0.2...

Treatment of Alcoholism and Alcohol Dependence

The most important aspect of treatment of alcoholism is recognition of the problem and referral for treatment.The need to state medical concerns about the level of consumption and the presence of any signs of physical dependence on alcohol is a key component of the intervention. This step does not need to be carried out by a specialist in treatment of alcoholism, but can be done by any concerned health care provider. It is important that additional steps be taken to refer the individual for...

Selective Malabsorption

These procedures are designed to establish a more selective type of malabsorption and to incorporate gastric restriction as well. The first type was the gastric bypass (Figure 36-1C). This operation partitioned the stomach (by a row of staples) into a small upper pouch completely discontinous with the distal stomach. A loop of jejunum was then anastomosed to the proximal pouch. This procedure worked in two ways first, by its gastric restriction of oral intake and second, by setting up a dumping...

Condylomata Acuminata

The management of condylomata acuminata depends on the extent and location of the lesions. Treatment options include destructive therapy (podophyllin, trichloroacetic acid, bichloroacetic acid, electrocautery, and laser surgery), excisional therapy, and immunotherapy. We prefer bichloroacetic acid 89 to 90 , a caustic agent that, unlike podophyllin, can be used on the perineum and inside the anal canal, has no systemic toxicity, and does not cause the histological changes resembling carcinoma...

Parviz NikoomaneshMD and Salim A JafferMD

Acute pseudo-obstruction of the colon is the massive dilatation of the colon without evidence of mechanical obstruction. When acute pseudo-obstruction occurs without evidence of colonic disease, it is known as Ogilvie's syndrome, and occurs as a complication of an underlying clinical condition. if perforation, usually of the cecum, occurs, the mortality rate can be as high as 50 . Patients with acute colonic pseudo-obstruction are usually postoperative or critically ill. The numerous conditions...

Treatment

Therapies for the patients with diarrheal diseases can be divided into antimicrobial therapies, and therapies for the associated diarrhea, dehydration, and malnutrition. There is no known effective therapy for cryptosporidiosis. Many agents have been tried, and the results have been disappointing. Some patients improved during treatment with paromomycin (Humatin, Parke Davis, Ann Arbor, MI), whereas controlled trials showed only modest improvement and no cures. An uncontrolled trial of...

Ablation with Laser Therapy

Two types of lasers have been used to ablate Barrett's epithelium, Nd YAG (1064 nm depth ofinjury 3 to 4 mm), and KTP (532 nm depth of injury 1 mm) (Eisen, 2003). Table 15-1 summarizes selected studies evaluating the success of laser therapy to achieve complete ablation of Barrett's epithelium. Most trials report eradication rates of approximately 70 to 80 with laser therapy and complication rates of 0 to 17 (Luman et al, 1996 Weston and Sharma, 2002). Bonavina and colleagues (1999)...

Cerebral Edema

Approximately 80 of patients with FHF and advanced (stage IV) encephalopathy will develop cerebral edema and this is the most common cause of death. Young patients and those with rapid onset (hyperacute) FHF are at higher risk for developing cerebral edema. The pathogenesis of brain swelling remains incompletely defined. The adult skull is in essence a rigid box with an internal volume occupied by brain parenchyma (80 ), cerebrospinal fluid (CSF) (10 ), and blood (10 ). The ICP, normally less...

Two Way Sensitivity Analysis

Similarly, the physician may have only vague ideas concerning the actual costs of treating the patient with the PPI plus NSAID drug combination. In the middle panel of Figure 2-2, the drug costs of PPI plus NSAID were varied between 0 and 3,000. Again, a negative value on the y-axis indicates a cheaper COX-2 than the PPI plus NSAID strategy. As expected, any increase in PPI plus NSAID cost renders the COX-2 alternative increasingly more advantageous. Only with a PPI plus NSAID cost of less than...

Management of Mild to Moderately Severe C difficileAssociated Diarrhea

Mild Diarrhea

In patients with suspected C. difficile-induced diarrhea, the first priority is to discontinue the inciting antibiotic, if it is safe to do so. Up to 25 of all C. difficile infections will resolve spontaneously upon the discontinuation of antibiotics. However, patients with more severe symptoms should be treated with specific C. difficile-directed antibiotics. The two most commonly used agents are metronidazole and FIGURE 51-3. Colon specimen from a patient with severe, refractory Clostridium...

Combination Therapy Injection Therapy Thermocoagulation

Many centers combine injection therapy and thermocoagulation for the endoscopic control of bleeding peptic ulcers. Injection therapy is carried out first followed by thermocoagulation. Supportive evidence includes the study by Lin and colleagues (1999) in which 96 patients with active peptic ulcer bleeding or nonbleeding visible vessels were randomized to receive either epinephrine, BPEC, or combination therapy. Recurrent bleeding episodes were fewer and the volume of blood transfused was less...

Laser Thermocoagulation

Although laser thermocoagulation was one of the earliest modalities used to treat bleeding peptic ulcers, today it is seldom used due to its expense and technical complexity. A randomized study compared the efficacy of Nd YAG laser, HP, and MPEC in the treatment of active bleeding from peptic ulcers (Hui et al, 1991). Ninety-one patients were randomized to receive laser, HP, or MPEC. There was no significant difference between the groups in the rate of recurrent bleeding, the duration of...

