Oxford American Handbook of Gastroenterology and Hepatology

488 Pages·2011·2.24 MB·English

by  Adam S Cheifetz, Alphonso Brown, Michael Curry, Alan C Moss

Oxford American Handbook of
Gastroenterology
and Hepatology

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Oxford American
Handbook of
Gastroenterology
and Hepatology

Edited by

A dam S . C heifetz, MD
Assistant Professor of Medicine, Harvard Medical School
Director, Center for Infl ammatory Bowel Disease
Beth Israel Deaconess Medical Center
Boston, Massachusetts
A lphonso B rown, MD
Assistant Professor of Medicine, Harvard Medical School
Co-Director, Pancreas Center
Beth Israel Deaconess Medical Center
Boston, Massachusetts
M ichael C urry, MD
Assistant Professor of Medicine, Harvard Medical School
Director for Liver Transplantation, Liver Center
Beth Israel Deaconess Medical Center
Boston, Massachusetts
A lan C . M oss, MD
Assistant Professor of Medicine, Harvard Medical School
Director of Translational Research
Center for Infl ammatory Bowel Disease
Beth Israel Deaconess Medical Center
Boston, Massachusetts

with
S tuart B loom
G eorge W ebster

3

3

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Copyright © 2011 by Oxford University Press, Inc.

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Oxford is a registered trademark of Oxford University Press

First published 2011
UK version: 2006

All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise, without the prior
permission of Oxford University Press,

Library of Congress Cataloging in Publication Data

Oxford American handbook of gastroenterology and hepatology / edited by Adam S
Cheifetz … [et al.] ; with Stuart Bloom, George Webster.
p. ; cm.
Other title: Handbook of gastroenterology and hepatology
Includes index.
ISBN 978-0-19-538318-8
1. Gastroenterology–Handbooks, manuals, etc. 2. Hepatology–Handbooks,
manuals, etc. I. Cheifetz, Adam S. II. Title: Handbook of gastroenterology and
hepatology.
[DNLM: 1. Gastrointestinal Diseases–Handbooks. WI 39]
RC802.O94 2011
616.3′3–dc22
2010028005

10 9 8 7 6 5 4 3 2 1

Printed in China
on acid-free paper

This material is not intended to be, and should not be considered, a sub-
stitute for medical or other professional advice. Treatment for the con-
ditions described in this material is highly dependent on the individual
circumstances. And, while this material is designed to offer accurate infor-
mation with respect to the subject matter covered and to be current as
of the time it was written, research and knowledge about medical and
health issues is constantly evolving and dose schedules for medications are
being revised continually, with new side effects recognized and accounted
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uct information and data sheets provided by the manufacturers and the
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including, without limitation, that they make no representation or war-
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This page intentionally left blank

Preface

vii
Preface

The Oxford American Handbook of Gastroenterology and Hepatology is
intended for medical students, residents, and gastroenterology fellows. It
is by no means a complete referendum on gastroenterology but a place
to start your learning. Nor is it meant to replace full literature searches or
the experience of direct patient care. It will, however, provide you with
an accessible and convenient reference and help build a fund of know-
ledge about gastroenterology at a time when you are most likely to retain
it—on the wards or in the clinic, working directly with patients. The hand-
book is designed to fi t in your pocket and organized to make your life
easier. We hope you fi nd it helpful. The rest of the advice we will leave to
Sir William Osler:

“He who studies medicine without books sails an uncharted sea, but he
who studies medicine without patients does not go to sea at all.”

Adam S. Cheifetz
Alan C. Moss
Alphonso Brown
Michael Curry

viii

Acknowledgments

We would like to thank our friends and family and those physicians,
patients, and nurses that have helped to train us and make us the physi-
cians we are today.

Special thanks go to Martin Smith, MD and Robert Najarian, MD for pro-
viding the majority of the radiology and pathology images shown within
this handbook.

We also thank the authors of the original British edition, Stuart Bloom and
George Webster.

Contents

ix

Contents

Detailed contents xi
Abbreviations xxiii

1 Top 10 clinical problems
1
2 Emergencies
61
3 Upper gastrointestinal tract

3.1 Esophagus
95
3.2 Stomach
113
3.3 Small intestine
137
4 Liver
157
5 Pancreas and biliary tree

5.1 Pancreas
217
5.2 Biliary tree
237
6 Colon and rectum

6.1 Colon
249
6.2 Rectum
297
7 Intestinal infections
309
8 Intestinal manifestations of systemic disease
333
9 Procedures and nutrition

9.1 Procedures
375
9.2 Nutrition
417
Appendix
429

Index 433

Contents

Detailed contents xi
Abbreviations xxiii

1 Top 10 clinical problems
1
2 Emergencies
61
3 Upper gastrointestinal tract

3.1 Esophagus
95
3.2 Stomach
113
3.3 Small intestine
137
4 Liver
157
5 Pancreas and biliary tree

5.1 Pancreas
217
5.2 Biliary tree
237
6 Colon and rectum

6.1 Colon
249
6.2 Rectum
297
7 Intestinal infections
309
8 Intestinal manifestations of systemic disease
333
9 Procedures and nutrition

