Blueprints surgery pdf free download

Topical mesalamine, in the form of enemas, is effective for mild and moderate disease. Newer immunosuppressive agentsincluding infliximab, a monoclonal antibody against tumor necrosis factormay be useful. High-fiber diet and bulking agents are often useful.

Indications for surgery include colonic obstruction, massive blood loss, failure of medical therapy, toxic megacolon, and cancer. The recommendation of prophylactic colectomy for these patients is being reconsidered on the basis of recent data that suggest the incidence of cancer is not as high as once thought.

When elective surgery is performed, sphincter-sparing operations allow the ileum to be anastomosed to the rectal stump or anus, preserving continence and bowel movement. The ileum is fashioned into a J-pouch, which serves the fecal reservoir role of the removed rectum.

Because of reduced intraluminal stool volume, the normal segmental colonic peristaltic contractions are extra forceful, which increases intraluminal pressure and causes herniation of the mucosa through the circular muscles of the bowel wall where the marginal artery branches penetrate. Men and women are equally affected, and the prevalence increases dramatically with age. Approximately one third of the population has diverticular disease, but this number increases to more than half of those older than 80 years of age.

They may have had previous episodes of bleeding or crampy abdominal pain, commonly in the left lower quadrant. If bleeding continues, diagnostic. These are acquired or false diverticula because not all layers of the bowel wall are included. Most diverticula occur in the sigmoid colon Figs. Diverticulosis is the most common cause of lower gastrointestinal hemorrhage, usually from the right colon. Figure Blood supply to the colon A and formation of the diverticulum B.

Note the passage of the mucosal diverticulum through the muscle coat along the course of the artery. From Snell RS. Clinical Anatomy. Figure Diverticulosis, diverticulitis. Reprinted with permission from Willis MC. Figure Extensive sigmoid diverticular disease with slight spasm but no stigmata of acute inflammation. In the absence of classic symptoms and signs of diverticulitis, surgery is not advised solely on the basis of this radiographic appearance.

Asymptomatic individuals require no treatment. Elective segmental or subtotal colectomy is not usually recommended at first episode. However, depending on the ability to accurately determine the site of bleeding, the severity of the initial bleeding episode, and the general status of the patient, it may be indicated.

Patients with recurrent bleeding are usually offered surgical resection. Active bleeding is treated colonoscopically if the colon can be cleaned and the bleeding site identified. Embolization of the bleeding vessel may be possible using selective angiography. In the face of massive bleeding, if the above methods fail and no bleeding site is identified, emergent subtotal colectomy is performed. Before embarking on such an irreversible procedure, which involves removing most of the colon, it is of utmost importance to ensure that the bleeding source is not from hemorrhoids or a rectal source.

If a colonic bleeding site is identified, segmental colectomy can be performed, usually based on the arterial branch feeding the bleeding site. Infection leads to localized or free perforation into the abdomen. Diverticulitis most commonly occurs in the sigmoid and is rare in the right colon. Each attack makes a subsequent attack more likely and increases the risk of complications. The pain is usually progressive over a few days and may be associated with diarrhea or constipation.

Figure The Hartmann procedure for diverticulitis: primary resection for diverticulitis of the colon. The affected segment clamp attached has been divided at its distal end. In a primary anastomosis, the proximal margin dotted line is transected and the bowel attached end-to-end. In a two-stage procedure, a colostomy is constructed at the proximal margin with the distal stump oversewn Hartmann procedure, as shown or brought to the outer surface as a mucous fistula.

The second stage consists of colostomy takedown and anastomosis. Local peritoneal signs of rebound and guarding may be present. Significant colonic inflammation may present as a palpable mass. Diffuse rebound tenderness and guarding as evidence of generalized peritonitis suggests free intra-abdominal perforation. Radiographs of the abdomen are typically normal, except for cases of perforation or obstruction. In cases of perforation, free air is seen under the diaphragms on chest x-ray.

Computed tomography CT may demonstrate pericolic fat stranding, bowel wall thickening, or abscess. Colonoscopy and barium enema should not be performed during an acute episode because of the risk of causing or exacerbating an existing perforation. Combination treatment with ciprofloxacin and metronidazole Flagyl is appropriate to cover aerobic and anaerobic organisms. For severe cases or cases in older adult patients or debilitated patients, hospitalization with bowel rest and broadspectrum intravenous antibiotics e.

