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Disorders of the Bladder, Prostate, and Seminal Vesicles. IN: Tanagho, E.; McAninch, J., eds. Smith’s General Urology. 17th ed. Columbus, OH: McGraw Hill. 2008. pp 574-588.
This chapter about disorders of the bladder, prostate, and seminal vesicles is from an updated edition of a comprehensive textbook about urology that offers an overview of the diagnosis and treatment of diseases and disorders common to the genitourinary tract. The author begins by describing congenital anomalies of the bladder, including exstrophy, persistent urachus, and contractures of the bladder neck. The next section reviews acquired diseases of the bladder, including interstitial cystitis, internal vesical herniation, urinary incontinence, enuresis, foreign bodies introduced into the bladder and urethra, vesical manifestations of allergy, diverticula, vesical fistulas, perivesical lipomatosis, radiation cystitis, noninfectious hemorrhagic cystitis, and empyema of the bladder. A final brief section mentions congenital anomalies of the prostate and seminal vesicles, as well as bloody ejaculation. The chapter is illustrated with black-and-white drawings and photographs. The chapter concludes with an extensive list of references, categorized by topic. 3 figures. 197 references.
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Urinary Stone Disease. IN: Tanagho, E.; McAninch, J., eds. Smith’s General Urology. 17th ed. Columbus, OH: McGraw Hill. 2008. pp 246-277.
This lengthy chapter about urinary stone disease is from an updated edition of a comprehensive textbook about urology that offers an overview of the diagnosis and treatment of diseases and disorders common to the genitourinary tract. The author notes that urinary stones are common, yet their cause remains uncertain. The author begins with a discussion of the etiology, role of urinary ions, stone varieties, and symptoms and signs at the presentation of urinary tract stones. Symptoms can include pain, hematuria, infection, associated fever, nausea, and vomiting. The author reviews diagnostic approaches to urinary stones and outlines the treatment options, including conservative observation, dissolution agents, relief of obstruction, extracorporeal shock wave lithotripsy, ureteroscopic stone extraction, percutaneous nephrolithotomy, open stone surgery, pyelolithotomy, anatrophic nephrolithotomy, radial nephrotomy, and ureterolithotomy. The chapter includes a section on special situations, including renal transplantation, pregnancy, dysmorphia, obesity, medullary sponge kidney, renal tubular acidosis, associated tumors, pediatric patients, caliceal diverticula, and kidney malformations. Prevention strategies are also outlined, including metabolic evaluation and the use of oral medications. A brief review of bladder, urethral, and prepucial stones is given. The chapter is illustrated with numerous black-and-white drawings and photographs. The chapter concludes with an extensive list of references, categorized by topic. 24 figures. 110 references.
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Acute Lower Gastrointestinal Tract Bleeding. IN: Wexner, S.; Stollman, N., eds. Diseases of the Colon. . New York, NY: Informa Healthcare USA. 2007. pp 363-374.
This chapter about acute lower gastrointestinal (GI) bleeding is from a comprehensive text that offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the authors cover clinical classification, differential diagnosis, specific causes of lower GI tract bleeding, management of acute lower GI tract bleeding, and anticipated outcomes. They stress that severe acute lower GI tract bleeding is associated with unstable vital signs, rapidly developing anemia, and a possible need for transfusion. Types of GI bleeding include low-volume and high-volume hematochezia, melena, occult GI bleeding, and pseudobleeding. Specific causes of lower GI tract bleeding include diverticulosis, angiodysplasia and vascular ectasia, Dieulafoy lesions, colonic varices, Meckel’s diverticulum, postpolypectomy bleeding, colitis, ulcers, neoplasia, endometriosis, and aortoenteric fistula. The risk of mortality in acute lower GI bleeding increases with age, transfusion requirements, comorbid conditions, and the frequency of rebleeding. 2 tables. 44 references.
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Benign Prostatic Hyperplasia, Bladder Neck Obstruction, and Prostatitis. IN: Atlas of Urodynamics. 2nd ed. Williston, VT: Blackwell Publishing Inc. 2007. pp 96-119.
The purpose of urodynamic testing is to measure and record various physiological variables while the patient is experiencing those symptoms which make up the presenting complaint. This chapter on benign prostatic hyperplasia (BPH), bladder neck obstruction, and prostatitis is from an atlas of urodynamics that provides a comprehensive, detailed look at the indications, technology, and use of urodynamics in modern urologic practice. The chapter begins with a section defining the terminology currently in use, then goes on to cover mechanical obstruction, smooth muscle obstruction, differential diagnosis, urodynamic evaluation, primary bladder neck obstruction, acquired voiding dysfunction, bladder diverticula, the neurogenic bladder and BPH, and chronic pelvic pain syndrome and prostatitis. The authors then present case illustrations, accompanied by figures and black-and-white photographs of actual urodynamic tests. The authors note that, even in patients with documented prostatic obstruction, factors other than the mechanical effects of prostatic bulk play an important role. These include detrusor muscle strength and tone, bladder wall compliance, smooth muscle function of the bladder neck and prostatic urethra, striated muscle function of the prostate-membranous urethra, and interstitial factors such as elastin and collagen type. 18 figures. 1 table. 15 references.
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Bladder Outlet Obstruction and Impaired Detrusor Contractility in Women. IN: Atlas of Urodynamics.2nd ed. Williston, VT: Blackwell Publishing Inc. 2007. pp 120-144.
The purpose of urodynamic testing is to measure and record various physiological variables while the patient is experiencing those symptoms which make up the presenting complaint. This chapter on bladder outlet obstruction and impaired detrusor contractility in women is from an atlas of urodynamics that provides a comprehensive, detailed look at the indications, technology, and use of urodynamics in modern urologic practice. The chapter begins with a section on etiology and diagnosis, then present cases illustrations, accompanied by figures and black-and-white photographs of actual urodynamic tests. The authors note that urethral obstruction can be caused by prior surgery, prolapse, stricture, primary bladder neck obstruction, detrusor external sphincter dyssynergia (DESD), acquired voiding dysfunction, or urethral diverticulum; the two most common causes of genital prolapse and complications after anti-incontinence operations. From a urodynamic standpoint, the diagnosis of impaired detrusor contractility is characterized by a low flow and low detrusor pressure. 21 figures. 2 tables. 27 references.
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Colonic and Rectal Obstruction. IN: Wexner, S.; Stollman, N., eds. Diseases of the Colon. New York, NY: Informa Healthcare USA. 2007. pp 23-36.
