Severe inflammation causes destruction of the myenteric plexus and muscular layer, leading to massive distention and perforation. Patients are invariably septic and mortality high unless emergent subtotal colectomy is performed. Once the diagnosis of ulcerative colitis is made, routine colonoscopic surveillance is mandatory. Corticosteroids, other immunosuppressives, and sulfasalazine are all effective. Topical mesalamine, in the form of enemas, is effective for mild and moderate disease. Newer immunosuppressive agents—including infliximab, a monoclonal antibody against tumor necrosis factor—may 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. 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.
Note the passage of the mucosal diverticulum through the muscle coat along the course of the artery. From Snell RS. Clinical Anatomy. Reprinted with permission from Willis MC. 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.
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. For this reason, these polyps are considered premalignant lesions.
Risk factors include high-fat and low-fiber diets, age, and family history. 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. 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. 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. 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. 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. 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. 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. 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. 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 and swelling of the appendix and the latter due to peritoneal irritation. 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.
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. 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. 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. 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.
Prevalence of diverticula increases with age. Cause is related to low-fiber dietary intake. Emergent surgical therapy is indicated for free perforation and usually requires segmental colon resection and end colostomy Hartmann procedure. Adenomatous polyps are considered premalignant and must be removed entirely. Screening for colon cancer should begin at age 50 for normal-risk patients. Both open and laparoscopic techniques are accepted surgical therapies for resection.
Right lower quadrant abdominal pain, fever, and leukocytosis are hallmarks of the disease. Appendectomy can be performed with either open or laparoscopic techniques. It is covered by Glisson capsule and peritoneum. The right and left lobes of the liver are defined by the plane formed by the gallbladder fossa and the inferior vena cava. The falciform ligament between the liver and diaphragm is a landmark between the lateral and medial segments of the left lobe. The coronary ligaments continue laterally from the falciform and end at the right and left triangular ligaments.
These ligaments define the bare area of the liver, an area devoid of peritoneum. The liver parenchyma is divided into eight segments on the basis of arterial and venous anatomy see Color Plate 5. Segment 1 is also known as the caudate lobe.
It is not visible from the ventral surface of the liver, being tucked behind segment 4. The caudate is juxtaposed to the inferior vena cava and has venous branches that drain directly into the cava. These branches are quite fragile and must be carefully controlled if resection of the caudate is required. Segments 2, 3, and 4 form the left lobe of the liver, whereas segments 5, 6, 7, and 8 comprise the right lobe. Segment 4 may be divided into cranial segment 4a and caudal segment 4b.
The hepatic circulation is based on a portal circulation that provides the liver with first access to all intestinal venous flow. Seventy-five percent of total hepatic blood flow is derived from the portal vein, which is formed from the confluence of the splenic and superior mesenteric veins. The remaining blood supply comes from the hepatic artery via the celiac axis. When this occurs, the artery will run posterior to the bile duct on the right side of the hilum, and it is termed a replaced right hepatic artery.
In this instance, the artery will run in the cranial portion of the gastrohepatic ligament. Other arterial variants include a completely replaced hepatic artery, which arises from the superior mesenteric artery, and a middle hepatic artery, which occurs when the segment 4 branch arises in the hilum. Blood leaving the liver enters the inferior vena cava via the right, middle, and left hepatic veins. Often there is an accessory right hepatic vein that leaves the liver caudad to the principle right hepatic vein.
This vein must be controlled separately during right hepatic lobectomy. The hepatic hilum can be palpated by placing a finger through the foramen of Winslow epiploic foramen into the lesser sac Fig. This is an important maneuver because it provides control of the hepatic hilum hepatoduodenal ligament , within which runs the hepatic artery, portal vein, and bile duct.
A Pringle maneuver, which involves placing a clamp on the hilum, disrupts most blood flow to the liver and can greatly reduce bleeding during liver resection Fig. This maneuver also makes the liver ischemic and can cause arterial thrombosis. As a result, it should be used for a limited amount of time and only when necessary. The liver is the site of many critical events in energy metabolism and protein synthesis.
Glucose is taken up and stored as glycogen, and glycogen is broken down, as necessary, to maintain a relatively constant level of serum glucose. The lesser sac is behind the hepatoduodenal and hepatogastric ligaments.
Entry is through the epiploic foramen foramen of Winslow. From Sadler T. Occlusion of the porta hepatis decreases blood flow to the liver to slow bleeding during liver surgery. From Blackbourne LH. Advanced Surgical Recall. The anticoagulant warfarin Coumadin affects these vitamin K—dependent pathways, resulting in an increased prothrombin time.