For patients who do not improve in 24 to 48 hours, repeat CT scan with percutaneous drainage of any identifiable abscess cavity may obviate the need for emergency operation. In the event of free perforation or failure of medical management, surgical exploration with resection and colostomy is usually required Hartmann procedure; Fig. In addition, surgical intervention is indicated in the presence of the complications previously described. With repeated attacks of diverticulitis, the risk of developing complications increases significantly.

Stricture, perforation, or fistulization with the bladder, skin, vagina, or other portions of the bowel may develop. Recent evidence suggests that colon cancer follows an orderly progression in which adenomatous polyps undergo malignant transformation over a variable time.

For this reason, these polyps are considered premalignant lesions. Risk factors include high-fat and low-fiber diets, age, and family history. Ulcerative colitis, Crohns disease, and Gardner syndrome all predispose to cancer, and cancer develops in all patients with familial polyposis coli if they are not treated.

The higher the villous component, the higher the risk of malignancy. As the lesion grows in size, the likelihood of its having undergone malignant transformation increases significantly. Other types include squamous, adenosquamous, lymphoma, sarcoma, and carcinoid. Figure Model of colorectal carcinogenesis.

A genetic model of colorectal cancer tumorigenesis. Cell ; Screening is aimed at detecting polyps and early malignant lesions.

In theory, colon cancer is a preventable disease, because if all patients underwent thorough screening and timely polyp removal, the mortality rate from colon cancer would be drastically reduced. The current screening recommendations from the American Gastroenterological Association divide people into two groups: average risk and increased risk.

Average-risk persons lack any identifiable risk factors. Increased-risk persons have either a personal history of adenomatous polyps or colorectal cancer, firstdegree relatives with colorectal cancer or adenomatous polyps, a family history of multiple cancers, or a history of inflammatory bowel disease.

Screening should begin at age 50 years for average-risk patients and age 40 years for increased-risk patients. American Cancer Society guidelines for the early detection of colorectal cancer include the following: yearly fecal occult blood test or fecal immunochemical test.

Although the Dukes classification system devised in was simple and uncomplicated, it was eventually found to be inferior with respect to prognostication than the subsequently developed Astler-Coller system. T2: Tumor invades muscularis propria. T3: Tumor invades through the muscularis propria into the subserosa or into the pericolic or perirectal tissue. N0: No regional lymph node metastasis. N1: Metastasis in one to three regional lymph nodes.

N2: Metastasis in four or more regional lymph nodes. M0: No distant metastasis or residual tumor. M1: Distant metastasis present. Staging is based on a combined evaluation of characteristics involving the tumor, lymph nodes, and presence of metastasis. Small proximal ascending colonic neoplasms are often asymptomatic. Occult blood in the stool and weight loss from metastatic disease may be the only signs.

As the size of a lesion increases, right colon cancers usually cause bleeding that is more significant, whereas lesions in the left colon typically present with obstructive symptoms, including a change in stool caliber, tenesmus, or constipation.

In general, this is due to fecal matter entering the right colon in liquid form and easily transiting a large cecal lesion, whereas desiccated stool in the left colon tends to obstruct when confronted with malignant luminal narrowing.

Rectal bleeding from a low rectal cancer should never be mistakenly explained away as symptomatic hemorrhoids. Simple digital rectal examination will demonstrate the tumor and prevent delay in diagnosis. Rectal cancer also can present with passage of mucus per rectum, arising from tumor surface secretions.

Complete acute large bowel obstruction may also occur. Any older adult patient who lacks a history of prior abdominal surgery or recent colonoscopy who presents with a large bowel obstruction must be considered to have obstructing colon cancer until proven otherwise.

Any sizable lesion may produce abdominal pain. Perforation typically causes frank peritonitis. Constitutional symptoms, including weight loss, anorexia, and fatigue, are common with metastatic disease. For large bulky tumors, a mass may be noted on abdominal examination.

Stigmata of hereditary disorders, including familial polyposis syndrome or Gardner syndrome, may be present. Laboratory evaluation should include a hematocrit, which often reveals microcytic anemia from chronic occult blood loss. The liver is the most common site. Carcinoembryonic antigen may also be obtained; although it is not a useful screening test, it is valuable as a marker for recurrent cancer. Colonoscopy has the advantage of examining the entire colon while also performing confirmatory biopsy for tissue diagnosis.

Flexible sigmoidoscopy reaches up to 70 cm of the most distal large intestine, whereas colonoscopy can examine the entire colon and even intubate the distal ileum. Rigid sigmoidoscopy is only useful for examining the lower 25 cm and is therefore often used to evaluate rectal cancers.