This chapter about colonic and rectal obstruction is from a comprehensive text that offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the authors describe the etiology, pathophysiology, clinical presentation, evaluation, and treatment of colonic and rectal obstruction. They emphasize that obstruction of the large intestine is a serious medical problem that requires urgent attention and intervention. The most common causes of bowel obstruction include colorectal cancer, volvulus, and diverticular disease. Symptoms of obstruction include abdominal pain and distention and severe constipation, also called obstipation. The chapter concludes with a discussion of the recommended treatment for specific causes of colonic obstruction, including colorectal cancer, diverticular disease, volvulus, and colonic pseudo-obstruction. The chapter concludes with an extensive list of references. 2 tables. 65 references.
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Diseases of the Colon. New York, NY: Informa Healthcare USA. 2007. 809 p.
This comprehensive text offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. The book is designed as a useful, definitive, and concise reference source for internists, gastroenterologists, and general and colorectal surgeons, as well as residents and fellows in these fields. The book includes 36 chapters in eight sections: colonic development; disorders of function; diagnostics, imaging, and therapeutic techniques for colonic evaluation and intervention; infectious disorders; vascular disorders; motor disorders; neoplastic disorders of the colon; inflammatory—noninfectious—bowel disorders; anorectal disorders; and miscellaneous colonic disorders. Specific topics covered include embryology, colonic and rectal obstruction, fecal incontinence, rectal prolapse, constipation, colonoscopy, radiology of the colon, laparoscopic surgery of the colon, anorectal physiology testing, ultrasound, biofeedback for pelvic floor disorders, infectious colitis, pseudomembranous colitis, colon ischemia, radiation injury, acute lower gastrointestinal (GI) tract bleeding, vascular disorders of the colon, irritable bowel syndrome, diverticular disease, megacolon, pseudo-obstruction, volvulus, adenocarcinoma, benign and malignant colonic tumors, intestinal polyposis, ulcerative colitis, Crohn’s disease, diversion colitis and pouchitis, hemorrhoids, anal fissures, anorectal neoplastic disorders, the colon and systemic disease, and medications, toxins, and the colon. Each chapter includes black-and-white photographs and illustrations and concludes with an extensive list of references. A detailed subject index concludes the volume.
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Diverticular Disease. IN: Wexner, S.; Stollman, N., eds. Diseases of the Colon. . New York, NY: Informa Healthcare USA. 2007. pp 399-434.
This chapter about diverticular disease is from a comprehensive text that offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the authors cover historical aspects, epidemiology, natural history, pathologic anatomy, etiology and pathogenesis, uncomplicated diverticulosis, complicated diverticular disease, and hemorrhage associated with diverticular disease. They note that most people with diverticulosis are asymptomatic, which makes the pathogenesis and natural history of diverticular disease somewhat difficult to study. Particular emphasis is placed on the role of colonoscopy in the diagnosis and management of diverticular disease and on the emerging role of minimally invasive surgical management of diverticular complications. Dietary fiber may play a preventive role and should be recommended to those patients with asymptomatic or mild disease. Medical management of diverticulitis involves a combination of antibiotics and, when necessary, percutaneous drainage. Surgery is used electively after multiple attacks of diverticulitis and more urgently for complications such as abscess, free perforation, fistula, or obstruction. A patient care algorithm is provided. The chapter includes black-and-white photographs and illustrations and concludes with an extensive list of references. 11 figures. 3 tables. 211 references.
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Diverticular Disease: Evidence for Dietary Intervention?. Practical Gastroenterology. 31(2): 38-46. February 2007.
This review considers the present evidence supporting the hypothesis that a low-fiber diet is responsible for rising trends in the incidence of diverticular disease and its complications. In addition, a high-fiber diet is thought to prevent the occurrence of symptoms in patients with diverticular disease. The author notes that most of the evidence for a causal relationship is based on observational, uncontrolled studies, and that evidence from the only two randomized controlled trials conducted to test this hypothesis is inconsistent. However, the findings from the epidemiologic observational studies have been consistent and are based on a plausible biologic explanation. The author concludes that more research is needed to test these hypotheses regarding the interplay between dietary fiber and diverticulosis. 18 references.
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Diverticulitis. New England Journal of Medicine. 357(20): 2057-2066 .November 2007.
This article presents a case vignette of a patient with diverticulitis, with the evidence supporting various strategies for patient diagnosis and treatment. The author discusses formal guidelines for this disorder and presents clinical recommendations. In this case, a previously healthy 45-year-old man presents with severe lower abdominal pain on the left side, which had started 36 hours earlier. Symptoms include nausea, anorexia, and vomiting associated with any oral intake. The patient's temperature is 38.5 degrees Celsius and his heart rate is 110 beats per minute. He has abdominal tenderness on the left side, without peritoneal signs. The author reviews the terms diverticulosis and diverticular disease, the causes of colonic diverticular disease, the pathogenesis of diverticulitis, complications associated with diverticulitis, including in immunocompromised patients, diagnosis and staging, the use of imaging and endoscopy tests to confirm diagnosis, the decision to hospitalize a patient for diverticulitis, percutaneous drainage, operative intervention, and laparoscopic procedures. The author includes a section about areas of uncertainty; the section outlines recommended areas for future research. 5 figures. 1 table. 49 references.
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Laparoscopic Surgery of the Colon. IN: Wexner, S.; Stollman, N., eds. Diseases of the Colon. New York, NY: Informa Healthcare USA. 2007. pp 211-234.
This chapter about laparoscopic surgery of the colon is from a comprehensive text that offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the authors describe laparoscopy, the visualization of the abdominal cavity, and the use of laparoscopy for both diagnosis and treatment. They note that the use of therapeutic laparoscopy in the management of colorectal diseases has been slower to evolve than that used in abdominal cavity procedures, including appendectomy, cholecystectomy, and hernia. Topics covered in this chapter include rectal prolapse, diverticular disease, inflammatory bowel disease, laparoscopic colectomy, resection for colorectal cancer, and complications and conversions in laparoscopic colonic surgery. Inflammatory processes such as Crohn’s disease, ulcerative colitis, and diverticulitis may present a hostile environment for the laparoscopic surgeon due to distorted anatomy, particularly if approached in the acute phase. Pelvic disorders such as rectal prolapse are challenging because they may require the advanced laparoscopic skills of intracorporeal suturing to achieve proper fixation of the rectum. Successful laparoscopic colorectal surgery for neoplastic diseases depends on the surgeon’s ability to perform an oncologically sound resection. The chapter includes black-and-white photographs and illustrations and concludes with an extensive list of references. 5 figures. 6 tables. 161 references.
