Chapter 22 Manifestation of
Principles of Surgery Companion Handbook
MANIFESTATION OF GASTROINTESTINAL DISEASE
|Weight Loss and Cachexia|
|Small and Large Intestine|
|Upper Gastrointestinal Bleeding|
|Lower Gastrointestinal Bleeding|
|Multiple Organ Failure Syndrome (MOFS)|
Pain is the most common symptom of gastrointestinal disease. The amount and quality of perceived pain are determined by physiologic and psychological
Pain impulses from the abdomen reach the central nervous system (CNS) through (1) visceral sympathetic afferents and (2) visceral parasympathetic afferents and (3) from the parietal peritoneum, the diaphragm, and the root of the
The abdominal viscera have bilateral afferent autonomic innovation, except the kidneys, ureter, cecum, and
Referred Visceral Pain This pain is more localized and is referred to the dermatomes and myotomes that are supplied by the same spinal cord segment as the affected viscus; e.g., increased distention of the abdomen causes abdominal wall discomfort and backache.
Pain sensation is transmitted by A-delta fibers. The pain is well localized; nerve endings are stimulated by chemicals, changes in pH, inflammatory mediators, bacteria, and neutrophil breakdown products.
Referred Parietal Pain This is the result of afferent neurons that innervate two separate, anatomically distinct structures having a common embryologic origin, e.g., left shoulder pain with ruptured spleen.
TABLE 22-1 POSSIBLE ORIGINS FOR REFERRED PAIN
Other pain is back pain as a result of neural infiltration, e.g., infiltration of the celiac plexus by pancreatic cancer or
ACUTE ABDOMINAL PAIN
Sudden pain is seen with perforation, obstruction, acute arterial ischemia, and acute intraperitoneal bleeding. Pain of gradual onset is seen with inflammatory pathology (Table 22-2). The site and character of pain, radiation, aggravating and
TABLE 22-2 DIAGNOSIS RELATED TO THE MODE OF ONSET OF ABDOMINAL PAIN
General Visual Assessment
Is the patient looking sick? What is the
This should include the lungs and the abdomen. Crepitations, rales, and bronchial breathing
Percussion distinguishes between gas and fluid causes of distention; liver dullness is obliterated by large amounts of free air, indicating a hollow viscus perforation.
Examine for masses; make a diligent search for herniae. Remember that light touch is essential when there is peritoneal inflammation. Guarding may be
Complete blood count with differential,
Upright anteroposterior (AP) and lateral chest x-rays and upright and supine abdomen views (free air series) show pulmonary pathology or free air under the diaphragm, abnormal gas patterns (air in the biliary tract indicating gallstone ileus, extraluminal air indicating perforation or abscesses), displaced organs (gastric fundus indented by splenic hematoma), fluid levels of intestinal obstruction, radiopaque ureteric and
Symptoms of an acute abdomen may be masked in the pediatric population, in elderly patients, in patients on steroids, and immune-compromised patients.