Albumin and alpha globulin are produced solely in the liver. The digestive functions of the liver include bile synthesis and cholesterol metabolism. Heme is used to form bilirubin, which is excreted in the bile after conjugation with glycine or taurine. Bile emulsifies fats to aid their digestion and plays a role in vitamin uptake.
Bile salts excreted into the intestine are reabsorbed into the portal circulation. This cycle of bile excretion and absorption is termed the enterohepatic circulation. The rate-limiting step of cholesterol synthesis involving the enzyme 3-hydroxymethylglutaryl—coenzyme A reductase occurs in the liver, as does cholesterol metabolism to bile salts.
Detoxification occurs in the liver through two pathways. Phase I reactions involve cytochrome P and include oxidation, reduction, and hydrolysis. Phase II reactions consist of conjugation.
These reactions are critical to destruction or renal clearance of toxins. The dosing of all oral drugs is determined only after considering the first-pass effect of the drug through the liver. The initial hydroxylation of vitamin D occurs in the liver. Immunologic functions are mediated by Kupffer cells, the resident liver macrophages. Hemangiomas are categorized into capillary and cavernous types, the former being of no clinical consequence and the latter capable of attaining large size and rupturing.
The incidence of adenoma is one per million in women without a history of oral contraceptive use. These medicines increase the risk by a factor of This lesion most commonly occurs in women between 30 and 50 years of age. Adenoma and focal nodular hyperplasia are five times more common in female patients. HISTORY Patients with adenomas and hemangiomas can be asymptomatic or present with dull pain; rupture can produce sudden onset of severe abdominal pain. These lesions can also become large enough to cause jaundice or symptoms of gastric outlet obstruction, including nausea and vomiting.
Focal nodular hyperplasia is rarely symptomatic. Jaundice may occur in patients if the tumor causes bile duct obstruction. Laboratory evaluation is often unremarkable, although hemorrhage in an adenoma can lead to hepatocellular necrosis and a subsequent increase in transaminase levels. Hemangioma can cause a consumptive coagulopathy. Ultrasound differentiates cystic from solid lesions. Triple-phase computed tomography CT is the best study for distinguishing between various types of benign and malignant lesions, but in certain cases, this determination is not possible.
Adenomas are typically low-density lesions; focal nodular hyperplasias may appear with a filling defect or central scar, whereas hemangiomas have early peripheral enhancement after contrast administration. Hemangiomas should not be biopsied because of the risk of bleeding.
If the lesion does not regress, resection should be considered in otherwise healthy individuals because of the risk of malignant degeneration or hemorrhage. Relative contraindications to resection include a tumor that is technically difficult to resect or tumors of large size in which a large portion of the liver would need to be removed.
Symptomatic hemangiomas should be resected, if possible. Because focal nodular hyperplasia is not malignant and rarely causes symptoms, it should not be resected unless it is found incidentally at laparotomy and is small and peripheral enough to be wedged out easily.
It is more common in male than in female patients. Fungal-derived aflatoxins have been implicated as causes of hepatoma, as have hemochromatosis, smoking, vinyl chloride, and oral contraceptives. Hepatic metastases are often indistinguishable from primary hepatocellular carcinoma. Jaundice occurs in approximately half of patients. Radiographic studies are used to differentiate benign and malignant lesions.
Ultrasonography can distinguish cystic from solid lesions, whereas CT or magnetic resonance imaging can reveal multiple lesions and clarify anatomic relationships Fig.
They can also demonstrate nodularity of the liver, hypersplenism, and portal hypertension, indicative of underlying liver disease. Hepatic arteriography can diagnose a hemangioma. Because most cancers occur in the setting of liver disease and cirrhosis, it is important to perform viral studies for hepatitis. Computed tomography image demonstrates portal vein thrombus black arrows on thrombosed right and left portal veins. A mass curved white arrows is present in the right lobe of the liver.
If the patient is a surgical candidate, treatment involves resection of the tumor. Patients with Child class C disease will generally not tolerate a resection; patients with Child class B disease may tolerate a limited resection.
When possible, wedge resection should be performed, because formal hepatic lobectomy does not provide any additional survival benefit. Patients with small tumors who are not candidates for resection because of tumor location or concomitant cirrhosis should be considered for liver transplantation.
Liver transplantation is becoming an increasingly attractive option for these patients, providing good long-term survival. Metastatic disease occurs in decreasing frequency from lung, colon, pancreas, breast, and stomach.
When colon cancer metastasizes to the liver, resection of up to three lesions has been shown to improve survival and should be attempted as long as the operative risk is not prohibitive. In general, liver metastases from other tumors should not be resected. Travel to an endemic region may suggest Echinococcus. Bacterial abscesses usually arise from an intra-abdominal infection in the appendix, gallbladder, or intestine but may be due to trauma or a complication of a surgical procedure.