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Overactive Bladder. IN: Atlas of Urodynamics. 2nd ed. Williston, VT: Blackwell Publishing Inc. 2007. pp 83-95.
The purpose of urodynamic testing is to measure and record various physiological variables while the patient is experiencing those symptoms which make up the presenting complaint. Overactive bladder (OAB) is defined by the International Continence Society as urgency to urinate, with or without urge incontinence, and usually presenting with frequency and nocturia. This chapter on OAB is from an atlas of urodynamics that provides a comprehensive, detailed look at the indications, technology, and use of urodynamics in modern urologic practice. The chapter begins with a brief section describing OAB and then presents case illustrations, accompanied by figures and black-and-white photographs of actual urodynamic tests. The authors define OAB as a symptom complex caused by one or more of these conditions: detrusor overactivity, sensory urgency, and low bladder compliance. Conditions causing or associated with OAB can include urinary tract infection (UTI), urethral obstruction, pelvic organ prolapse, neurogenic bladder, sphincteric incontinence, urethral diverticulum, bladder stones, foreign body, and bladder cancer. The authors stress that diagnostic evaluation should be directed at early detection of these conditions because in many instances the symptoms are reversible if the underlying etiology is successfully treated. 7 figures. 12 references.
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Prebiotics, Probiotics, and Dietary Fiber in Gastrointestinal Disease. Gastroenterology Clinics of North America. 36(1): 47-64. 2007.
The microecology of the gastrointestinal tract consists of the gastrointestinal tract itself, primarily the intestines, the foods that are fed into the tract, and the flora living within. In this ecology, normal flora and probiotics ferment dietary fiber and prebiotics to produce short-chain fatty acids (SCFA) and substances that are absorbed and that affect the host at the intestinal and systemic levels. This article, from a special issue of Gastroenterology Clinics of North America that covers nutrition in gastrointestinal illness, discusses prebiotics, probiotics, and dietary fiber in gastrointestinal disease. After a definition of the terms and concepts used, the authors discuss the role of these interventions on colon neoplasia, diverticular disease, irritable bowel syndrome (IBS), constipation, inflammatory bowel disease (IBD, including Crohn's disease and ulcerative colitis), pouchitis, diarrhea, antibiotic-associated diarrhea, and hepatic encephalopathy. 108 references.
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Provocation Of Bleeding During Endoscopy in Patients With Recurrent Acute Lower Gastrointestinal Bleeding. Gastroenterology and Hepatology. 3(7): 570-573. July 2007.
This brief article considers the problem of provocation of bleeding during endoscopy in people with recurrent acute lower gastrointestinal bleeding (GIB). The authors caution that management of this problem is difficult because the bleeding tends to be intermittent and often ceases by the time of diagnostic or therapeutic intervention. They use a case report to illustrate the recommended patient approach. The case report features a 65-year-old man with two prior episodes of left-sided diverticular bleeding who was eventually diagnosed with a distal ileal carcinoid that was found as the source of his bleeding. The authors discuss the patient’s care and offer generalized recommendations for managing patients with recurrent acute GIB. The authors conclude that provocative testing should not be avoided for fear of causing uncontrollable hemorrhage because the anticoagulative effects of heparin are short-lived and are easily reversible with protamine. However, the optimal dosage for anticoagulation with heparin is not known and most likely will need to be individualized for each patient. Appended to the case report is a commentary by Steven B. Ingle and Jeffrey A. Alexander, who summarize some of the guidelines for managing recurrent obscure gastrointestinal bleeding. 22 references.
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Radiology of the Colon. IN: Thoeni, RF.; Thorton,R ., eds. Diseases of the Colon. . New York, NY: Informa Healthcare USA. 2007. pp 163-210.
This chapter about radiology of the colon is from a comprehensive text that offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the authors describe the use of plain films, barium enema, defecography, cross-sectional imaging with magnetic resonance (MR) or computerized tomography (CT), positron emission tomography (PET), nuclear studies for bleeding, and angiography and transcatheter techniques for gastrointestinal (GI) bleeding. Diseases and conditions diagnosed include extraluminal gas collections, colonic obstruction, volvulus, toxic megacolon, ischemic colitis, appendicitis, colitis, Crohn’s disease, polyps, cancer, and diverticulitis. The authors note that, in most cases, results with MR or CT for the colon are similar, but MR examinations are longer and some patients may experience claustrophobia. For functional abnormalities, for reduction of intussusception, and in screening for polyps and cancer, the double-contrast barium enema still has a role. For optimal staging of colorectal tumors, particularly for recurrence, PET is the emerging technique, used in combination with CT for assessment of primary site or scar versus recurrence, as well as metastases. The chapter includes black-and-white photographs and illustrations and concludes with an extensive list of references. 32 figures. 4 tables. 216 references.
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Rifaximin: Recent Advances in Gastroenterology and Hepatology. Gastroenterology and Hepatology. 3(6): 474-483. June 2007.
This article reviews data that have been presented at medical meetings or published in medical journals since the publication of a 2006 review of rifaximin in this journal. Rifaximin is an antibiotic that was initially developed to treat bacteria-related diarrhea, but its uses have increased as the understanding of the role of enteric bacteria has advanced. The author presents data that suggest rifaximin may be useful in several enteric conditions, including Clostridium difficile-associated diarrhea, cryptosporidial diarrhea, Helicobacter pylori-associated gastritis, inflammatory bowel disease (IBD), pouchitis, traveler’s diarrhea, diverticular disease, hepatic encephalopathy, small intestinal bacterial overgrowth, and irritable bowel syndrome. For each condition, the author reviews the related research, focusing on administration and dosage, as well as patient selection. The author concludes that rifaximin may be beneficial as monotherapy or in combination with other agents for the treatment of multiple enteric conditions. 2 figures. 5 tables. 72 references.
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Uncommon Cause of Recurrent Painless Gastrointestinal Bleeding in an Adult Male. Practical Gastroenterology. 31(8): 66, 68-69. August 2007.
This article presents the case of a 31-year-old male patient with recurrent, painless lower gastrointestinal bleeding of obscure origin. The patient underwent an extensive gastrointestinal (GI) workup, finally being diagnosed with Meckel’s diverticulum after the use of a Technetium 99m-pertechnate scan. The patient presented with the complaint of sudden onset of bright red blood per rectum; he had had a similar episode of massive GI bleeding 3 years prior. The Technetium 99m-pertechnate scan showed focal activity in the right hemi pelvis, medial to the iliac vessels. The findings were consistent with gastric mucosa containing Meckel’s diverticulum, which was subsequently resected laparoscopically. A brief discussion of this case is included, along with full-color laparoscopic images. 4 figures. 3 references.