Diarrhea

The treatment of diarrhea can be approached in a variety of ways. Although not supported in randomized clinical trials, the use of low doses of fiber can occasionally help to reduce TABLE 39-1. Medications for the Treatment of Pain in Irritable Bowel Syndrome TABLE 39-1. Medications for the Treatment of Pain in Irritable Bowel Syndrome 10 mg every 6 hours up to 40 mg every 6 hours, if tolerated 0.125 to 0.25 mg orally every 4 to 6 hours 0.125 to 0.25 mg sublingually every 4 to 6 hours 0.375 to...

Osmotic Laxatives

These agents include magnesium salts, sorbitol, lactulose, and polyethylene glycol (PEG) solutions. They may be used in patients who do not tolerate or respond poorly to fiber. The decision to use a particular laxative is often determined by individual preference, costs, and underlying medical conditions. Sorbitol and lactulose are poorly absorbed sugars that are hydrolyzed to acidic metabolites by coliform bacteria, which stimulate fluid accumulation in the colon and usually produce soft,...

Perianal Abscess

When a patient with IBD presents with perianal pain, perianal sepsis is the most common cause. In turn, the two most common causes of perianal abscess are cryptoglan-dular infection or an obstructed fistula tract. The treatment of perianal abscess includes prompt and adequate surgical drainage. The location of the abscess will determine the surgical approach. For superficial abscesses, simple incision and drainage is effective in the majority of cases. Abscesses which are deep to the sphincter...

The Current Operation of RP and IPAA Indications

It follows that RP IPAA is a suitable and preferred operation for patients where subtotal colectomy or TPC and Brooke ileostomy are not indicated. In general, these are patients who are in good condition mentally and physically have had no previous small bowel (SB) resections have good anal sphincter function are without evidence of CD, such as perianal fistula (past or present) may be diagnosed of indeterminate colitis have no history of radiation to the abdomen may undergo RP with curative...

Abdominal Pain

Abdominal pain raises a broad differential diagnosis because SCT patients, often treated with corticosteroids and having transient neutropenia, may not manifest the pain syndromes characteristic of specific GI diseases. Crampy, abdominal pain can be a prominent feature of those patients with severe gut GVHD, but usually diarrhea and or nausea and vomiting coexist. GVHD is discussed in more detail above. SCT patients are at risk for developing both calculous and acalculous cholecystitis. Seventy...

Investigated and Uninvestigated Dyspepsia

An important distinction should be drawn between patients with dyspeptic symptoms that have not been examined (uninvestigated dyspepsia) and those who have been. Investigated dyspeptics can be divided into two groups those with an identified cause for their symptoms and those whose symptoms have either no obvious cause or a related finding of uncertain clinical significance. Examples of the former category include peptic ulcer disease, gastro-esophageal reflux disease (GERD), or...

Sanjay JagannathMD and Marcia I Canto MD MHS

Barrett's esophagus, defined as the replacement of normal esophageal squamous epithelium with specialized columnar metaplasia characterized by goblet cells (Sampliner, 1998), is a condition that often arises in the setting of chronic gastroesophageal reflux disease. The presence of Barrett's epithelium is clinically important because it represents a premalignant condition that predisposes to the development of esophageal adenocarcinoma (AC). There is a separate chapter on endoscopic ultrasound...

Hemorrhoids Anal Fissures and Rectal Ulcers

The anorectum is a frequent source ofsignificant lower GI bleeding. It frequently manifests with small amounts of bright red blood noted on the toilet paper, coating the stool, or dripping into the toilet bowl. Many causes of anorectal bleeding, such as hemorrhoids and fissures, are recurrent. Constipation occasionally causes stercoral ulcers due to fecal impaction or the solitary rectal ulcer syndrome from mucosal trauma, rectal prolapse, or direct digital trauma to aid evacuation, which can...

Challa AjitMD and Santiago MunozMD

Hepatic encephalopathy is a neuropsychiatric syndrome consisting of altered neurological function associated with acute or chronic liver disease and portal systemic shunting. Exclusion of other disorders of the central nervous system (CNS) is important to establish the diagnosis. The development of hepatic encephalopathy in a cirrhotic patient indicates decompensation of a previously stable liver disease, or more frequently, it represents the effect of a transient precipitating factor. Hepatic...

Management of Internal and Mixed Hemorrhoids Nonsurgical Treatment

Most patients visiting a physician have already tried some form of conservative therapy and come for medical attention because of persistent symptoms. A variety of office-based therapies are available, and common to these nonoperative procedures is the aim of abolishing the underlying patho- physiologic mechanism of advanced hemorrhoidal disease. By promoting tissue fibrosis in various ways, the vascular cushions become fixed to the underlying muscular tissue. Injection sclerotherapy has been...

Shwachman Diamond Syndrome

Shwachman-Diamond syndrome (SDS) is an autosomal recessive genetic disorder that is caused by mutations of the SBDS gene (Boocock et al, 2003). Although the exact function of the SBDS protein is currently unknown, the most common clinical manifestations are characterized by exocrine pancreatic dysfunction, bone marrow dysfunction, and skeletal abnormalities (Mack et al, 1996). Other organs may be involved including the liver, kidneys, heart, central nervous system, and teeth. The difficulty in...