Causative organisms are principally gut flora, including Escherichia coli, Klebsiella, enterococci, and anaerobes including Bacteroides. Amebic abscesses owing to Entamoeba histolytica are an infrequent complication of gastrointestinal amebiasis. The liver may be tender or enlarged, and jaundice may occur.
Rupture of an abscess can lead to peritonitis, sepsis, and circulatory collapse. Risk factors include HIV, alcohol abuse, and foreign travel. Echinococcus is most commonly seen in Eastern Europe, Greece, South Africa, South America, and Australia; although rare in the United States, it is the most common cause of liver abscesses worldwide Fig. From Sun, Tsieh MD. Parasitic Disorders: Pathology, Diagnosis, and Management.
Sampling of the cyst contents with CT or ultrasound guidance reveals the causative organism in the case of pyogenic abscesses but does not usually lead to a diagnosis in amebic abscesses. Aspiration of echinococcal cysts is contraindicated because of the risk of contaminating the peritoneal cavity. Amebic abscesses are treated with metronidazole Flagyl , with or without chloroquine, and surgical drainage is reserved for complications, including rupture.
Echinococcal abscesses require an open procedure. Scolecoidal agents e. Portal hypertension is caused by processes that impede hepatic blood flow, either at the presinusoidal, sinusoidal, or postsinusoidal levels.
Presinusoidal causes include schistosomiasis and portal vein thrombosis. The principal sinusoidal cause in the United States is cirrhosis, usually caused by alcohol but also by hepatitis B and C. Postsinusoidal causes of portal hypertension include Budd-Chiari syndrome hepatic vein occlusion , pericarditis, and right-sided heart failure. Endoscopic surveillance and banding are useful in preventing bleeding episodes. For patients with upper gastrointestinal bleeds, largebore intravenous lines and volume resuscitation should be started immediately.
A nasogastric tube should be placed to confirm the diagnosis. If the patient cannot be lavaged clear, suggesting active bleeding, emergency endoscopy is both diagnostic and therapeutic. Should this fail, balloon tamponade with a Sengstaken-Blakemore tube and vasopressin infusion should be considered. Use of the Sengstaken-Blakemore tube involves passing the gastric Bleeding varices are a life-threatening complication of portal hypertension.
When portal pressures increase, flow through the hemorrhoidal, umbilical, or coronary veins becomes the low-resistance route for blood flow. The coronary vein empties into the plexus of veins draining the stomach and esophagus Fig. Engorgement of these veins places the patient at risk of bleeding into the esophagus or stomach. Laboratory examination may reveal increased liver enzymes, which may return to normal with advanced cirrhosis as the amount of functioning hepatic parenchyma decreases.
Tests of liver synthetic function, including clotting times and serum albumin, may be abnormal. Although effective in stopping life-threatening hemorrhage, the tube can produce gastric and esophageal ischemia and must be used with extreme caution. Transjugular intrahepatic portosystemic shunting has a high rate of success in controlling acute bleeding and is usually preferred to an emergent surgical shunt, although this is also an option Fig.
Seventy percent of patients with a first episode will rebleed. For this reason, a definitive procedure should be considered after the initial episode is controlled. Patients with bleeding varices and cirrhosis will ordinarily be considered for liver transplantation.
If there is no cirrhosis, or if the patient has good residual liver function, Temporary catheter entrance site surgical shunts have better long-term patency than transjugular intrahepatic portosystemic shunting. Surgical shunts are divided into nonselective and selective shunts. Nonselective shunts divert the entire portal blood flow into the systemic circulation.
An example is an end-toside portacaval shunt, in which the portal vein is divided and drained directly into the inferior vena cava. Selective shunts divert only a portion of the portal blood away from the liver.
The most common is the distal splenorenal shunt, in which portal blood is shunted through the renal vein and into the cava. Because there is still blood going to the liver to be detoxified, patients with selective shunts have less encephalopathy and equivalent success in preventing rebleeding.
As a last resort in patients with bleeding esophageal varices, a Sugiura procedure can be performed. During this procedure, the varices are disconnected from the portal circulation by complete esophageal transection and reanastomosis.
This procedure also includes splenectomy, proximal gastric devascularization, vagotcomy, and pyloroplasty. In patients with Budd-Chiari syndrome, side-toside portacaval shunt can be life-saving.
A metallic shunt is placed from the hepatic vein to the right portal vein via a catheter introduced through the internal jugular vein. Our ultimate goal remains integrating depth of factual knowledge with breadth of practice information in order to optimize both understanding and retention. We have been pleased to hear from our readers that the book is utilized by many medical students during their pediatric clinical rotations, as well as in preparation for shelf and board examinations.
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