Radiologic evaluation can be performed with double-contrast barium enema, which uses both a radio-opaque contrast medium barium to coat the colon wall and air to provide luminal distention.

The classic finding on barium enema is a constricting filling defect, known as an apple core lesion Fig. CT is useful for evaluating extent of disease and the presence of metastases, particularly in the liver. Figure Adenocarcinoma of the colon presenting as an apple core lesion. Image from a barium enema study demonstrates a circumferential mass arrows. This mass has disrupted the normal mucosal pattern and has irregular overhanging edges.

Gastrointestinal Oncology: Principles and Practice. Magnetic resonance imaging may be better for evaluating liver metastases but usually does not add more overall information than that which is obtained with CT.

Positron-emission tomography scan is useful for showing metastatic disease or else late recurrence in a patient who previously underwent resection and who has an increasing carcinoembryonic antigen level.

For rectal lesions, endorectal ultrasound is the standard of care for assessing the depth of tumor invasion and the presence of lymph node metastases. The oncologic principles underlying segmental colon resection for malignancy are based on the blood supply of the segment of colon containing the lesion, as well as the distribution of the parallel draining lymph node network.

For cancers of the cecum and ascending colon, right hemicolectomy is indicated. Tumors of the transverse colon require transverse colectomy, with removal of the hepatic and splenic flexures.

Descending colon tumors require left colectomy, and sigmoid tumors are treated with sigmoidectomy. Most rectal tumors are treated with low anterior resection, whereas the very low rectal cancers near the anus occasionally require abdominoperineal resection, which entails resection of the anus with closure of the perianal skin and creation of a permanent end colostomy, because anastomosis may not be technically feasible.

Examples of the extent of resection for different types of colectomy are shown in Figure Historically, open surgery has been the standard approach for colon resection; however, the laparoscopic technique has gained rapid acceptance, given the reduced morbidity compared with open surgery, in addition to studies showing the less invasive approach to be equally effective as open surgery in terms of survival.

The widely quoted randomized trial results by the Clinical Outcomes of Surgical Therapy COST Study Group, published in , showed no difference in either recurrence or 3-year survival between laparoscopic or open groups.

In summary, despite the development of new surgical techniques, the basic oncologic. Figure Types of colectomy. A Sigmoid colectomy; B transverse colectomy; C left colectomy; D right colectomy.

With respect to the extent of resection, guidelines from the American Joint Committee on Cancer, the American College of Pathology, and the National Comprehensive Cancer Network recommend 12 or more lymph nodes to be sampled during surgery.

Thorough sampling and examination of the draining lymph nodes is thought to improve staging accuracy, which allows more appropriate adjuvant chemotherapy administration. By upstaging patients, some investigators believe patients will therefore be offered more aggressive treatment that will likely result in improved overall survival. Most open resections are performed via a midline incision. The rationale and extent of excision for various tumors is described above and in Figure Mobilization of the right or left colon involves incising the white line of Toldt on the respective side.

Care is taken to avoid the ureter, which can be injured as the colon is mobilized. Consideration of a. The transverse colon is intraperitoneal and does not require mobilization. Once adequate length of colon has been mobilized, the peritoneum overlying the mesentery is incised to its root, and all the mesenteric vessels in the specimen are ligated.

In the open technique, noncrushing clamps are usually placed alongside the resection margin to reduce spillage, and the ends of the bowel are usually stapled and the specimen removed. Reconstruction of bowel continuity is performed with either hand-sewn or stapled anastomosis. For low colon or rectal anastomosis, use of an end-to-end anastomosis stapler placed through the anus is a preferred technique. Because many angiodysplastic lesions rebleed, definitive treatment may occasionally require segmental colectomy.

Angiodysplasia is being recognized with increasing frequency as a significant source of lower gastrointestinal hemorrhage. These anomalous vascular lesions are histologically similar to telangiectasia and arise most commonly in the cecum and right colon.

The incidence of volvulus is approximately two in , Risk factors include age, chronic constipation, previous abdominal surgery, and neuropsychiatric disorders.

The relative redundancy of the sigmoid loop causes torsion around the mesenteric axis, whereas poor fixation of the cecum in the right iliac fossa leads to either axial torsion cecal volvulus or anteromedial folding cecal bascule.

The prevalence increases with age, to an incidence of approximately one fourth of the older adult population. Age and resulting bowel wall strain are thought to cause vascular tissue proliferation, leading to angiodysplastic lesions.