Fertility and Disease Activity

Most studies support normal fertility rates in females with UC. However, Swedish physicians (Olsen et al, 2002) report a markedly reduced potential of reproductive capacity of women after restorative proctocolectomy. It has been noted that women with IBD have fewer children than unaffected individuals. This may reflect decreased libido, dyspareu-nia, abdominal pain, diarrhea, or a conscious decision not to procreate. Active CD does impair fertility (Khosla et al, 1984). Ileal inflammation can...

Isospora belli Isosporiasis

This organism's clinical presentation is similar to that of cryp-tosporidium. It is an opportunistic infection that causes chronic, watery diarrhea in AIDS patients (CD4 < 100 mm3). Unlike cryptosporidium, effective treatments for Isospora belli are available, including trimethoprim (160 mg) and sulfamethoxazole (800 mg) taken either as 2 double strength (DS) orally twice daily or, if immunocompromised, 1 DS 3 times daily for 10 days to 4 weeks, or sulfadiazine (4 g) and pyrimethamine (35 to...

Clinical Presentation

A cross-sectional analysis by Mann and colleagues (1997) demonstrated that the median age of symptom onset was 17 years with a range of 2 weeks to 59 years (11 males, 9 females). The frequency and severity of symptoms may vary remarkably depending upon the section and the extent of the GI tract involved. The most common symptoms included pain (80 ), vomiting (75 ), constipation (40 ), and diarrhea (20 ) (Stanghellini et al, 1987).When the esophagus is involved, decreased esophageal motility and...

Esophageal Symptoms

Gastroesophageal reflux, dysphagia, and odynophagia are common complaints in the SCT patient. Severe mucositis extending down into the esophagus is common in patients receiving methotrexate for GVHD prophylaxis, and is usually treated with narcotics and TPN until it resolves. If given before initiation of the preparative regimen, sulcralfate 1 g given as an elixir 4 times a day may decrease the incidence of mucositis (Castagna et al, 2001). Dysphagia and odynophagia may result from infectious...

Examination of the Gastroenterology Patient for Metabolic Bone Disease

The diseases discussed in this chapter are all associated with inappropriately low BMD resulting from a variety of distinct mechanisms. Given that the causes of bone loss are distinct, the examination of the patient with GI-related metabolic bone disease should be tailored to the particular situation. Figure 55-2 presents an algorithm that is useful in various scenarios. Diseases such as celiac disease commonly cause osteoporosis. Indeed, in studies of asymptomatic osteoporotic women, 10...

Esophageal Cancer

Accurate measurement of the depth of tumor and the extent of metastasis are critical factors that determine the therapeutic options and prognosis of patients with carcinoma of the esophagus, and may reduce the cost of care. EUS is currently the most accurate modality available to determine the depth of tumor and the status of regional lymph node involvement. Based on a review of 739 reported cases, EUS is accurate for evaluation of tumor depth in 85 of cases, and of nodal stage in 79 (Rosch and...

Fap

The striking number of adenomatous polyps that often carpet the colon and the 100 lifetime risk of CRC characterize FAP. The average age of colorectal polyp formation is 16 years and of CRC is 39 years (Burt and Jacoby, 2003). The adenomatous polyposis coli (APC) gene is mutated in FAP, and patients inherit the disease in an autosomal dominant fashion, though about one-third of patients have no known family history and presumably are new mutation carriers. The frequency of FAP in the general...

Abnormal Liver Function Tests

Abnormal liver function tests (LFTs) have been reported to occur in > 40 and 80 of patients in the first year after autologus or allogeneic SCT, respectively. Many individuals have abnormal LFTs prior to transplantation, as a result of previous chemotherapy. In addition, iron overload is commonly found among SCT patients as a result of increased red cell turnover and multiple blood transfusions. Chronic viral hepatitis B or C may also be identified prior to transplantation. Although the...

Evaluation of Ascites

The presence of ascites can usually be determined with a high degree of accuracy by history and physical examination. The most common symptom of ascites is an increase in abdominal girth accompanied by weight gain, frequently with lower extremity edema. Patients should be questioned about the risk factors for, symptoms associated with, and family history of liver disease. A full bulging abdomen should prompt percussion of the flanks. If the degree of flank dullness is more than usual, then one...

Daniel H Present MD

Since the classic paper published by Crohn and colleagues in 1932 describing the chronic inflammatory process of the bowel there have been multiple articles published on the complications of this illness. The description of perianal fistula was followed 6 years later with the incorrect concept that the inflammatory process extended from the bowel down to the perianal area. There are multiple problems that can affect the perianal area, including simple skin tags, fissures, hemorrhoids, high and...

Duodenal Switch with BPD

This form of selective malabsorptive operation involves a modified gastric restriction by tubularizing the lesser curvature of the stomach via a greater curvature gastrectomy (Figure 36-3), and a diversion of biliopancreatic secretions to the distal ileum. The latter is accomplished by transecting the duodenum proximal to the ampulla of Vater (Figure 36-3, site A B), oversewing the distal end of the duodenum (site B), transecting the proximal ileum 250 cm proximal to the ileocecal valve (site C...

Portal andor Splenic Vein Thrombosis

The presence of thrombus in the portal vein causes obstruction of the venous drainage of much of the GI system. Risk factors include cirrhosis, abdominal sepsis, pan- TABLE 118-4. Causes of Portal Vein Thrombosis Tumor invasion of portal vein Hepatocellular carcinoma Cholangiocarcinoma Abdominal sepsis Oral contraceptive pill Pancreatitis Prothromotic disorders Trauma creatitis, hepatic malignancies, trauma surgery, decreased portal venous flow, and hypercoagulable states, although idiopathic...