INTERMITTENT AND RECURRENT PAIN
Hemolytic disorders such as sickle cell disease, autoimmune hemolytic anemia, and thrombotic thrombocytopenia can present with abrupt severe abdominal pain;
Chronic hemolytic anemias, hereditary spherocytosis, and thalassemia can cause abdominal pain, anemia, jaundice, splenomegaly, and cholelithiasis. Acute intermittent porphyria, an inherited dominant
Bouts of pain with entirely normal intervals are seen in acute intermittent porphyria, internal
Chronic pain also can be from abdominal wall pathology such as peripheral nerve injuries, hernias, myofascial pain syndromes, the rib tip syndrome, and
The control of intractable pain could be challenging, e.g., pain from unresectable
Cytokines activated by the inflammatory response and pyrogens from macrophages (interleukin-1, tumor necrosis factor, and interferon) that are released locally within the brain and peripherally into the bloodstream act on the hypothalamus in endocrine fashion. The resulting upward resetting of the thermal regulatory apparatus triggers vasoconstriction that limits heat loss and shivering, which
Patients also may establish the environmental temperature that is most comfortable for them. This temperature is called
For example, burn patients and patients with large wounds, peritonitis, sepsis, and multi-organ system failure feel cold at
Fevers of gastrointestinal origin usually result from intraabdominal infection, e.g., urinary tract infection, peritonitis. Postoperative fevers are common (15–30 percent) in patients after celiotomy, but only 10–20 percent of such fevers are from infections such as pulmonary complications, urinary tract infections, wound sepsis, and thrombophlebitis. Twenty percent of fevers of unknown origin are secondary to cancers that are primary or metastatic in the abdomen, e.g., hypernephroma, liver
Anorexia is seen in many illnesses such as inflammatory diseases (indicates significant inflammation), endocrinopathies such as hyperparathyroidism, and
The physiologic mechanisms that control feeding and satiety are complex and multifaceted, involving receptors in both the brain and the periphery; stimuli include changes in glucose utilization rate, changes in the rate of lipid metabolism, alterations in brain and peripheral peptides, imbalances in plasma and brain amino acid profiles, increases and decreases in neurotransmitter activity, and alterations in cytokine levels. The hypothalamus is the feeding center of the brain; afferents are important for communicating peripheral nutrition-related information from the gastrointestinal tract or from glucose-sensitive
It is likely that cancer anorexia results from tumor-induced aberrations of neurochemical mechanisms that normally control hunger and satiety. Aberrations in plasma and brain amino acid profiles have been
Patients have significantly negative prognostic implications; a loss of 10–15 percent over a 3–4-month period is indicative of nutritional or immunologic
Decreased intake and weight loss may occur in obstruction to the esophagus or be secondary to postprandial pain, chronic infections, and malabsorption. Thyrotoxicosis, Addison's disease, and diabetes mellitus may produce rapid weight loss over a short period. The most common cause of weight loss is malignancy. Up to 70 percent of cancer patients die from the effects of starvation, with infection the final common pathway. Weight loss in the elderly could be from treatable causes such as poorly fitting dentures. In a small percentage of patients, weight loss is of psychological origin.
Hiccups often is transient and
Abdominal conditions such as gastric distention, pancreaticobiliary disease, bowel obstruction, and intraoperative surgical manipulation stimulate the afferent vagal branches. The vagus could be stimulated by intrathoracic pathology such as neoplasms, myocardial infarction, pulmonary edema, and infectious processes. Intraabdominal phrenic nerve stimulation can arise from
HEARTBURN AND DYSPEPSIA
Frequent heartburn indicates gastroesophageal reflux disease. The defense mechanisms of the esophagus are a competent lower esophageal sphincter (LES), rapid esophageal clearing of refluxed material, neutralization of refluxed acid by bicarbonate-rich saliva, and an intact mucosal diffusion
Heartburn is a substernal burning often associated with bitter taste, and when severe, it is associated with regurgitation of gastric contents. A minority of patients with gastroesophageal reflux dysmotility develop esophagitis (19 percent of patients undergoing upper endoscopy for upper abdominal symptoms have esophagitis).