The patient usually relates the acute onset of crampy abdominal pain and distention. Frank peritonitis and shock may follow. Patients usually present with multiple episodes of low-grade bleeding. Angiography with highly selective embolization or vasopressin infusion is often. The distended colonic loop has the appearance of a bent tire or large coffee bean.

Rectal tubes are sometimes used to prevent acute recurrence and aid decompression. Because of the high rate of recurrence, operative repair after resolution of the initial episode is recommended.

In the acute setting and depending on the operative findings, fixation of the untwisted loop to the respective fossa may suffice for cases of viable bowel; otherwise, resection is performed with either primary anastomosis or end colostomy Hartmann procedure in cases of sepsis and gangrene. Treatment of cecal volvulus is usually operative at the outset, because nonoperative intervention is rarely successful, and the incidence of gangrenous ischemic changes is high.

The causes of appendiceal inflammation and infection are related to processes that obstruct the appendiceal lumen, thereby causing distal swelling, decreased venous outflow, and ischemia. The most common extraluminal cause of obstruction is the swelling of submucosal lymphoid tissue in the wall of the appendix in response to a viral infection.

This is illustrated by the incidence of viral syndromes often seen in pediatric patients shortly before developing appendicitis.

The most common intraluminal cause of obstruction is from a fecalith small, firm ball of stool. Cases of obstruction with fecaliths have a higher incidence of perforation. Perforation at the time of surgery is more often seen in very young children and in older adults as a result of delayed diagnosis. The initial discomfort is thought to be due to obstruction.

Retrocecal appendicitis may cause pain higher in the right abdomen, whereas appendicitis located in the pelvis may cause vague pelvic discomfort. Anorexia is an almost universal complaint. Nausea and emesis may occur after the onset of pain. Generalized abdominal pain may signify rupture and diffuse peritonitis.

Nearly all patients have right lower quadrant tenderness, classically located at McBurneys point, two thirds the distance from the umbilicus to anterior superior iliac spine. Rebound and guarding develop as the disease progresses and the peritoneum becomes inflamed. Signs of peritoneal irritation include the obturator sign pain on external rotation of the flexed thigh and the psoas sign pain on right thigh extension.

Rovsings sign is eliciting pain in the right lower quadrant on palpation of the left lower quadrant. In cases of contained perforation, the omentum walls off the infectious process, occasionally resulting in a palpable mass in thin patients. If the perforation is free and not contained, then diffuse peritonitis and septic shock may develop.

Rectal examination may reveal tenderness if the appendix hangs low in the pelvis. Urinalysis should be performed to rule out a urinary tract infection. Depending on a patients age, presenting history and physical examination, and available resources, radiologic studies may include ultrasound or CT scanning.

Plain abdominal x-rays supine and upright usually provide no useful information in confirming the diagnosis of appendicitis. Ultrasonographic evidence of appendicitis includes appendiceal wall thickening, luminal distention, and lack of compressibility.

Ultrasound is also useful in female patients for demonstrating ovarian or other gynecologic pathology. CT scanning may show appendiceal enlargement, periappendiceal inflammatory changes, free fluid, or right lower quadrant abscess Fig. CT scanning is also useful for ruling in or out alternative diagnoses, thereby reducing the negative appendectomy rate in many hospitals.

Figure Computed tomographic appearance of appendicitis. The Clinical Practice of Emergency Medicine. Both open and laparoscopic techniques are appropriate. Laparoscopic appendectomy is associated with less postoperative pain, a shorter hospital course, better cosmesis, and faster return to work. Selected advanced cases with appendiceal abscess may initially be managed nonoperatively with antibiotics and percutaneous CT-guided abscess drainage.

Once the infection has abated and the inflammatory process resolved, interval appendectomy may be performed at a later date. Diverticulosis is the most common cause of lower gastrointestinal bleeding. Prevalence of diverticula increases with age.

Cause is related to low-fiber dietary intake. Elective surgical therapy for diverticulitis is indicated for repeated attacks because of the high. Emergent surgical therapy is indicated for free perforation and usually requires segmental colon resection and end colostomy Hartmann procedure. Colon cancer follows a progression from adenoma to carcinoma.

Blueprints Series: Medicine. Blueprints Series: Cardiology. Author: Seth J. Karp James P. Blueprints Surgery, 5th Edition Blueprints Series. Read more. Blueprints Medicine Blueprints Series 5th Edition. Blueprints Series: Surgery. Blueprints Pediatrics, 5th Edition. Read the quick review below and download the PDF by using links given at the end of the post.