Perineal Rectosigmoidectomy

Perineal rectosigmoidectomy was first described by Mikulicz in 1889. Renewed interest in this procedure, particularly in the United States, can be attributed to W.A. Altemeier, whose 1971 report claimed only 3 recurrences in a series of 106 patients. A few series have recurrence rates comparable to those seen after abdominal repairs, but several reports have considerably higher recurrence rates. The variability in results reported by different centers stands in contrast to the marked uniformity...

Safe Foods

Plain meat, fish, beans, legumes, eggs, and nuts are allowed in the gluten-free diet. Other safe foods include plain veg etables, fruits, and plain peanut butter. Although dairy products and cheeses are allowed, patients should be aware that the coat of certain cheeses may contain gluten. Also acquired live lactase levels are common in active celiac disease leading to lactose intolerance. Rice can be ingested in all its varieties including white rice, brown rice, rice bran, rice polish, sweet...

Bariatric Surgery

An alternative approach to weight reduction is obesity surgery. Bariatric surgery can be offered to carefully selected patients if it is to be performed at centers with significant experience that offer a multidisciplinary approach to patient selection and postoperative management. There is a separate chapter on surgery for obesity (see Chapter 35, Obesity). Results of bariatric surgery suggest improvement in NASH is associated with the intended weight loss. Significant variability in the...

Lactose Intolerance

Globally, lactose intolerance is the most common adverse reaction to a specific food, with most cases the result of declining levels of intestinal lactase activity in later childhood and adult life, although rare congenital deficiencies can occur. Symptoms of lactase insufficiency are usually dose related and include bloating, flatulence, and diarrhea. Secondary lactase deficiency can result from viral gastroenteritis, radiation enteritis, Crohn's disease (CD), and celiac sprue. It is important...

Intestinal Compression or Obstruction

A minority of patients will present with obstruction of the second or third portion of the duodenum. Upper endoscopy and CT scan should be performed to rule out the presence of a neoplastic process. Then a loop gastrojejunostomy can be done to bypass the obstruction. Obstruction of the colon (usually the transverse or splenic flexure) can also occur from chronic pancreatitis. If this is due to an episode of acute inflammation, the obstruction will likely resolve. If it persists, then a...

General Contraindications to Liver Transplantations

Some patients referred for liver transplantation can benefit more from a different therapy. There is also risk involved with pursuing another therapy that turns out to be ineffective and thus delays the referral for liver transplantation. In many cases, it makes sense to place the patient on the active transplant waiting list while closely observing the effects of other therapeutic interventions. Special consideration should be given to the young infant who presents with liver failure. Some of...

Summary and Conclusions

HH is a common disorder that is increasingly being recognized in clinical practice. The quality of diagnosis has been improved with the use of genetic testing that has come about since the gene for hemochromatosis was discovered in 1996. Over the last few years, we have learned that approximately 50 of patients who are C282Y homozygotes may not have evidence of phenotypic expression. Also, many other patients will have mild degrees of iron overload. Because iron overload is so easy to treat, it...

Monitoring

During antibiotic treatment, remission of symptoms and of abnormal diagnostic findings should be followed and documented at regular intervals. The initial response of patients is usually prompt. Diarrhea often resolves within several days, arthralgias within a few weeks, and significant weight gain occurs within a few months. When this clinical improvement is occuring, noninvasive laboratory examinations may be sufficient during the first 6 months. A potential pitfall of monitoring patients is...

H pylori and PGL

It was recognized in 1988 that the cause of acquired gastric MALT is a chronic infection associated with the anti-genic H. pylori. The first epidemiological studies, in the early 1990s, demonstrated that seropositivity to H. pylori was associated with a six-fold increased risk of subsequent gastric lymphoma an increasing body of evidence has accumulated to strongly support this association (Parsonnet et al, 1994). Other studies validated the dependence of the incidence of MALT lymphoma on the...

Acute Pouchitis

IBD of the pouch (pouchitis) is a syndrome defined by clinical, endoscopic and histologic criteria that occurs in UC-IPAA patients (Mahadevan and Sandborn, 2003), and seldom, if ever, affects familial adenomatous polyposis-IPAA patients. Patients complain of fecal frequency, and the motions are commonly loose and watery and may contain mucous and blood. Urgency and leakage, especially at night, are common. In addition, depending on the severity of pouch inflammation, the presence of associated...

Pouchitis

This term covers a spectrum of symptomatic inflammatory conditions of the ileal pouch mucosa. We understand this to be a syndrome combining histopathologic evidence of ileal pouch mucosal inflammation with clinical features characterized by one or more of the following 1. Significant increase in stool frequency above the patient's usual base level Most cases respond to metronidazole with or without ciprofloxacin given over a 5 to 10 day period. A chronic variety of pouchitis is much less...

Goals of Treatment

The goal of treating patients with functional abdominal pain is restoration of normal function. Treatment may not provide total freedom from pain symptoms, and must be TABLE 40-7. Tests to be Done On All Patients with Chronic Recurrent Abdominal Pain TABLE 40-8. Selective Tests to be Done if Indicated and or Parents Will Not Accept Functional Diagnosis 1. Ultrasonography of upper and lower abdomen 2. Upper gastrointestinal and small bowel series 6. C13 urea breath test for Helicobacter pylori...