9.1 Procedures
375
9.2 Nutrition
417
Appendix
429

Index 433

This page intentionally left blank

xi
Detailed contents

1 Top 10 clinical problems
1

Anemia and occult GI bleeding 2
Anemia 2
Increased red cell destruction: hemolysis 3
Anemia in liver disease 4
Iron defi ciency anemia presumed due to occult GI blood loss 5
Ascites 7
Assessment of ascites 7
Ascites: Management 9
Chronic or recurrent abdominal pain 11
Cirrhosis and Chronic liver disease 15
Background 15
Compensated cirrhosis 16
Decompensated cirrhosis 17
Constipation 19
Evaluation 19
Diagnostic approach and investigations 21
Treatment considerations 23
Acute diarrhea (less than 14 days) 26
Classifying acute diarrhea 27
Investigations 29
Treatment 30
Diarrhea in travelers 32
Chronic diarrhea 34
Defi nition 34
Pathophysiology and causes 34
History and examination 37
Diagnostic tests 39
Antidiarrheal therapy 41
Dyspepsia and gastro-esophageal refl ux 42
Defi nitions and common causes 42
Epidemiology 42
When and how to investigate 42
Starting treatment 43
Managing gastro-esophageal refl ux disease (GERD) 44
Managing peptic ulcer disease 44
Managing nonulcer dyspepsia 46
The role of Helicobacter testing and eradication in managing
dyspepsia 47

Mouth and swallowing problems 48
Problems with the mouth 48
Problems with swallowing 49

DETAILED CONTENTS
xii

Nausea and vomiting 52
Defi nitions and neurophysiology 52
Clues in reaching a diagnosis 52
Approach to investigation 53
Management 53
Causes of nausea and vomiting 54
Recent onset jaundice 55
Background 55
Type of jaundice 55
Clinical assessment 58
Management 59

2
Emergencies
61

Acute abdominal pain 62
Clinical assessment 62
Investigations 64
Management 64
Acute diarrhea 66
Management 67
Common mistakes and important points in early
management 69

Complications 69
Acute liver failure 70
Defi nition 70
Clinical syndrome 70
Making the diagnosis 72
Management 72
Prognosis and liver transplantation 74
Acute lower gastrointestinal bleeding 75
Defi nition 75
Clinical presentation 75
Diagnosis 75
Management 75
Acute upper gastrointestinal bleeding 77
Defi nitions 77
Initial assessment and management 78
Suspected nonvariceal acute upper GI bleed 81
Suspected acute variceal bleed 85
Esophageal obstruction 88
Causes 88
Clinical features 88
Management 88
Esophageal rupture 90
Causes 90
Diagnosis 90
Management 91

DETAILED CONTENTS
xiii

Gastrointestinal foreign bodies 92
Swallowed foreign bodies 92
Colonic and rectal foreign bodies 92
Special considerations 93

3
Upper gastrointestinal tract

3.1
Esophagus
95

Achalasia 96
Barrett’s esophagus 97
Barrett’s surveillance 98
Boerhaave syndrome 98
Caustic injury 99
Chagas’s disease 100
Diaphragmatic hernia 101
Drug-induced esophagitis 101
Dysplasia 102
Gastro-esophageal refl ux (GERD) 103
Hiatus hernia 103
Mallory–Weiss syndrome 103
Esophageal motility disorders 103
Esophageal rings 105
Esophageal stricture 105
Esophageal tumors 106
Esophagitis 110
Los Angeles grading 110
Pharyngeal pouch (“Zenker’s diverticulum”) 111
Plummer–Vinson/Patterson–Kelly syndrome 111
Pseudoachalasia 111
Schatzki ring 111
Tracheo-esophageal fi stula (TEF) 112
Variceal bleeding 112
Video capsule endoscopy 112

3.2
Stomach
113

Achlorhydria 114
Atrophic gastritis 114
Bezoars 115
Billroth 115
Dieulafoy lesion 115
Ectopic mucosa 115
Gastrectomy/gastroenterostomy 116
Gastric antral vascular ectasia (GAVE) 116
Gastric cancer 117
Gastric emptying 118
Gastric polyps 120
Gastric ulcers 120
Gastrinoma (Zollinger-Ellison syndrome) 120

DETAILED CONTENTS
xiv

Gastritis 122
Helicobacter pylori (HP) 123
Intrinsic factor (IF) 125
MALT lymphoma 125
Ménétrier’s disease 125
Nonsteroidal anti-infl ammatory drugs (NSAIDs) and the GI
tract 126

Nonulcer dyspepsia 127
Obesity surgery 128
Peptic ulceration 128
Pernicious anemia (PA) 132
Postgastrectomy syndromes 133
Proton pump inhibitors 134
Pyloric stenosis 134
Superior mesenteric artery syndrome 135
Zollinger–Ellison syndrome 135

3.3
Small intestine
137

Afferent loop syndrome 138
Ampullary cancer 138
Angiodysplasia 138
Aorto-enteric fi stulae 139
Bacterial overgrowth 140
Bile acid malabsorption 141
Blind loop 142
Brush border 142
Celiac disease 143
Dumping syndrome 145
Duodenal diverticulum 145
Duodenal ulcer 146
Embolization 146
Fat malabsorption 146
GIST (gastrointestinal stromal tumors) 147
Hereditary hemorrhagic telangiectasia (HHT),
(Osler–Weber–Rendu syndrome) 147

Ileus 148
Intussusception 149
Jejunal diverticulum 149
Lactose intolerance 149
Lymphangiectasia 149
Lymphoma in GI tract 150
Meckel’s diverticulum 152
Mesenteric venous thrombosis 152
Peutz–Jeghers syndrome 153
Protein-losing enteropathy 153
Roux-en-Y anastomosis 154
Short bowel syndrome 155
Tropical sprue 155
VIPoma 156