In the adult, the length of the small bowel varies from 300 to 600 cm and correlates directly with body surface area. Several factors determine the severity of short-bowel syndrome, including the extent of resection, the portion of the GI tract removed, the type of disease necessitating the resection, the […]
A. General Upper and lower gastrointestinal bleeding are discussed in Chapters 9 and 12, respectively. Small-bowel lesions are the most common cause of “obscure gastrointestinal bleeding,” defined as hemorrhage that persists or recurs after negative initial upper and lower endoscopies. B. Diagnosis Enteroscopy Push enteroscopy employs a 400-cm enteroscope to […]
Meckel Diverticulum Meckel Diverticulum is the most common congenital anomaly of the gastrointestinal tract. It occurs from failure of the vitelline or omphalomesenteric duct to obliterate by the sixth week of fetal development. It is a true diverticulum that contains all layers of the bowel wall and is located on […]
Adhesions are the most common cause of small-bowel obstruction in U.S. adults. Most adhesions result from previous abdominal operations or inflammatory processes, although isolated congenital adhesions can occur as well.
Incarcerated hernias are the second-most-common cause of small-bowel obstructions in industrialized nations. They are the most common cause of SBO worldwide. In industrialized nations, they are the most common cause of SBO in children and in patients without prior abdominal surgery.
Intussusception occurs when one portion of bowel (the intussusceptum) telescopes into another (the intussuscipiens). Tumors, polyps, enlarged mesenteric lymph nodes, or even a Meckel diverticulum may serve as lead points of the telescoped segment. Unlike in children, intussusception in an adult should always prompt a workup for bowel pathology.
Volvulus is often caused by adhesions or congenital anomalies such as intestinal malrotation. It more commonly occurs in the colon.
Strictures secondary to ischemia, inflammation (Crohn disease), radiation therapy, or prior surgery may cause obstruction.
Gallstone ileus occurs as a complication of cholecystitis. Fistulization between the biliary tree and the small bowel allows gallstones to travel distally and become lodged, typically at the ileocecal valve.
External compression from tumors, abscesses, hematomas, or other masses can cause functional SBO.
Foreign bodies typically pass without incident. Items presenting with obstruction may require operation if they cannot be retrieved endoscopically. Pathology due to swallowing foreign bodies is more common in institutionalized patients.
Embryology A. Origin The small intestine forms during the fourth week of fetal development. The duodenum arises from the foregut, and the jejunum and ileum derive from the fetal midgut. The endoderm forms the absorptive epithelium and the secretory glands. The splanchnic mesoderm gives rise to the rest of the […]
Postgastrectomy Syndromes are caused by changes in gastric emptying as a consequence of gastric operations. They may occur in up to 20% of patients who undergo gastric surgery, depending on the extent of resection, disruption of the vagus nerves, status of the pylorus, type of reconstruction, and presence of mechanical or functional obstruction. Clearly defining the syndrome that is present in a given patient is critical to developing a rational treatment plan (World J Surg 2003;27:725). Most are treated nonoperatively and resolve with time.
Gastric Carcinoids are rare neuroendocrine tumors accounting for less than 1% of all gastric neoplasms. Carcinoid tumors arise from enterochromaffin-like cells and can be secondary to hypergastrinemia associated with pernicious anemia or chronic atrophic gastritis. Tumors tend to be small, multiple, and asymptomatic, although larger solitary tumors may cause ulceration […]
Gastrointestinal Stromal Tumors (GISTS) comprise only 3% of all gastric malignancies and arise from mesenchymal components of the gastric wall. The median age at diagnosis is 60 years, with a slight male predominance. GISTs frequently display prominent extraluminal growth and can attain large sizes before becoming symptomatic. Presentation can be […]
Benign Gastric Tumors account for fewer than 2% of all gastric tumors. They are usually located in the antrum or corpus. Presentation can be similar to that of peptic ulcer or adenocarcinoma, and diagnosis is made by EGD or contrast radiography. A. Gastric polyps Gastric polyps are classified by histologic […]
Primary Gastric Lymphoma (PGL) accounts for fewer than 5% of gastric neoplasms. However, PGL comprises two thirds of all primary GI lymphomas because the stomach is the most commonly involved organ in extranodal lymphoma. PGLs are usually B-cell, non-Hodgkin lymphomas. Most PGLs occur in the distal stomach. Patients typically present […]
The etiology of gastric cancer is complex and multifactorial, involving a combination of genetic, environmental, and infectious risk factors. Risk factors for gastric cancer include male gender, family history, polyposis syndromes, diets high in nitrates, salts, or pickled foods, adenomatous gastric polyps, previous gastric resection, Ménétrier disease, smoking, H. pylori infection, and chronic gastritis. Aspirin, fresh fruits and vegetables, selenium, and vitamin C may be protective against the development of gastric cancer.