Systemic Mastocytosis

In the 23 to 43 of patients with systemic mastocytosis, the diarrhea is mild to moderate in the majority, with > 90 having a stool volume < 1 L d. In systemic mastocytosis, the primary cause of the most troubling diarrhea is gastric hypersecretion owing to hyperhistaminemia therefore, it has a pathogenesis similar to that seen in patients with Zollinger-Ellison syndrome. However, villous atrophy and a secretory component, perhaps owing to prostaglandins,may be important diarrheal factors in...

Stomach and Duodenum EGC

The EMR is now an established treatment for patients with small EGC. The outcome of 479 ECGs treated by EMR has been reported. Among patients with intramucosal cancers, 5.7 had recurrence. In the group of 127 patients with incomplete resection, 24 had surgery and 9 had further endo-scopic therapy. Among patients with unfavorable prognosis, 18 had a local recurrence, after a median follow-up of 4 months. The perforation rate was 5 . Tanabe and colleagues (2002) performed EMR in 106 patients with...

Psychiatric Treatment of Eating Disorders Outpatient Treatment

The mainstay of outpatient treatment for adults with AN and BN is psychotherapy, the goal of which is the interruption of problem behaviors and normalization of eating behavior. To recover, the patient must undergo a conversion from seeing dieting behavior as a solution to viewing it as the primary problem. Only after behavioral change is accomplished should treatment move on to address predisposing factors, such as family conflict, personality vulnerabilities, and a chaotic personal life....

Lifestyle Changes

Establishing and maintaining abstinence from alcohol is vital in order to prevent further ongoing liver injury, fibrosis, and, possibly, hepatocellular carcinoma. Abstinence allows total resolution of alcoholic steatosis. There are limited studies evaluating the effects of abstinence from alcohol on the progression of ALD, but virtually all of them show beneficial effects on survival. Moreover, data from recent Veterans Health Administration (VA) cooperative studies suggest that reducing, but...

TABLE 52 Endoscopic Ultrasonography TStage Accuracy for Pancreatic Cancer

Author Number of Patients Staged by EUS Number of Surgical Patients Staging Accuracy Accuracy ( ) (95 CI, 70 to 83) TABLE 5-3. Endoscopic Ultrasonography N-Stage Accuracy for Pancreatic Cancer Author Number of Patients Staged by EUS Number of Surgical Patients Staging Accuracy Accuracy ( ) (95 CI, 51 to 71) superior to CT in its overall utility in pancreatic cancer. A recent review of studies comparing EUS to helical CT by Hunt and Faigel (2002) is summarized in Table 5-4. This review shows...

Treatment of Diverticular Disease Bleeding

Management of acute lower GI bleeding from diverticular disease should start with resuscitation of the patient followed by identification of the bleeding site. Most patients either stop bleeding spontaneously, or respond to medical or less invasive measures. However, almost a quarter of these patients will require surgical intervention for treatment of their disease. FIGURE 103-1. Contrast enema demonstration filling of the bladder due to a colovesiclefistula. FIGURE 103-1. Contrast enema...

Joseph R BloomerMD

The porphyrias are metabolic disorders which are characterized biochemically by the increased production, accumulation and excretion of porphyrins and or porphyrin precursors, compounds which are intermediates of the heme biosynthetic pathway. The liver and bone marrow are the major sites of expression of the biochemical abnormality. The clinical manifestations are varied and include complications for which the gastroenterologist or hepa-tologist may be consulted for evaluation and management....

Surreptitious Use of Laxatives or Diuretics

Patients with a factitious cause frequently have large-volume diarrhea (> 1 L d). It should be remembered that this condition is not infrequent, occurring in 15 to 20 of patients referred to a referral center with chronic diarrhea. The primary treatment of these patients is having a high suspicion for the diagnosis because no clinical feature except for a history of psychiatric illness or macroscopic melanosis coli on sigmoidoscopy assists in the diagnosis. Some patients have a medical or...

Prokinetic Therapy Dopamine Antagonists

Ges Disease

Metoclopramide (Reglan) is the most commonly used prokinetic drug and the agent that we employ as first line therapy. It is a central and peripheral dopamine receptor (D2) antagonist and a powerful antiemetic at the chemorecep-tor trigger zone level while also being effective in improving gastric emptying by increasing antral contractions and decreasing receptive relaxation of the proximal stomach. However, as many as 40 of patients cannot tolerate metoclopramide because of central nervous...

Pathophysiology Of Cholithiaisis

ERCP plays a key role in the management of acute cholan-gitis. The most common cause of cholangitis is choledo-cholithiaisis, and it occurs in approximately 80 of cases of cholangitis. Other causes of acute cholangitis include congenital abnormalities of the biliary tree (choledochal cyst), and malignant obstruction of the biliary tree from ampullary tumors, cholangiocarcinoma, and pancreatic tumors. The management of malignant biliary obstruction and congenital abnormalities will be discussed...

Conclusions

The success of p-cell replacement therapy through transplantation of the endocrine pancreas as either whole organ or isolated islets has been steadily increasing over the past decade. The shortage of organs and the need for chronic recipient immunosuppression remain major hurdles, limiting the applicability of allogeneic p-cells transplantation to a wider number of patients with insulin-dependent diabetes. As we better appreciate the complex phenomena involved in the immunobiology of...