Dyspepsia includes symptoms such as substernal pressure,
The timing to food helps: Duodenal ulcer pain is relieved by food, and gastric ulcer pain is provoked by food. Fried, fatty, or greasy
Dysphagia (difficulty in swallowing) and painful swallowing (odynophagia) require investigation. Pain accompanying dysphagia is a result of inflammation or spasm. Because of the risk factors for squamous cell cancer of the esophagus, the history should include questions about chronic medications (e.g., nonsteroidal anti-inflammatory drugs), dietary habits, substance abuse, smoking, and the taking of undiluted alcohol. Regurgitation of undigested, foul-smelling food is suggestive of Zenker's diverticulum. A barium swallow should be followed with upper gastrointestinal endoscopy with biopsy; if Barrett's esophagus is suspected, multiple biopsies at various levels should be performed. Studies include manometry and 24-h pH monitoring. The esophagus is the most common part of the gastrointestinal tract to be affected by scleroderma; lower esophageal dysmotility also can occur in association with other connective tissue disorders such as rheumatoid arthritis. Dysphagia lusoria is caused by an aberrant origin of the right subclavian artery or pulmonary artery; it is suspected when there is a posterior indentation of the upper esophagus on barium swallow. If neoplasm is suspected, CT scan of the chest and abdomen and bronchoscopy are indicated. In addition, dysphagia may be a symptom in patients with conversion hysteria, anxiety, and anorexia nervosa.
NAUSEA AND VOMITING
Nausea and vomiting may be related or unrelated to disease of the gastrointestinal (GI) tract. When the GI tract is excessively irritated or overdistended, vomiting may result. Impulses of the GI tract are transmitted by both vagal and sympathetic fibers to the vomiting center in the medulla; motor
Any CNS disorder that leads to increased
Consequences of Vomiting
Continued vomiting and resulting hypovolemia can produce
Gaseous Distention, Eructation, and Flatulence Intestinal gas produces symptoms of bloating, left shoulder pain (splenic flexure syndrome), audible bowel sounds, eructation, and flatulence. Postoperative gas pains are not uncommon but usually resolve spontaneously in 3–4 months.
Chronic belching/eructation may be seen in cholelithiasis, peptic ulcer disease, and esophageal reflux disease. Patients who do not have decreased LES pressure should not undergo fundoplication because the procedure can cause severe distress/gas bloat syndrome. Small intestinal gas is a combination of swallowed gas and gas from bacterial fermentation; the total is less than 1 L/day. Distention of the colon may reflect partial obstruction. Lactase deficiency also can result in eructation and flatulence.
Treatment with activated charcoal, simethicone, and enzymes may be helpful in patients with no correctable cause.
Digestion starts in the stomach. Gastric emptying is achieved within 3–4 h. In the duodenum and small intestine, 3–4 L of biliary and pancreatic secretions and 2 L of succus entericus are added per 24 h. Protein absorption occurs in the first 120 cm and carbohydrate absorption within the first 150–180 cm. Water
This is an abnormal retention of fecal material or delay in bowel evacuation compared with usual bowel habits. Investigation is required for a change in bowel habits to rule out neoplastic disease.
Defecation occurs when peristaltic waves move the fecal bolus stored in the sigmoid colon into the rectum. Relaxation of the circular muscles at the rectosigmoid junction and impulses from the
This is often a result of intestinal obstruction. Reflex acute constipation may occur in trauma associated with retroperitoneal hematoma. Painful perianal conditions such as fissures and thrombosed hemorrhoids also cause acute constipation. Other causes of constipation include psychological factors, lack of bulky foods, excess laxatives and drugs, decreased skeletal muscle power, and extrinsic pressure on the GI tract. Intestinal atony is seen in hypokalemia, hypercalcemia, and uremia; collagen and endocrine disorders also can cause intestinal atony (e.g.,
Evaluation includes a history of previous bowel habits; changes in stool caliber,
Chronic Constipation Congenital disorders, motility disorders, functional problems of the defecatary mechanisms in the pelvic floor, specific problems of the elderly, medications, diverticulosis with chronic scarring, and neoplastic disease are causes of chronic constipation. The age at onset, endoscopy and biopsy, manometry, and motility studies help in the diagnosis. Rectal prolapse and pelvic floor laxity are some of the pelvic floor abnormalities in the elderly resulting in constipation. Laxative abuse, anticholinergic use, and phenothiazine use can result in chronic constipation. A palpable left colon associated with constipation can be seen in chronic diverticulitis with scarring. Chronic constipation in the elderly always should raise a suspicion of neoplastic disease.