We have uploaded these PDF and EPUB files to our online file repository so that you can enjoy a safe and blazing-fast downloading experience. This best-selling Blueprints title is an ideal resource for the obstetrics and gynecology rotation and board preparation. Causes of hyponatremia should be divided into two types, depending on whether there is reduced plasma osmolality.

If plasma osmolality is normal or high, the differential diagnosis is hyperlipidemia, hyperproteinemia, hyperglycemia, and mannitol administration. In this case, the treatment focuses on correcting the abnormality in the osmotically active agent. In this case, the question becomes whether the circulating plasma volume is high, as in congestive heart failure, cirrhosis, nephrotic syndrome, and malnutrition; normal, as in syndrome of inappropriate secretion of antidiuretic hormone, paraneoplastic syndromes, endocrine disorders, and various drugs morphine, aminophylline, indomethacin ; or low, with excessive losses or inadequate replacement.

This should only be done in consultation with a neurologist, as faster rates can result in central pontine myelinolysis from the osmotic shift. Patients in whom the effective plasma volume is high should be treated with fluid restriction. Causes of hypernatremia are divided into water loss and sodium administration. Water loss can result from insensible losses from infection, burns, or fever; renal loss from diabetes insipidus; gastrointestinal losses; or hypothalamic disorders.

Sodium administration can be performed via ingestion or intravenously. Treatment consists of addressing the underlying abnormality and administering fluid. Rapid correction of hyponatremia can result in seizures, cerebral edema, and death. Hypokalemia is usually due to potassium loss. Hypokalemia can result in cardiac arrhythmias, especially in patients taking digoxin. Treatment is with exogenous replacement. Chloride Calcium Lactate Hyperkalemia is usually due to exogenous administration or from intracellular stores.

It can result in weakness and cardiac arrhythmias. Kayexalate decreases total body potassium but takes longer to be effective. Dialysis is extremely effective in decreasing potassium. Goldman criteria can help assess cardiac risk. Peptic ulceration is the most common inflammatory disorder of the gastrointestinal tract and is responsible for significant disability.

The stomach and duodenum are principally affected by peptic ulceration. The ascending fourth portion terminates at the ligament of Treitz, which defines the duodenal—jejunal junction.

The arterial supply to the duodenum is via the superior pancreaticoduodenal artery, which arises from the gastroduodenal artery, and via the inferior pancreaticoduodenal artery, which arises from the superior mesenteric artery. The fundus is the superior dome of the stomach; the body extends from the fundus to the angle of the stomach incisura angularis , located on the lesser curvature; and the antrum extends from the body to the pylorus.

Hydrochloric acid—secreting parietal cells are found in the fundus, pepsinogen-secreting chief cells are found in the proximal stomach, and gastrin-secreting G cells are found in the antrum.

Six arterial sources supply blood to the stomach: the left and right gastric arteries to the lesser curvature; the left and right gastroepiploic arteries to the greater curvature; the short gastric arteries, branching from the splenic artery to supply the fundus; and the gastroduodenal artery, branching to the pylorus Fig. The vagus nerve supplies parasympathetic innervation via the anterior left and posterior right trunks.

These nerves stimulate gastric motility and the secretion of pepsinogen and hydrochloric acid. The duodenum is divided into four portions Fig. The first portion begins at the pylorus and includes the duodenal bulb. The ampulla of Vater, through which the common bile duct and pancreatic duct drain, is located in the medial wall of the descending second portion of the duodenum.

Substances that alter mucosal defenses include nonsteroidal antiinflammatory drugs, alcohol, and tobacco. Alcohol directly attacks the mucosa, nonsteroidal anti-inflammatory drugs alter prostaglandin synthesis, and tobacco restricts mucosal vascular perfusion. However, the most important and remarkable advancement in understanding the pathogenesis of peptic ulceration was the radical idea that infestation with the organism Helicobacter pylori was the causative factor in gastric and duodenal ulceration.

This discovery destroyed prevailing dogma and profoundly altered the medical and surgical treatment for this disease process. So profound was this discovery that the Nobel Prize in Medicine was awarded to Drs. Arterial supply. Observe that the stomach receives its main blood supply from branches of the celiac trunk.