Acetaminophen

For acetaminophen overdose, the treatment includes N-acetylcysteine. The mechanism for acetaminophen hepatotoxicity is related to its toxic metabolite, N-acetyl-p-benzoquinoneimine (NAPQI). Acetaminophen is primarily metabolized by sulfation and glucuronidation to derivatives that are excreted in urine. However, a small amount of acetaminophen is metabolized by cytochrome P-4502E1 (CYP2E1) to NAPQI. NAPQI is preferentially conjugated with glutathione and excreted as a nontoxic mercapturic acid....

Rudra RaiMD

Hepatitis C virus (HCV) is a single stranded RNA virus of the Hepacivirus genus in the Flaviviridae family. Discovered in 1990 as a causative agent for posttransfusion non-A, non-B hepatitis, it is now known to infect 1.8 of the US population (between 4 to 5 million seropositive individuals). Recent studies performed on serum samples from 21,241 persons 6 years of age or older who participated in the third National Health and Nutrition Examination Survey, conducted during 1988 through to 1994,...

Second Threshold Analysis Nonulcer Dyspepsia [NUD

The next example serves to further illustrate the powers of threshold analysis and deepen the understanding of its versatility. The clinical scenario represents only a slight deviation from the previous examples of above. Consider the case of a 60-year-old man who presents with symptoms of dyspepsia, nausea, and epigastric pain. An upper gastrointestinal endoscopy has not been performed, but a serologic test for H. pylori has returned positive. The patient has had similar symptoms for the past...

TABLE 32 Monitoring and Rescusitation Equipment Required for Moderate Sedation

Procedure Room Immediately Accessible Oxygen source Emergency drug box abuse. The time and nature of last oral intake is important and avoidance of fluids or solid foods for a sufficient period to allow for complete gastric emptying before the procedure (as recommended by the American Society of Anesthesiologists ASA Guidelines for Preoperative Fasting) is essential and has potential medico-legal implications. In urgent, emergent situations, or situations in which gastric emptying is impaired,...

Colonic Complications of NSAIDs

Some of the side effects of NSAIDs on the large bowel are rare, such as erosions, solitary or multiple ulcers, inflammation (which may resemble classic inflammatory bowel disease IBD ), aggravation of diverticulitis, or even appendicitis in the elderly (Bjarnason et al, 1987). Treatment is the same as for the underlying disease, with discontinuation of the particular NSAID and with COX-2 selective agents being the preferred antiinflammatory analgesic. One common and clinically relevant side...

Types of Esophageal Motor Dysfunction

The terminology used in describing esophageal motility disorders is not fully standardized. At Washington University we classify dysmotility using a simple scheme representing the two principal types of motor dysfunction (Figure 18-1). The first leads to impaired contraction in the esophageal body and or lower esophageal sphincter (LES). Resultant hypomotility predisposes the patient to gastroesophageal reflux disease (GERD), either by increasing reflux events or delaying clearance of...

We are having the baby Prince Leopold and we shall have the chloroform Queen Victoria 1853

Adequate sedation for endoscopy is a critical process for successful procedural outcome. The last decade has seen a move to sedation-less endoscopy by the use of ultrathin endoscopes, but this has not gained widespread popularity in the United States mainly because of patient acceptance (Faulx et al, 2002). This chapter will describe the approach to intravenous (IV) sedation in patients having both routine and complex therapeutic procedures in the endoscopy setting. A review of the levels of...

Barretts Esophagus

Patients with Barrett's esophagus (BE) are advised to undergo endoscopic surveillance with multiple biopsies to detect HGD and or early adenocarcinoma (AC). Several endoscopic methods have been used to remove HGD, including photodynamic therapy (PDT) and Argon Plasma Coagulator (APC), but the disadvantage is the lack of final histological assessment. Moreover, PDT with photofrin caused severe esophageal stenoses in 34 of patients. EMR could become a therapeutic alternative to esophagectomy in...

Esophageal Endoprostheses

Cook Medical Esophageal Stent

The insertion of esophageal endoprostheses or stents is a common approach to the palliative management of dysphagia (Baron, 2001 Siersema et al, 2003). Stent placement should only be undertaken after very careful scrutiny of the clinical situation (eg, tumor stage, length, position, and expected prognosis of the patient). Because of the potential complications associated with stent placement (eg, stent migration, perforation, and stent tumor ingrowth or overgrowth), consideration of these...

Pancreatic Islet Cell Transplantation

Transplantation of isolated pancreatic islets offers the advantage of a minimally invasive procedure associated with very low incidence of adverse effects (Hering and Ricordi, 1999). Following islet infusion a dramatic reduction of insulin requirement is generally observed, and insulin independence can be achieved when an optimal islet mass has been implanted (Shapiro et al, 2000 and 2003 Goss et al, 2002 Markmann et al, 2003). Transplantation of islets of Langerhans consists in the...

Enterocytozoan bienusi and Encephalitozoon intestinales Microsporidiosis

This organism's clinical presentation is similar to that of cryptosporidium and isospora. In immunocompetent patients, the diarrheal illness is usually self-limited. In immunocompromised persons, particularly AIDS patients with CD4 < 100 mm3, it is a common cause of chronic diarrhea and can be remitting over months. Treatment depends on the species identified. For Encephalitozoon intestinales, the preferred regimen is albendazole 400 mg orally 2 times daily for at least 3 weeks alternatively,...