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Understanding Diverticulosis. Oak Brook, IL: American Society for Gastrointestinal Endoscopy. 2007. 2 p.
This brochure from the American Society for Gastrointestinal Endoscopy (ASGE) familiarizes readers with diverticulosis, a condition in which there are small pouches or pockets in the wall or lining of any portion of the digestive tract. The pouches associated with diverticulosis are most often located in the lower part of the large intestine, also called the colon. The brochure describes the risk factors for diverticulosis, the causes of the condition, the symptoms of diverticulosis, diagnostic tests used to confirm a diagnosis, treatment options, and complications from diverticulosis, notably diverticulitis. The brochure notes that most people do not have symptoms of diverticulosis, so the condition is found incidentally during a screening exam for another problem such as polyps. When diverticulosis is accompanied by abdominal pain, bloating, or constipation, patients may be advised to follow a high-fiber diet to help make stools softer and easier to pass. Diverticulitis occurs when the pouches become infected or inflamed; minor cases can be treated with oral antibiotics. The brochure concludes with a brief description of the activities of and contact information for the ASGE. The brochure is also available in Spanish.
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Videourodynamics. IN: Atlas of Urodynamics. 2nd ed. Williston, VT: Blackwell Publishing Inc. 2007. pp 62-68.
The purpose of urodynamic testing is to measure and record various physiological variables while the patient is experiencing those symptoms which make up the presenting complaint. Videourodynamics provides the synchronous measurement and display of urodynamic parameters with radiographic visualization of the lower urinary tract and is a precise diagnostic tool for evaluating disturbances of micturition. This chapter on videourodynamics is from an atlas of urodynamics that provides a comprehensive, detailed look at the indications, technology, and use of urodynamics in modern urologic practice. The chapter begins with a brief section describing how videourodynamics can be used and then presents case illustrations, accompanied by figures and black-and-white photographs of actual urodynamic tests. The authors also outline the technique and equipment used. Videourodynamics is used to evaluate overall bladder control; degree of cystocele and urethrocele at rest and with straining; the state of the bladder neck at rest and straining (closed, beaked, or open); the presence of vesicoureteral reflux, bladder or urethral diverticula or fistula; and the site of urethral obstruction. 4 figures. 6 references.
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What I Need to Know About Diverticular Disease. Bethesda, MD: National Digestive Diseases Information Clearinghouse. June 2007. 12 p.
Diverticular disease includes two conditions: diverticulosis and diverticulitis. Diverticulosis occurs when pouches, called diverticula, form in the colon. Diverticulitis occurs if the pouches become inflamed or infected. This brochure explains diverticular disease, its causes, and how it can be managed. Written in nontechnical language, the brochure covers a definition of diverticular disease, the typical symptoms of diverticular disease, the risk factors and causes of diverticular disease, how to know when to consult a health care provider, diagnostic tests to confirm the condition or determine the cause of the problem, treatment options for diverticulosis and diverticulitis, and self-care strategies to help manage the condition. The booklet includes a list of resources where readers can get more information, and a list of acknowledgements. A final section briefly describes the goals and work of the National Digestive Diseases Information Clearinghouse (NDDIC). The brochure is illustrated with line drawings designed to clarify the concepts discussed in the text. 3 figures.
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Case Closed?: Diverticulitis: Epidemiology and Fiber. Journal of Clinical Gastroenterology. 40(3): S112-S116. August 2006.
A diverticulum is a sac-like protrusion on the wall of the colon; thus, diverticulosis is the presence of diverticula. Diverticulitis is a condition where these diverticula are inflamed. Approximately 10 to 25 percent of individuals with diverticular disease will develop diverticulitis. This article considers the interplay of dietary fiber and diverticulitis. Risk factors for symptomatic diverticula have been increasingly described in recent years with obesity and red meat intake being of particular importance, in addition to age. Insoluble fiber, but not soluble fiber, has been viewed as the principal component which has been deficient in the Western diet and increased risk for the development of diverticular disease and then diverticulitis. The author details how soluble fiber and its effect on the intestinal flora could have a significant influence on the development of diverticulitis. The author uses the increased frequency of right-sided diverticular disease in Asian countries compared with the west, as evidence for the role of different types of dietary fiber. 2 tables. 36 references.
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Diagnosis and Treatment of Chronic and Recurrent Diverticulitis. Journal of Clinical Gastroenterology. 40(3): S145-S149. August 2006.
Diverticulitis is a condition where diverticula (sac-like protrusions in the intestine) are inflamed. This article considers the diagnosis and treatment of chronic and recurrent diverticulitis. The authors note that the prevalence of diverticular disease has increased over the past century in Western countries. Although most patients with diverticula remain asymptomatic, among those who experience diverticulitis, one-third will have recurrent symptoms and a further third will have a subsequent episode. The authors also consider the indications for surgery after treatment of acute diverticulitis. They note that complications such as fistula to the urinary tract often require surgery; however, complicated disease such as an abscess or phlegmon can be managed conservatively and subsequent surgery is selective (depending on the recovery from the initial episode). Surgery can result in a greatly improved quality of life for patients with chronic diverticular disease (persistent pain in the absence of inflammation). Immunocompromised patients should have definitive surgical therapy early on in the course of the disease. The authors caution that, in right-sided disease and in younger patients, misdiagnosis is common. Patients with chronic diverticular disease will have relief of left lower quadrant pain with a sigmoid resection. In the elective setting, a laparoscopic approach to surgery is rapidly becoming preferred because of less morbidity and shorter hospital stays. The authors conclude that patients who develop complications of diverticulitis such as abscess, fistula, or stricture are generally operated on once the inflammatory process subsides or the abscess is drained by interventional radiology. 40 references.
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Dietary Treatment of Gastrointestinal Diseases. IN: Buchman, A., ed. Clinical Nutrition in Gastrointestinal Disease. Thorofare, NJ: Slack Incorporated. 2006. pp 63-76.