The fundus of the stomach is supplied by short gastric arteries arising from the splenic artery. The spleen is supplied by the splenic artery, the largest branch of the celiac trunk, which runs a tortuous course to the hilum of the spleen and breaks up into its terminal splenic branches.

Venous drainage. The drainage of the stomach is directly or indirectly into the portal vein. The splenic vein usually receives the inferior mesenteric vein and then unites with the superior mesenteric vein to form the portal vein as shown here. Clinically Oriented Anatomy. Sensations of fullness and mild nausea are common, but vomiting is rare unless pyloric obstruction is present secondary to scarring. Physical examination is often benign except for occasional epigastric tenderness. Serum testing determines whether there are antibodies to H.

Definitive diagnosis is made by direct visualization of the ulcer using endoscopy see Color Plate 1. For nonhealing gastric ulcers refractory to medical therapy, it is extremely important that biopsy of the ulcer be performed to rule out gastric carcinoma. Duodenal ulcers are rarely malignant. The goals of medical therapy are to decrease production of or neutralize stomach acid and to enhance mucosal protection against acid attack. Medications include antacids CaCO3 , H2-blockers cimetidine, ranitidine , mucosal coating agents sucralfate , and proton-pump inhibitors omeprazole.

As a result of the advent of proton pump inhibitors PPIs and the increased understanding of the role H. Indications for surgical treatment in the acute setting are either perforation or massive bleeding.

Indications for elective operation are a chronic nonhealing ulcer after medical therapy or gastric outlet obstruction. The operation chosen must address the indication for which the procedure is performed.

Historically, before the era of PPIs and H. In most instances, vagotomy and distal gastrectomy antrectomy , with Billroth I or II anastomosis, fulfilled these criteria Figs. Today, most cases of perforation are treated with closure of the defect with omental patch, and cases of bleeding are treated with suture ligation of the bleeding vessel. The commonly accepted etiology of stress gastritis and ulceration is mucosal ischemia induced by an episode of hypotension from hemorrhage, sepsis, hypovolemia, or cardiac dysfunction.

Ischemia disrupts cellular mechanisms of mucosal protection, resulting in mucosal acidification and superficial erosion. Areas of erosion may coalesce and form superficial ulcers. Stress ulcers may be seen throughout the stomach and proximal duodenum. The incidence of life-threatening hemorrhagic gastritis has decreased as intravenous H2-blocker therapy and oral cytoprotectants have been introduced to the intensive care setting. Ulcers are single and deep and may involve the esophagus, stomach, and duodenum.

Because of the depth of ulceration, perforation is a common complication. Zollinger-Ellison syndrome occurs in patients with severe peptic ulceration and evidence of a gastrinoma non—B-cell pancreatic tumor. Peptic ulceration results from the production of large volumes of highly acidic gastric secretions owing to elevated serum gastrin levels.

Persistent or recurrent bleeding unresponsive to endoscopic techniques requires surgical intervention. Depending on the circumstances, operations for control of bleeding stress gastritis or ulcer require oversewing of the bleeding vessel. Usually, vagotomy is also performed to reduce acid secretion.

In many cases, because bleeding is often diffuse and cannot be controlled by simple suture ligation, partial or total gastrectomy is performed. Gastrin-secreting tumors produce a clinical picture of epigastric pain, weight loss, vomiting, and severe diarrhea. Massive upper gastrointestinal bleeding is the usual finding. Somatostatin analogs octreotide have been found to be effective in decreasing tumor secretion of gastrin and in controlling the growth of tumor metastases.

Gastrinoma is a curable disease, despite the malignant nature of most tumors. When simple excision or enucleation for cure is not feasible, an attempt is made to prolong survival by debulking and performing lymph node dissection to reduce tumor burden and acid hypersecretion. Illustrative of geographic variation, stomach cancer is endemic in Japan. Smoked fish and meats contain benzopyrene, a probable carcinogen to gastric mucosa.

Nitrosamines are known carcinogens that are formed by the conversion of dietary nitrogen to nitrosamines in the gastrointestinal tract by bacterial metabolism. Atrophic gastritis, as seen in patients with hypogammaglobulinemia and pernicious anemia, is considered to be a premalignant condition for developing gastric cancer, because high gastric pH encourages bacterial growth.

Most tumors are located in the antral prepyloric region. Gastric tumors can be typed according to gross appearance. Polypoid fungating nodular tumors are usually well differentiated and carry a relatively good prognosis after surgery. Ulcerating or penetrating tumors are the most common and are often mistaken for benign peptic ulcers because of their sessile nature.