Between 5 and 8 L per 24 h is the volume secreted by the stomach, hepatobiliary tree, and small bowel. Profuse diarrhea can result in hemodynamic instability.
Secretory diarrhea is seen after ileal resection, in pancreatic insufficiency, and from improper mixing of bile and pancreatic
Clinical Evaluation Onset of diarrhea; frequency; associated symptoms such as pain, fever, nausea, and vomiting; family history; and character of the stool are important clues; e.g., diarrhea associated with fever and pain suggests an infectious cause. Small-caliber stools indicate partial distal colonic obstruction. A large amount of mucus with the stool is seen in inflammatory bowel disease, rectal cancer, and villous tumors of the rectum. In the physical examination, look for fever (inflammatory process), skin disorders (pyoderma gangrenosum or erythema nodosum in inflammatory bowel disease), abdominal distention (neoplasm or inflammation), perianal examination for fistulas (Crohn's disease), digital examination of the rectum for a mass, and fecal impaction. A stool test for occult blood may lead to a diagnosis.
Tests include a full blood count, liver
This depends on the cause of the diarrhea. Nonspecific
Intestinal obstruction accounts for 20 percent of surgical admissions. It is
The accumulation of fluid and gas above the point of obstruction and
Most bowel distention is from fluid sequestration, and some of it is from intestinal gas. Peristalsis increases in an attempt to overcome the obstruction; the higher the obstruction, the more frequent are the high-pitched peristaltic sounds.
This is seen in
This is a dangerous form of obstruction. Both the afferent and efferent
The physiologic effects on the patient are less traumatic because the colon is
Abdominal distention and hyperactive bowel sounds may be the only finding in simple mechanical obstruction. Fever, tachycardia, localized tenderness, and rebound tenderness suggest compromised bowel. The disappearance of peristalsis in progressive mechanical obstruction indicates gangrenous bowel. In the early postoperative phase, intestinal obstruction is difficult to diagnose.
Laboratory Findings Abnormal tests include elevated BUN level, hemoconcentration, hyponatremia and hypokalemia, high urinary specific gravity, and abnormal acid–base balance depending on the nature of the fluid loss. A very high white blood cell count may indicate the presence of strangulated bowel. High amylase levels may be seen with strangulated bowel, but there is no specific laboratory test indicative of intestinal ischemia.
The majority of small bowel obstructions resolve without
The timing of the operation is critical. Strangulation, closed-loop obstruction, colon obstruction, and early simple mechanical obstruction require operation as soon as possible. General anesthesia and a generous incision, preferably a long midline, are preferred. The obstruction is relieved with appropriate procedures such as lysis of adhesions, reduction of intersussusption and incarcerated hernia, resection of an
When adhesions are present, multiple sites of obstruction may be
Postoperative care includes adequate fluid and electrolyte replacement and correction and return of intestinal motility (5–6 days). Parenteral nutrition may be needed.
The most common type of ileus is adynamic or inhibition ileus from inhibition of normal neuromuscular activities; when the bowel is contracted without coordinated propulsive activity, it is described as spastic ileus. In low floor states or when there is vascular occlusion, ischemic ileus is seen.
Adynamic ileus is common after abdominal operations. Gastric ileus and colonic ileus last for approximately 2 days and 3–4 days, respectively. Prolonged ileus may result from metabolic causes (e.g., hypokalemia, hyponatremia, hypomagnesia, intraabdominal sepsis, anastomotic leak), drugs (e.g., narcotics), or epidural anesthesia. Adynamic ileus also is seen with retroperitoneal hematoma, spinal fractures, rib fractures, and pelvic fractures. Clinical manifestations include abdominal distention and hypoactive bowel sounds. Abdominal x-rays show
Management consists of nasogastric suction or gastrostomy tube drainage, the correction of fluid and electrolyte abnormalities, and parenteral nutrition. Erythromycin (a motilin agonist), bethanechol, vasopressin, metoclopramide, and cisapride are used.