This chapter about the dietary treatment of gastrointestinal (GI) diseases is from a comprehensive textbook that compiles available data, clinical experience, and research on the role of nutrition in the management of patients with disorders that affect the GI tract. The author defines medical nutrition therapy (MNT) as diet modification, nutrient supplementation, nutrition support, and nutrition counseling as modes of therapy for disease. The chapter focuses on dietary modifications that are used to treat hospitalized or ambulatory patients with diseases of the mouth, esophagus, stomach, intestine, liver, and pancreas. The chapter covers modifications in consistency, including the clear liquid diet, the soft low-residue diet, mechanically altered diets, and the liquid diet following oral surgery; a diet for gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD); a diet following gastrectomy, including dietary modifications for dumping syndrome, and those for gastric bypass or gastric stapling for obesity; a diet for lactose intolerance or hypolactasia; a gluten-restricted diet for celiac disease; MNT for inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis, and the role of foods or dietary patterns in the etiology of IBD; a diet for ileostomy and colostomy; a diet for short bowel syndrome; a diet for acute and chronic pancreatitis; a diet to control diarrhea; a diet for constipation and diverticulosis; and sodium and protein restricted diets for liver disease, including concerns about ascites and sodium intake, and the use of protein restriction and branched chain amino acid formulas in patients with chronic liver disease and hepatic encephalopathy. The author concludes by cautioning that these diets should be used with moderation, particularly when they do not provide all nutrients. They may exacerbate existing nutrition problems and malabsorption, altered metabolism, and increased secretory losses of nutrients. 4 tables. 95 references.
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Gastrointestinal Bleeding in Older Adults. Practical Gastroenterology. 30(3): 15-42. March 2006.
This article discusses etiologic factors, clinical presentations, and management options of upper and lower gastrointestinal (GI) bleeding in older adults (older than 60 years). The authors caution that GI bleeding in older adults is associated with more morbidity and mortality than in the young, in part attributable to increased co-morbid illnesses, and greater medication use (including of nonsteroidal anti-inflammatory drugs). The article covers epidemiology, upper gastrointestinal bleeding (UGIB), peptic ulcer disease (PUD), symptoms of UGIB, the evaluation and management of patients with GI bleeding (including the use of esophagogastroduodenoscopy), the endoscopic control of UGIB, clinical course and expected outcome, lower gastrointestinal bleeding (LGIB), diverticulosis, vascular ectasias (angiodysplasias or arteriovenous malformations), colitis (ischemic, infectious, and inflammatory), and neoplasms as a cause of bleeding. A final section discusses occult or obscure GI bleeding and how to recognize it. Patient care algorithms for both upper and lower GI bleeding are provided. 2 figures. 7 tables. 90 references.
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Gastrointestinal Bleeding. IN: Nilsson, K.R.; Piccini, J.P., eds. Osler Medical Handbook. Philadelphia, PA: Saunders. 2006. pp. 428-441.
This chapter on gastrointestinal bleeding is from a handbook that provides the essentials of diagnosis and treatment, as well as the latest in evidence-based medicine, for residents working bedside, in-patient care. The chapter begins with a presentation of essential Fast Facts and concludes with Pearls and Pitfalls useful to the practicing internist. The body of the chapter is divided into sections: Epidemiology, Clinical Presentation, Diagnosis, and Management. Specific topics covered in this chapter include the management of gastrointestinal (GI) hemorrhage; how to assess the hemodynamic stability of the patient; the classification of upper and lower GI bleeding; the most common causes of upper GI bleeding (UGIB), which include peptic ulcer disease and esophageal varices; mortality from variceal and nonvariceal GI bleeding; the need for intensive care management of patients with special situations, including orthostasis, hemodynamic instability, or active bleeding; the most common causes of lower GI bleeding (LGIB), which include diverticulosis and angiodysplasia; and the need for patient follow-up after any episode of LGIB. The chapter concludes with a list of references, each labeled with a 'strength of evidence' grade to help readers determine the type of research available in that reference source. 3 figures. 5 tables. 45 references.
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Neurology, Urodynamics, and Urogynecology. IN: Kellogg Parsons, J.; James Wright, E., eds. Brady Urology Manual. New York, NY: Informa Healthcare USA. 2006. pp 63-70.
This chapter about neurourology, urodynamics, and urogynecology is from a reference handbook that offers a comprehensive overview of urology, presented in outline and bulleted formats for ease of access in the busy health care world of hospital emergency rooms and outpatient clinics. The authors remind readers that voiding is the culmination of a complex, exquisitely coordinated neuromuscular system under voluntary control but subsuming numerous visceral reflex arcs acting independently of volitional awareness or control. They discuss voiding function, the neuropharmacology of voiding, pathological conditions affecting lower urinary tract function, patterns of neurogenic dysfunction, indications for urodynamic testing, the storage/filling phase of urination, the emptying phase of urination, female urinary incontinence, vesicovaginal fistula, and urethral diverticulum. Urodynamic testing provides manometric, neuromuscular, and perceptual information to inform the practitioner diagnosing a patient with voiding dysfunction. Goals of therapy for neurogenic voiding dysfunction include preservation of kidney function, adequate urinary continence, and maximum independence or ease of care. The chapter concludes with a list of references for additional reading. 14 references.
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PKD Patient's Manual: Understanding and Living with Autosomal Dominant Polycystic Kidney Disease. Kansas City, MO: Polycystic Kidney Disease Foundation. 2006. 33 p.
This booklet provides information about autosomal dominant polycystic kidney disease (ADPKD) to those who have the disease, those who are at risk due to an affected family member, and people who care about someone who has been diagnosed with ADPKD. The primary manifestation of ADPKD is cysts in the kidney, cysts as well as other abnormalities can occur in other areas of the body. Written in a question-and-answer format, this booklet covers the epidemiology of ADPKD, symptoms, genetics and inheritance, the ADPKD genes, screening tests for ADPKD, kidney anatomy and function, cysts and their impact on the kidney, high blood pressure (hypertension), weight loss, exercise, sodium, potassium, tobacco use, acute and chronic pain in ADPKD, blood in the urine, urinary tract infection (UTI), kidney stones, liver cysts, dialysis and transplantation, mitral valve prolapse, intracranial aneurysms, hernias, diverticula, pregnancy, diet therapy, fluids, caffeine, children with ADPKD, symptoms of kidney failure, and common tests that are done to diagnose and monitor cystic disease. The booklet concludes with a list of resource organizations through which readers can get more information. 12 figures. 1 table. 2 references.
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Prebiotics, Probiotics, and Dietary Fiber. IN: Buchman, A., ed. Clinical Nutrition in Gastrointestinal Disease. Thorofare, NJ: Slack Incorporated. 2006. pp 123-138.