Supplemental Reading

Two words to improve physician-patient communication what else Mayo Clin Proc 2003 78 211-4. Brant SR, Panhuysen CIM, Bailey-Wilson JE, et al. Linkage heterogeneity for the IBD1 locus in Crohn's disease. Pedigrees by disease onset and severity. Gastroenterology 2000 119 1483-90. Cuffari C, Dassopoulos T, Turnbough L, Bayless TM. Thiropurine methyl-transferse activity influences clinical responses to aza-thioprine therapy in inflammatory bowel disease. Clin...

Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy (IHCP) is heralded by the development of pruritus, liver enzyme abnormalities, and occasionally jaundice. Most cases occur within the third trimester of pregnancy (Table 120-2). The worldwide incidence varies ICHP occurs in less than 1 to 2 of all pregnancies in the United States, Asia, Australia, and Europe, but in Bolivia, Chile, and Scandinavia, the incidence is as high as 14 , with rates of 24 in the Araucanian Indians of Chile. There is a greater...

Ear Nose and Throat Disease

GERD may be associated with a number of ENT syndromes, including recurrent hoarseness, throat clearing, sore throat, and globus, and signs, such as laryngitis, vocal cord granulomas, ulcers, leukoplakia, sinusitis, and even laryngeal cancer. These patients are usually diagnosed by our ENT colleagues based upon symptoms and signs of inflammation involving the posterior third of the vocal cords and interarytenoid areas, which are both in close proximity to the upper esophageal sphincter. However,...

Clinical Staging

Grading of malignancy and staging of disease are the decisive factors that influence the therapeutic modalities in PGL. Staging of gastric lymphomas should include computed tomography (CT) scans of the chest abdomen and pelvis, which demonstrate the extent of the lesion and rule out metastatic disease from a nongastric primary site. Localized GI lymphoma frequently displaces, rather than invades, associated vascular structures. The limitations of CT are the difficulties in differentiating...

Acid Suppression

Antisecretory medications are the most widely used agents in the treatment of nonulcer dyspepsia. A number of studies have evaluated the efficacy of H2 receptor antagonists (H2RAs) and several meta-analyses have analyzed these trials. Many of the studies with H2RAs have methodological flaws in either study design or enrollment criteria. Epigastric pain and postprandial fullness are the symptoms that are the most relieved (Redstone et al, 2001 Moayyedi et al, 2003). H2RAs provide a modest...

Eosinophilic Colitis

Infiltration of the GI tract with eosinophils may involve the entire GI tract but usually entails the stomach and small intestine. Isolated colonic involvement (eosinophilic colitis) is limited to sporadic case reports. Eosinophilic colitis can occur as a component of the inflammatory response in Crohn's disease, ulcerative colitis, parasitic diseases, milk protein-induced colitis, and eosinophilic gastroenteritis. Eosinophilic GI disease is estimated to have an incidence of 1 100,000, whereas...

Symptomatic Therapy

In patients with symptomatic collagenous lymphocytic colitis, several factors should be considered. Because small bowel secretion has been noted in some patients, dietary secretagogues such as caffeine- or lactose-containing foods should be eliminated from the diet. Because of a possible association between collagenous colitis and nonsteroidal anti-inflammatory drugs, these agents should be discontinued. If steatorrhea is documented, a low-fat diet maybe helpful. In the presence of bile salt...

Oral and Esophageal Disease

Candidiasis decreases taste sensation and affects swallowing, in addition to causing oral or substernal discomfort. Most cases are due to Candida albicans. Candidiasis in the esophagus and may occur in the presence or absence of thrush. Hairy leukoplakia, a hyperkeratotic lesion found along the sides of the tongue and adjacent gingiva, may be mistaken for Candida, but is asymptomatic. Severe gingivitis or peri-odontitis, infectious or idiopathic ulcers, or mass lesions, such as Kaposi's sarcoma...

Asthma

Studies have suggested that pulmonary disease, especially asthma, may be associated with GERD, based on symptoms or pH testing, in up to 70 of these patients. In reality, studies by Irwin and colleagues (1993) suggest that those patients with difficult to manage asthma (ie, multiple visits to emergency room or hospitalization for asthma exacerbations) are the most likely to have acid reflux as a major cause of their asthma. Other asthmatic groups to consider are nonallergic asthmatics with...

Use of Computed Tomography Colonography As Screening

Consider the following scenario Executive physicals with widespread application of computed tomography (CT) scanning to detect a variety of disease states has been gaining popularity. You have been asked by your hospital administration whether or not they should initiate a CT colonography program to screen patients for colorectal cancer. A search of the literature databases reveals several articles about the use of CT colonography, or virtual colonoscopy, for the identification of adenomatous...

Outcome and Followup

The tendency for GC to present at advanced stages has led to an overall 5-year survival of 24 , whereas in those patients who undergo a curative resection, overall survival improves to 50 , according to our prospectively maintained GC data base. Figures 34-2 and 34-3 show the overall survival rates of resected patients stratified by T-stage and N-stage, respectively. Close follow-up is important in patients with GC, although no standard guidelines exist. Weight maintenance is essential and the...