Superficial spreading lesions diffusely infiltrate through mucosa and submucosa and have a poor prognosis because most are metastatic at the time of diagnosis. The pathologic staging of gastric cancer is based on depth of tumor invasion and lymph node status. Survival is closely correlated with the pathologic stage of a specific tumor Fig. Upper abdominal discomfort, dyspepsia, early satiety, belching, weight loss, anorexia, nausea, vomiting, hematemesis, or melena is common.

Definite symptoms do not occur until tumor growth causes luminal obstruction, tumor infiltration results in gastric dysmotility, or erosion causes bleeding. By the time of diagnosis, tumors are usually unresectable. Later symptoms indicative of metastatic disease are abdominal distention owing to ascites, resulting from hepatic or peritoneal metastases, and dyspnea and pleural effusions, resulting from pulmonary metastases.

A firm, nontender, mobile epigastric mass can be palpated, and hepatomegaly with ascites may be present. Other distant signs of metastatic disease include Virchow supraclavicular sentinel node, Sister Joseph umbilical node, and Blumer shelf on rectal examination.

The anemia is usually hypochromic and microcytic secondary to iron deficiency. Stool is often positive for occult blood. In recent years, upper endoscopy has replaced the barium-contrast upper gastrointestinal study as the imaging modality of choice.

Endoscopy allows direct visualization and biopsy of the tumor. At least four biopsies should be made of the lesion. Once diagnosis is made, computed tomography is performed to evaluate local extension and to look for evidence of ascites or metastatic disease. Tumors are located either in the proximal, middle, or distal stomach. The type of operation performed for cure depends on tumor location.

Distal lesions located in the antral or prepyloric area are treated with subtotal gastrectomy and Billroth II or Roux-en-Y anastomosis Fig. Midgastric and proximal lesions are treated with total gastrectomy, with extensive lymph node dissection. The lesser and greater omentum are removed, along with the spleen.

If the body or tail of the pancreas is involved, distal pancreatectomy can be performed. Reconstruction is achieved via Roux-en-Y anastomosis Fig. Proximal lesions carry a poor prognosis, and surgical intervention is usually palliative. If there is extension into the distal esophagus, it is resected, along with the cardia and lesser curvature. The remaining stomach tube is closed, and the proximal aspect is anastomosed to the midesophagus through a right thoracotomy.

If extensive esophageal involvement is discovered, radical near-total gastrectomy and a nearcomplete esophagectomy are performed, with continuity restored using a distal transverse colon and proximal left colon interposition Fig.

In this case, the tumor is classified as T2. If there is perforation of the visceral peritoneum covering the gastric ligaments or the omentum, the tumor should be classified as T3. Intramural extension to the duodenum or esophagus is classified by the depth of the greatest invasion in any of these sites, including the stomach. Treatment consists of decreasing stomach acidity and enhancing mucosal protection.

Surgery is reserved for perforation, massive bleeding, gastric outlet obstruction, and nonhealing ulcers. Medical treatment includes H2 blockade, proton pump inhibition, and somatostatin analogs.

Complete surgical resection can be curative. Most tumors are located in the antral region. Esophageal involvement requires esophagogastrectomy. Its main function is to digest and absorb nutrients. Absorption is achieved by the large surface area of the small intestine, secondary to its long length and extensive mucosal projections of villi and microvilli.

A broad-based mesentery suspends the small intestine from the posterior abdominal wall once the retroperitoneal duodenum emerges at the ligament of Treitz and becomes the jejunum. Arterial blood is supplied from branches of the superior mesenteric artery, and venous drainage is via the superior mesenteric vein Fig.

The mucosa has sequential circular folds, called plicae circulares. The plicae circulares are more numerous in the proximal bowel than in the distal bowel. The mucosal villi and microvilli create the surface through which carbohydrates, fats, proteins, and electrolytes are absorbed Figs.

Obstruction of the small bowel lumen causes progressive proximal accumulation of intraluminal fluids and gas. Peristalsis continues to transport swallowed air and secreted intestinal fluid through the bowel proximal to the obstruction, resulting in small bowel dilation and eventual abdominal distention.

Depending on the location of the obstruction, vomiting occurs early in proximal obstruction and later in more distal blockage Fig. Crampy abdominal pain initially occurs as active proximal peristalsis exacerbates bowel dilation. With progressive bowel wall edema and luminal dilation, however, peristaltic activity decreases and abdominal pain lessens.