This chapter about prebiotics, probiotics, and dietary fiber is from a comprehensive textbook that compiles available data, clinical experience, and research on the role of nutrition in the management of patients with disorders that affect the gastrointestinal (GI) tract. The author emphasizes that the intestinal microflora is essential in maintaining health and that understanding the role of prebiotics, probiotics, and dietary fiber in the physiology of the GI tract is vital. Prebiotics are defined as food substances that are not absorbed in the small intestine, so they reach the large intestine. The section on prebiotics covers prebiotic substances used and available, the effect of prebiotics on intestinal flora, and clinical use. Probiotics are live microbial organisms obtained from humans and used in supplements. The section on probiotics discusses the organisms that are used, the physiologic effects resulting in benefit to the host, the immune process, barrier protection, the importance of fermentation, and clinical use for infections, inflammatory bowel disease (IBD) including ulcerative colitis and Crohn’s disease, pouchitis, and irritable bowel syndrome (IBS). Dietary fiber is defined as nonstarch polysaccharide in plant food that is poorly digested by human enzymes. The section on dietary fiber covers the chemical and physical properties of the fiber component of plant foods, mechanisms resulting in benefit, the effect on GI function, fermentation and short-chain fatty acids, dietary fiber intake and recommendations, the fiber contents of foods, and clinical use including the prevention of coronary heart disease and lipid control, diabetes mellitus, constipation and bowel movement regulation, diverticular disease, IBS, colon neoplasia, and IBD. The author concludes that dietary fiber is probably the best prebiotic. The intestinal microecology depends on a matrix within the colon, and the matrix depends on food to maintain a health bacterial flora. 153 references.
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Probiotics and Their Use in Diverticulitis. Journal of Clinical Gastroenterology. 40(3): S160-S162. August 2006.
This article considers the use of probiotics in diverticulitis. Probiotics are live microorganisms that, when ingested, affect the intestinal microbial flora and benefit the health of the host. The author outlines the theoretical framework for using probiotics to prevent or treat diverticular disease. Diverticulitis is a condition where the diverticula (sac-like protrusions on the wall of the colon) are inflamed. The author also summarizes two preliminary studies that explored the use of probiotics for maintenance of remission of uncomplicated diverticular disease. The results of the studies suggest that probiotics alone or in combination with mesalamine may be safe and useful in the prevention of recurrence of symptomatic diverticular disease. 10 references.
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Q & A on PKD [Polycystic Kidney Disease]. Kansas City, MO: Polycystic Kidney Disease Foundation. 2006. 47 p.
This patient education packet covers a wide variety of information about polycystic kidney disease (PKD). The first article brings readers up-to-date on autosomal dominant PKD (ADPKD) genes and proteins; the second section reviews strategies that can be used to treat hypertension and end-organ damage in patients with ADPKD. The remainder of the fact sheet answers questions that patients may have in the areas of diagnosis and genetics, extra-renal manifestations, renal manifestations, pregnancy and birth control, menopause, kidney failure, dialysis and transplantation, diet and drug therapy, surgery, the role of exercise, and pain management. Specific topics covered include multicystic kidneys, multicystic versus polycystic kidney, natural course of the disease in families, spontaneous onset of ADPKD, diagnostic criteria, fetal testing for PKD, medullary sponge kidney, symptom-free PKD, race and ethnic background as risk factors, screening family members for PKD, pancreatic cysts, diverticulosis and diverticulitis in people with PKD, malabsorption problems, polycystic liver disease, hernia and polycystic kidney, neurologic involvement, cerebral aneurysms in people with PKD, cardiovascular problems associated with PKD, pregnancy, drug therapy, blood pressure considerations, kidney infections, the use of antibiotics, urinary tract infections, kidney stones, estrogen replacement therapy, renal function tests, dialysis therapy, peritoneal dialysis, vascular access, recurrence of PKD in a newly-transplanted kidney, the impact of immunosuppressive drugs on PKD, nutrition, protein intake, soy protein versus animal protein, flax seed, phosphorus, sodium restriction, vitamins, chemotherapy, exercise, medical nutrition therapy (MNT), the relationship between primary care physicians and nephrologists, medications that can be damaging to the kidneys, diagnostic tests used to monitor PKD, and pain management. The fact sheet includes many brief case-report type questions to help readers with specific issues.
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Segmental Colitis Associated with Diverticular Disease and Other IBD Look-alikes. Journal of Clinical Gastroenterology. 40(3): S132-S135. August 2006.
A diverticulum is a sac-like protrusion on the wall of the colon; thus, diverticulosis is the presence of diverticula. Diverticulitis is a condition where these diverticula are inflamed. This article explores segmental colitis associated with diverticular disease (SCAD), an inflammatory disorder that has close clinical and histopathological similarities to idiopathic inflammatory bowel disease (IBD). SCAD is a chronic colitis that is confined to the diverticular segment in individuals with otherwise uncomplicated diverticular disease. The author compares SCAD with other IBD-like conditions, such as blind-ended pouches in ulcerative colitis, chronic granulomatous appendicitis, and delayed-surgery appendicitis. The author concludes that tissue morphology alone may be misleading in rendering a pathologic diagnosis of Crohn disease, a type of IBD. 2 tables. 26 references.
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Use of Mesalazine in Diverticular Disease. Journal of Clinical Gastroenterology. 40(3): S155-S159. August 2006.
This article considers the use of mesalazine in diverticular disease, defined as a spectrum of conditions sharing the underlying pathology of acquire diverticula of the colon. This pathology can include symptomatic uncomplicated diverticular disease, recurrent symptomatic uncomplicated diverticular disease, and complicated diverticular disease. The authors stress that goals of therapy in diverticular disease should be to improve symptoms and to prevent recurrent attacks in symptomatic uncomplicated diverticular disease, and to prevent the complications of disease such as diverticulitis. Inflammation seems to play a key role in all forms of the disease; this is the reason for the use of anti-inflammatory drugs such as mesalazine. The authors note that the mechanisms of action of mesalazine are not yet well understood. Mesalazine is an anti-inflammatory drug that inhibits factors of the inflammatory cascade (such as cyclo-oxygenase) and free radicals, and has an intrinsic antioxidant effect. The authors conclude that some recent studies confirm the effectiveness of mesalazine in diverticular disease both in relief of symptoms in symptomatic uncomplicated forms and in prevention of recurrence of symptoms and main complications. 47 references.
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What Do We Know About Diverticular Disease?: A Brief Overview. Journal of Clinical Gastroenterology. 40(3): S108-S111. August 2006.