PARTIAL OBSTRUCTION AND PSEUDO-OBSTRUCTION
Partial obstruction or pseudo-obstruction is seen in Crohn's disease and motility disorders, e.g., diabetic and postvagotomy gastroparesis. Symptoms include chronic nausea and vomiting. Abdominal examination may reveal generalized or localized distention.
Chronic intestinal pseudo-obstruction is secondary to abnormalities in the intestinal muscles or the nervous system and is seen in many diseases, including endocrine disorders, chronic infections, autoimmune diseases, neurologic disorders, and paraneoplastic syndromes. Tricyclic antidepressants, opiates, antihistamines, beta-adrenergic agonists, and amitriptyline can cause prolonged pseudo-obstruction. Presenting symptoms include nausea, vomiting, abdominal cramps, and distention. Constipation and diarrhea may occur. Recurrent attacks can lead to chronic obstruction with abdominal distention; if it occurs in the postoperative phase, it can result in multiple unnecessary operations with complications.
No specific test is diagnostic; hypokalemia, hypomagnesemia, and hypoalbuminemia are to be excluded. Endocrine tests, antinuclear antibody determinations, manometric studies, and intestinal biopsies may be necessary. Radiologic studies
Operation should be avoided unless a specific site of obstruction is identified; support with total parenteral nutrition may be necessary. Many operations have been performed with very poor results. If the pseudo-obstruction is primarily colonic, a
Bleeding can be occult, presenting as weakness, anemia, and orthostasis, or may be massive with sudden and rapid loss of blood. In one-third of patients it is the first symptom of GI disease, and in 70 percent there is no previous history of bleeding. Fifty percent of GI bleeding stops spontaneously. Hematemesis or vomiting of fresh blood implies bleeding above the ligament of Treitz. Altered blood vomitus is coffee ground emesis. Hematochezia or passage of blood per rectum can be of varied brightness and color and usually is seen in lower GI bleeding. Altered blood presents as black, tarry stool and is seen more commonly in upper GI bleeding. Between 50 and 60 mL of blood is required for a melanotic stool; guaiac-positive stool is seen with 10 mL of bleeding per day. Although iron produces a black stool, the stool is guaiac-negative. The consequences depend on the rate of bleeding and the site of bleeding.
Peptic ulcer disease
Reflux esophagitis more commonly causes chronic occult bleeding. Variceal bleeding is a result of ulceration of the varix secondary to reflux esophagitis or increased pressure within the varix. A failing liver and its inability to synthesize
Acute gastritis can be seen with nonsteroidal anti-inflammatory drugs, alcohol, steroids, and oral potassium. Chronic gastritis is most commonly associated with H. pylori infection.
Stress ulcers and acute gastroduodenal lesions may be seen in patients in shock, with sepsis, after major surgery, trauma, or burns, and with intracranial pathology; they are the result of decreased gastric blood flow, bile reflux, infection, coagulopathy, and activation of cytocrines.
Among neoplasia, benign lesions such as leiomyomas can present with hematemesis. Dieulafoy's vascular malformations are rare submucosal dilated arterial lesions that can present with massive GI bleeding, as do aortoenteric fistulas. Patients should be questioned about past peptic ulcer disease, medications, alcohol abuse, and the onset of pain and vomiting as it
Resuscitation is by the placement of a wide-bore intravenous line, restoring blood volume, Foley catheter, and nasogastric tube (iced saline lavage of the stomach may be useful). Laboratory tests include complete blood count, prothrombin time (PT), partial thromboplastin time (PTT), blood chemistry, and cross-match of adequate blood.