Peptic Ulcer Disease (PUD) represents a spectrum of disease characterized by ulceration of the stomach or proximal duodenum due to an imbalance between acid secretion and mucosal defense mechanisms.
The principal role of the stomach is to store and prepare ingested food for digestion and absorption through a variety of motor and secretory functions. The stomach can be divided into five regions based on external landmarks: the cardia, the region just distal to the gastroesophageal (GE) junction; the fundus, […]
Epidemiology. Carcinoma of the esophagus represents 1% of all cancers in the United States and causes 1.8% of cancer deaths. The two principal histologies are adenocarcinoma and squamous cell carcinoma. Risk factors for squamous cell esophageal cancer include African American race, alcohol and cigarette use, tylosis, achalasia, caustic esophageal injury, […]
Barrett Esophagus is defined as a metaplastic transformation of esophageal mucosa resulting from chronic GER. Histologically, the metaplastic epithelium must demonstrate intestinal-type metaplasia characterized by the presence of goblet cells. The columnar epithelium of Barrett esophagus may replace the normal squamous epithelium circumferentially, or it may be asymmetric and irregular
Benign Esophageal Neoplasms are rare, although probably many remain undetected. The most common lesions are mesenchymal tumors such as gastrointestinal stromal tumors and leiomyomas, followed by polyps. Less common lesions include hemangioma and granular cell myoblastoma. A. Clinical features Clinical features depend primarily on the location of the tumor within […]
Liquid alkali solutions (e.g., Drano and Liquid-Plumr) are responsible for most of the serious caustic esophageal and gastric injuries, producing coagulation necrosis in both organs. Acid ingestion is more likely to cause isolated gastric injury.
Overall, perforation is associated with a 20% mortality rate. The etiologies may be broadly divided into intra- and extraluminal categories. Intraluminal causes Instrumentation injuries represent 75% of esophageal perforations and may occur during endoscopy, dilation, sclerosis of esophageal varices, transesophageal echocardiography, and tube passage. The most common sites are the […]
Esophageal Diverticula are acquired conditions of the esophagus found primarily in adults. They are divided into traction and pulsion diverticula based on the pathophysiology that induced their formation.
Esophageal Strictures are either benign or malignant, and the distinction is critical. Benign strictures are either congenital or acquired.
Functional Esophageal Disorders comprise a diverse group of disorders involving esophageal skeletal or smooth muscle. A. Motor disorders of esophageal skeletal muscle Motor disorders of esophageal skeletal muscle result in defective swallowing and aspiration. Potential causes can be classified into five major subgroups: neurogenic, myogenic, structural, iatrogenic, and mechanical. Most […]
Gastric Adenocarcinoma is the fourth-most common cancer worldwide and the tenth-most common malignancy in the United States. Its incidence has decreased dramatically over the last 60 years, perhaps secondary to improvements in refrigeration and diet. In addition, the anatomic pattern of gastric cancer is changing, with proximal or cardia cancers comprising a greater proportion of gastric cancers. Approximately one third of gastric cancers are metastatic at presentation. The overall 5-year survival rate is 15%.
Pathophysiology in GER relates to abnormal exposure of the distal esophagus to refluxed stomach contents. In 60% of patients, a mechanically defective lower-esophageal sphincter (LES) is responsible for the GER. The sphincter function of the LES depends on the integrated mechanical effect of the sphincter’s intramural pressure and the length of esophagus exposed to intra-abdominal positive pressure. Other etiologies of GER are inefficient esophageal clearance of refluxed material, fixed gastric outlet obstruction, functional delayed gastric emptying, increased gastric acid secretion, and inappropriate relaxation of the LES.
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