A diverticulum is a sac-like protrusion on the wall of the colon; thus, diverticulosis is the presence of diverticula. Diverticulitis is a condition where these diverticula are inflamed. This article provides an overview of diverticulosis and its complications, notably diverticulitis. The author stresses how common diverticulosis is and considers the lack of adequate fiber intake in the Western diet as a major factor in the development of diverticulosis. Diverticulitis may be complicated by abscess formation, fistula formation, peritonitis, or obstruction. The author supports the use of computed tomography scans to plan appropriate care for patients with Diverticulitis. Most cases of simple, uncomplicated diverticulitis respond to conservative therapy with bowel rest and antibiotics. The author describes some of the controversies that remain in the care of patients with diverticulitis, including the optimal timing of surgery. The article concludes with a brief review of recent research, including one area of research that considers the overlap of diverticulitis and inflammatory bowel disease (IBD), including the use of probiotics and mesalamine in diverticular disease. 38 references.
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Diverticular Disease: Diverticulosis and Diverticulitis. EndoNurse. 5(5): 38. October-November 2005.
Diverticular disease is a condition of the large intestine characterized by the growth of diverticula, small sacs or pouches that form in the wall of the large intestine. This continuing education article helps endoscopic nurses understand the diagnosis and management of diverticular disease, including diverticulosis and diverticulitis. The author notes that constipation and a low-fiber diet are the most likely causes of diverticulosis. When the pouches become infection or inflamed, the condition is called diverticulitis. The article reviews the symptoms of diverticulitis and its associated complications, including bleeding, infections, perforations or tears, blockages, or fistula. A final section discusses the use of dietary changes that may be useful treating diverticular disease. The article concludes with a brief glossary of terms.
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Diverticular Disease: How Fiber Can Help. Cincinnati, OH: Procter & Gamble Company. 2005. 8 p.
Diverticular disease is a common condition that consists of two types: diverticulosis, which is small pouches formed in the colon, or large intestine; and diverticulitis, which is inflammation of these pouches. This brochure describes diverticular disease and reviews the use of dietary fiber to prevent and treat these conditions. The brochure reviews the causes and symptoms of diverticular disease, diagnosis and treatment, the role of fiber in managing diverticular disease, daily fiber recommendations, easy ways to increase fiber, and the use of a fiber supplement. Readers are encouraged to eat more fiber and drink plenty of fluids, not to ignore the urge to have a bowel movement, and to exercise regularly, all efforts to prevent constipation, which plays a major role in the development of diverticular disease. One section shows a sample menu of increased-fiber foods; another chart offers a list of common foods and their fiber amount. The brochure is produced by the maker of Metamucil, a popular fiber supplement, and readers are encouraged to consider the use of Metamucil in their efforts to increase fiber intake. 5 figures. 2 tables.
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Diverticulosis and Diverticulitis. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2005. 6 p.
Many people have small pouches in their colons that bulge outward through weak spots (diverticula); the condition of having these pouches is called diverticulosis. When the pouches become infected or inflamed, the condition is called diverticulitis or diverticular disease and is characterized by pain and tenderness around the left side of the lower abdomen. This fact sheet describes diverticulosis and diverticulitis and their management. Topics include the symptoms and complications of diverticulitis (bleeding, abscess, perforation, peritonitis, fistula, and intestinal obstruction), the causes and diagnosis of diverticular disease, treatment options, the role of dietary fiber, and when surgery might be necessary to treat diverticular disease. Most people with diverticulosis never have any discomfort or symptoms. The most likely cause of diverticulosis is a low-fiber diet because it increases constipation and pressure inside the colon. For most people with diverticulosis, eating a high-fiber diet is the only treatment needed. Readers are encouraged to increase their fiber intake by eating whole grain breads and cereals, fruit, and vegetables. A final section describes the goals and work of the National Digestive Diseases Information Clearinghouse. 2 figures. 1 table.
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Gastrointestinal Conditions. Journal of the American College of Surgeons. 201(5): 940- 947. December 2005.
This article reports on new developments in surgery for gastrointestinal conditions, emphasizing new approaches to common diseases, and highlighting several common gastrointestinal diseases in which there is an emerging consensus. The author reviewed the major surgery journals for selection of articles about major advances in this area. Topics include hernia, small bowel obstruction, nasogastric decompression, bariatric surgery, gastroesophageal reflux disease, peptic ulcer disease, gastric cancer, hepatic (liver) resection, liver transplantation, portal hypertension, laparoscopic bile duct injuries, chronic pancreatitis, acute pancreatitis, hemorrhoids, preoperative bowel preparation, acute diverticulitis, and laparoscopic colectomy. In each area, the author briefly summarizes the main research studies of the past year. 44 references.
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Gastrointestinal Diseases in Patients with Chronic Kidney Disease. In: Clinical Dialysis. 4th ed. New York, NY: McGraw-Hill. 2005. pp. 677-690.
Gastrointestinal (GI) disorders are common in patients with chronic kidney disease (CKD) and encompass the full spectrum of diseases that affect the general population. This chapter on GI disease in patients with CKD is from a comprehensive textbook on the clinical management of patients on dialysis. The authors review common GI complaints that are often referred to gastroenterologists for further evaluation. These diseases merit special consideration in the patient with ESRD due to their increased incidence and severity. The authors organize their discussion based on clinical presentation and symptom complex, including nausea, vomiting, diarrhea, GI bleeding, and abdominal pain. Disorders discussed include metabolic imbalance, motility disorders, peptic ulcer disease, infection, and side effects of medications. Specific topics covered are gastroparesis, peptic ulcer disease, infection, bowel obstruction and infarction, acute and chronic diarrhea, diabetic enteropathy, upper and lower gastrointestinal bleeding, ischemic colitis, diverticular bleeding, small bowel bleeding, and abdominal pain. The authors conclude that diagnostic tests and treatment strategies are best formulated in conjunction with the radiologist, gastroenterologist, and surgeon. 6 figures. 5 tables. 106 references.
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Irritable Bowel Syndrome: Does it Cause Other Disease?. Digestive Health Matters. 14(1): 4-5. Spring 2005.
This article discusses the interplay between irritable bowel syndrome (IBS) and other diseases, including colon cancer, diverticular disease, inflammatory bowel disease, celiac disease, and other functional gastrointestinal disorders. The author notes the paradox that little is known about the cause of IBS, yet health providers are confident that it has no role in causing other intestinal diseases. The author addresses other intestinal diseases that may make it difficult to diagnose IBS (particularly in developing countries where there are many tropical gut infections), the connection of IBS and diseases outside the gut, and the role of psychological disorders and IBS. The author concludes with a brief discussion regarding the diagnosis of IBS and the importance of considering other diseases when making a diagnosis. 4 references.
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Small and Large Intestines. IN: Digestive Disorders 2005. Palm Coast, FL: Medletter Associated. pp 24-29. 2005.