At presentation, patients exhibit abdominal distention and complain of mild diffuse abdominal pain. Most adhesions are caused by postoperative internal scar formation. Discovering the actual mechanism of obstruction is important for therapeutic planning, because the mechanism of obstruction relates to the possibility of vascular compromise and bowel ischemia.

For example, a closed-loop obstruction caused by volvulus with torsion is at higher risk for vascular compromise than an SBO from a simple adhesive band Fig. A second mechanism causing bowel ischemia is incarceration in a fixed space. Incarceration and subsequent strangulation impedes venous return, causing edema and eventual bowel infarction. Other mechanisms of obstruction that rarely compromise vascular flow are intraluminal obstruction by a gallstone or bezoar and intussusception caused by an intramural or mucosal lesion at the leading edge.

HISTORY Patients usually present with complaints of intermittent crampy abdominal pain, abdominal distention, obstipation, nausea, and vomiting. Vomiting of feculent material usually occurs later in the course of obstruction. Note longer vasa recta in jejunum versus ileum.

Essentials of General Surgery. Elevation in temperature should not be present in uncomplicated cases. Tachycardia may be present from hypovolemia secondary to persistent vomiting or from toxemia caused by intestinal gangrene. Typically, there are no signs of peritonitis. If constant localized tenderness is apparent, indicating localized peritonitis, then ischemia and gangrene must be suspected.

Occasionally, the radiograph shows the etiology of the obstruction, the site of obstruction, and whether the obstruction is partial or complete. Dilated small bowel in the presence of a dilated colon suggests the diagnosis of paralytic ileus, not SBO. A small bowel contrast study may be necessary to demonstrate transit of contrast into the colon, thereby ruling out SBO.

Free air indicates perforation of the intra-abdominal gastrointestinal tract, whereas biliary gas and an opacity near the ileocecal valve indicate gallstone ileus. Abdominal computed tomography CT scans can often demonstrate the transition point, where the dilated bowel proximal to the point of obstruction transitions to the decompressed bowel more distally. No distention. Intermittent pain but not classic crescendo type. Middle Moderate vomiting. Moderate distention. Intermittent pain crescendo, colicky with free intervals.

Low Vomiting late, feculent. Marked distention. Variable pain; may not be classic crescendo type. Laboratory examination often reveals a hypokalemic alkalosis owing to dehydration from repeated emesis. Lactic acidosis is cause for concern and may indicate intestinal necrosis.

However, over the past few decades it became apparent that most patients can be safely managed medically in the absence of peritonitis or other worrisome clinical findings. Supportive therapy allows for spontaneous resolution of the obstruction and return of normal bowel function. For patients who are candidates for a trial of nonsurgical therapy, initial treatment consists of nasogastric decompression to relieve proximal gastrointestinal distention and associated nausea and vomiting.

Fluid resuscitation and supportive hydration is necessary because patients are typically intravascularly depleted from diminished oral fluid intake and vomiting. From Willis MC. On initial presentation, if ischemia or perforation is suspected, immediate operation is necessary. Otherwise, patients can be observed with serial physical examinations, serum tests, and abdominal radiographs for evidence of resolution.

Recent investigations with Mycobacterium paratuberculosis have proved inconclusive. An immunologic basis for the disease has also been advanced; however, although humoral and cellular immune responses are involved in disease pathogenesis, no specific immunologic disturbance has been identified.

The ileum is typically diseased, with frequent right colon involvement. The mucosa has a cobblestone appearance, with varying degrees of associated mucosal ulceration see Color Plates 2 and 3. Histologically, a chronic lymphocytic infiltrate in an inflamed mucosa and submucosa is seen.

Fissure ulcers penetrate deep into the mucosa and are often associated with granulomata and multinucleated giant cells. Granulomata are seen more frequently in distal tissues, which explains why granulomata are seen more often in colonic disease than in ileal disease. Ileal involvement is most common. The disease is characterized by skip lesions that involve discontinuous segments of abnormal mucosa.

Granulomata are usually seen microscopically, but not always. Areas of inflammation are often associated with fibrotic strictures, enterocutaneous fistulae, and intra-abdominal abscesses, all of which usually require surgical intervention. The incidence in the United States is approximately 10 times that of Japan.

Ashkenazi Jews have a far higher incidence of disease than do African Americans. The diarrhea is usually loose and watery, without frank blood.

Dull abdominal pain is usually in the right iliac fossa or periumbilical region.