Sleeping Position

With regard to sleeping position per se, it appears that the left lateral position does actually reduce acid reflux in the esophagus compared to the right lateral position, and it would be sensible to recommend that patients with significant heartburn complaints sleep in the left lateral position. There is a further physiologic basis for this in that the right lateral position does appear to induce a higher frequency of transient LES relaxations. In summary, regarding sleeping for better...

Difficulties for the Gastroenterologist in Engaging and Maintaining Patients in Treatment

Because patients with AN and BN are strongly ambivalent about giving up dieting behavior, gastroenterologists may find themselves unwitting accomplices of patients looking to feel better rather than to get better. Complaints about bloating, early satiety, constipation, nausea, reflux, and abdominal pain may prompt expensive, often invasive diagnostic or therapeutic procedures, the vast majority of which are unnecessary distractions from the task of behavioral change and recovery, which usually...

Dan LaheruMD

The challenges in managing patients with pancreatic cancer (PC) are underscored by the seemingly immutable survival data, including a 5-year survival of 15 to 20 with a median survival of 15 to 19 months for resectable disease and 3 survival for all stages combined. For patients with locally advanced unresectable disease, median survival is 6 to 10 months, and for patients with metastatic disease it is 3 to 6 months. This chapter will describe the current treatment recommendations as well as...

Diagnosis

C. difficile infection should be suspected in any patient presenting with diarrhea within 1 to 3 months of receiving an antibiotic, especially if this was administered in a hospital or nursing home. The diagnosis of C. difficile infection is confirmed by the finding of C. difficile toxins in the stool. Several stool tests are available for the diagnosis of C. difficile infection (Kyne et al, 2001). The gold standard is the tissue culture cytotoxicity assay for toxin B, with both a high...

Management of Complications of Sb Cd Fistulas and Abscesses

The major complications of perforating disease are fistulas and abscesses. Fistulas complicating SB CD are most commonly internal fistulas, or communications between two segments of bowel or between a segment of bowel and another organ. These fistulas in SB CD usually arise from terminal ileum. The most common enteroenteric fistulas are ileosigmoid fistulas, but ileoileal can occur. When enteroenteric fistulas are proximal or bypass a long segment of the SB, the fistula output will be greater...

Residual Inflammatory Bowel Disease Cuffitis

Modern pouch surgery leaves behind only a small cuff of rectal mucosa, of 1 or 2 cm at the most, when a doublestapled anastomosis is formed. No rectal mucosa should remain when the anastomosis is hand sewn in conjunction with a distal rectal mucosectomy. However, in some cases, for example in obese patients when it is difficult to bring the small bowel deep into the pelvis, the surgeon may need to leave behind a more substantial cuff of rectal mucosa to which the pouch is anastomosed. The term...

Bleeding Peptic Ulcers

Early studies lacking control groups demonstrated the safety and efficacy of hemoclips for the treatment of high risk bleeding peptic ulcers (Binmoeller et al, 1993). Randomized studies are available comparing HC to the other hemosta-tic modalities for bleeding peptic ulcers (Cipolletta et al, 2001) randomized 113 patients to either HP (10 F) or HC (Olympus MH-858 long clips) in the treatment of severe ulcer bleeding. HC was safe and effective and was reported superior to HP for the prevention...

Specific Preoperative Cardiovascular Conditions Hypertension

Despite earlier concerns, it is now abundantly clear that stable and reasonably well-controlled hypertension, and the drugs used to maintain this control, should not present an important risk for patients undergoing surgery. Antihypertensive medications should not be discontinued, tapered, or omitted prior to surgery because of concern over interaction with anesthetic agents. Stage 3 hypertension (systolic blood pressure > to 180 mm Hg and diastolic blood pressure > 100 mm Hg) should be...

Classification

Hughes developed the first pathologic classification of fistula in ano based on morphology. This classification was based on structural abnormalities such as (1) ulceration, (2) fistula abscess, and (3) stricture. More recently, several classification systems have been proposed. The most well known is, of course, Parks classic description of 1976. Park and colleagues developed the most anatomic and clinically relevant classification. Their use of the anatomy of the sphincter muscles as a...

Incomplete Evacuation And Soiling

Pruritus ani is a difficult condition to treat. A careful history and physical examination should be performed to exclude secondary causes, such as diseases of the anorec- tum, systemic diseases, diarrheal states, and dermatologic conditions, in which case appropriate therapy is instituted. The majority of cases, however, are idiopathic and there is no panacea treatment for this condition. First, it is important to reassure these patients that they do not have a cancer avoidance of scratching...

Summary

The combined use of serum biochemical markers and liver biopsies with various imaging tests has become the standard for evaluating liver disease. All of these, in combination with careful history and patient examination, allow the clinician to derive a diagnosis in most cases. The ongoing development of noninvasive markers of inflammation, steatosis, and fibrosis will continue to change the landscape of how liver disease is evaluated and managed. New imaging modalities, such a magnetic...

GI Manifestations in Other Primary Immunodeficiency Diseases

Other immunodeficiencies have been associated with GI disorders. Patients with XLA have intestinal biopsies that have a notable absence of lamina propria plasma cells. Giardiasis has been reported as a cause of chronic diarrhea, but GI complaints are rare in XLA patients. Patients with SCID often have intractable diarrhea resistant to medical treatment, leading to failure to thrive. Children with SCID also present with oral candidiasis and viral infections, including rotavirus and adenovirus....