Esophagogastroduodenoscopy is performed as soon as the patient is hemodynamically stable and is of diagnostic and therapeutic value, e.g., injection or ligation of varices, coagulation of bleeding vessels, etc. Radionuclide scan is unhelpful but may be a useful
Specific therapies for variceal bleeding are intravenous vasopressin, Sengstaken-Blakemore tube, transjugular intrahepatic portal systemic shunting (TIPS), and an emergency portal caval shunt. Tamponade is very effective in controlling bleeding from Mallory-Weiss tears. When blood need exceeds 4 units in 24 h and continues, operative treatment should be
Gastric neutralization with antacids and sucralfate, inhibition of secretion with H
antagonists and proton pump blockers, the correction of coagulation defects, invasive
Small intestinal bleeding (10–15 percent) is diagnosed by exclusion of upper GI bleeding and colonic bleeding. The causes include vascular malformations, neoplasia, Meckel's diverticula, enteric infections, and ulcers. Investigation includes radionuclide scanning, arteriography, and celiotomy.
Colon bleeding can be acute and massive or chronic. Massive lower GI bleeding occurring in the right colon usually is from angiodysplasia. Diverticular disease is a common cause of massive bleeding from the left colon.
Management starts with fluid resuscitation, placement of a nasogastric tube to rule out upper GI bleeding, Foley catheter placement, and proctosigmoidoscopy. Radionuclide scanning is sensitive and specific but does not pinpoint the site of bleeding accurately. Arteriography is definitive in locating the point of bleeding. CT scan and MRI may be useful. Barium study interferes with endoscopy and angiography. Celiotomy, intraoperative enteroscopy, and colectomy may be indicated if bleeding continues and the site of bleeding cannot be localized.
In chronic lower GI bleeding, neoplasia should be excluded. Investigations include rectosigmoidoscopy, colonoscopy, and barium enema. Rectal and anal bleeding, especially when associated with pain, is from fissures, proctitis, and hemorrhoids. A careful history and physical examination should exclude more proximal colon lesions.
Jaundice (excess bile pigments in the tissues and serum) is recognizable when the serum level of bilirubin approximates 2–3 mg/dL.
Normal Bilirubin Metabolism
Congenital or familial types of hyperbilirubinemia are characterized by increases in unconjugated or conjugated bilirubin. Hemolytic disorders result in increased production of unconjugated bilirubin; pigment gallstones may produce common bile duct obstruction, resulting in an elevated conjugated bilirubin level. Unconjugated hyperbilirubinemia is rarely a surgical condition. The ratio of unconjugated to conjugated bilirubin will not differentiate between intra-or extrahepatic causes of jaundice but may help differentiate between a parenchymal and obstructive etiology. In parenchymal dysfunction, serum transaminase levels are elevated, unlike in obstructive jaundice, where the alkaline phosphatase level is high.
Ask questions concerning loss of appetite (hepatitis), loss of weight, previous episodes of jaundice, the color of urine and stool, exposure to hepatitis, blood transfusions, drug (e.g., chlorpromazine, tetracycline, chlorthiazide, acetaminophen) and alcohol abuse, family history, abdominal pain (painless jaundice in carcinoma of the head of the pancreas), or pruritus (obstructive jaundice). Signs of liver dysfunction, lymph node enlargement,
Do a complete blood count and
The initial radiologic examination is ultrasound to demonstrate a dilated biliary system and gallstones. If ducts are dilated,
This is a progressive,
Several organ systems may show impairment. Pulmonary failure is manifest as the acute respiratory distress syndrome; poor urine output and a rise in BUN and creatinine levels indicate renal dysfunction. Liver failure presents as ischemic hepatitis (shock liver) and jaundice combined with associated abnormalities in liver chemistry and coagulation disorders. If septic shock syndrome is not
For a more detailed discussion, see Fischer JE, Nussbaum MS, Chance WT, and Luchette F: Manifestations of Gastrointestinal Disease, chap. 22 in Principles of Surgery, 7th ed.
Copyright 1998 McGraw-Hill
Seymour I. Schwartz
Principles of Surgery Companion Handbook