This lengthy section on the small and large intestines is from a White Paper on digestive disorders, including conditions that affect the esophagus, stomach, gallbladder, bile ducts, small intestine, and large intestine. This chapter covers normal anatomy of the small and large intestines; the examination of the colon and rectum, including barium enema, sigmoidoscopy, colonoscopy, virtual colonoscopy, and capsule endoscopy; and the causes, symptoms, diagnosis, and treatment of constipation, diverticulosis and diverticulitis, diarrhea, celiac disease (gluten intolerance), Crohn's disease, ulcerative colitis, irritable bowel syndrome, hemorrhoids, anal fissure, and colorectal cancer. Numerous sidebars cover some topics in greater detail: research on the clinical utility of virtual colonoscopy, specific foods and a suggested menu for people on a clear liquid diet, strategies for living with lactose intolerance, understanding changes in color of the feces (stool), the interrelationship between appendectomy and the risk of ulcerative colitis, the grains that are safe for people on a gluten-free diet (for celiac disease), a drug used in Crohn's disease that may reverse or delay the formation of fistulas, travel tips for people with inflammatory bowel disease (IBD), the risks associated with eating red meat and drinking alcohol for people with colitis, the impact of depression on IBD flare-ups, quality of life issues in irritable bowel syndrome (IBS), coping with pruritus ani (anal itching), the risks of colorectal cancer associated with a high-glycemic diet (one that includes a lot of simple and complex sugars), how high doses of aspirin may fight colon polyps, a new anticancer drug (Avastin, bevacizumab) used for metastatic colorectal cancer, laparoscopic surgery for colon cancer, and how colon cancer is staged. One illustration outlines the parts of the lower digestive system and the diseases or conditions that can affect each part. One chart summarizes the drugs used for IBD.
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Diverticular Disease of the Colon. In: Kelly, K.A.; Sarr, M.G.; Hinder, R.A., eds. Mayo Clinic Gastrointestinal Surgery. St. Louis, MO: Elsevier Science. 2004. p. 489-505.
A colonic diverticulum is a sac of mucosa protruding through the muscle wall of the colon; inflammation associated with diverticula is called diverticulitis. Complicated diverticulitis refers to the development of abscess, fistula, obstruction, bleeding, and perforation; simple diverticulitis describes the presence of diverticulitis in the absence of these complications. This chapter on diverticular disease of the colon is from a book that focuses on the major diseases treated by gastrointestinal surgeons, from the esophagus to the anal canal. The presentation has a definite clinical orientation and a major emphasis on practical applications as they are applied at the Mayo Clinic. The authors of this chapter review terminology, pathology and pathophysiology, clinical presentation, diagnosis and imaging, medical therapy and indications for operation, conduct of operation (emergency and elective laparotomy), outcomes and long-term follow-up, and diverticular bleeding. The chapter is illustrated with line drawings. 11 figures. 1 table. 95 references.
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Mayo Clinic Gastrointestinal Surgery. St. Louis, MO: Elsevier Science. 2004. 1020 p.
This book focuses on the major diseases treated by gastrointestinal surgeons, from the esophagus to the anal canal. The presentation has a definite clinical orientation and a major emphasis on practical applications as they are applied at the Mayo Clinic. Sections on etiology, pathophysiology, pathology, and diagnosis are also included by are purposely not the emphasis of the chapters. The book offers 49 chapters: the experience of being a Mayo Clinic surgeon; gastroesophageal reflux disease (GERD) and esophageal hiatal hernia; achalasia and other esophageal motility disorders; epiphrenic esophageal diverticula; cancer of the esophagus; gastric adenocarcinoma, primary gastric lymphoma; peptic ulcer; disorders of gastrointestinal motility and emptying after gastric operations; morbid obesity; hepatocellular carcinoma and intrahepatic cholangiocarcinoma; hepatic metastases from extrahepatic cancers; benign tumors and cysts of the liver; liver diseases necessitating liver transplantation; biliary stone disease; benign biliary strictures; cancer of the gallbladder; pancreatic and periampullary carcinoma; islet cell tumors; acute and chronic pancreatitis; pancreas transplantation after complications of diabetes mellitus; cystic tumors of the pancreas; thrombocytopenia and other hematologic disorders; malignant tumors of the small intestine; villous tumors of the duodenum; small intestinal diverticula; Crohn's disease; small bowel obstruction; acute mesenteric ischemia; acute mesenteric venous thrombosis; chronic mesenteric ischemia; visceral artery aneurysms; colonic motor disorders (constipation); diverticular disease of the colon; colon cancer; ischemic colitis; appendicitis; chronic ulcerative colitis; colonic volvulus; familial adenomatous polyposis; cancer of the rectum; common anorectal problems; rectal prolapse and solitary rectal ulcer syndrome; abdominal trauma; unclosable abdomen and the dehisced wound; ventral and incisional hernias; open repair of inguinal hernia; endoscopic inguinal hernia repair; and common pediatric gastrointestinal disorders. Each chapter is illustrated with line drawings, black and white photographs, and some color plates. References are provided with each chapter and a detailed subject index concludes the text.
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Small Intestinal Diverticula. In: Kelly, K.A.; Sarr, M.G.; Hinder, R.A., eds. Mayo Clinic Gastrointestinal Surgery. St. Louis, MO: Elsevier Science. 2004. p. 397-408.
Diverticula are found throughout the small intestine. However, because of their relative rarity and the infrequency with which they cause complications, they have historically been viewed as anatomical curiosities rather than life-threatening disorders. This chapter on small intestine diverticula is from a book that focuses on the major diseases treated by gastrointestinal surgeons, from the esophagus to the anal canal. The presentation has a definite clinical orientation and a major emphasis on practical applications as they are applied at the Mayo Clinic. The authors of this chapter note that complications of small intestine diverticula can indeed occur, and when they do, serious morbidity and even mortality (death) can result. The authors cover duodenal diverticula, jejunoileal diverticula, Meckel's diverticulum. For each type, the authors discuss location, incidence, cause, symptoms and signs, diagnosis, and treatment. The chapter is illustrated with line drawings and full-color photographs. 8 figures. 83 references.
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Acute Bleeding from Diverticulosis and Ischemic Colitis. In: Chung, P. and Kim, K.E. Acute Gastrointestinal Bleeding: Diagnosis and Treatment. Totowa, NJ: Humana Press. 2003. p. 163-174.
Lower gastrointestinal (GI) bleeding is a common medical problem in the United States. Two common causes of such bleeding are diverticulosis and ischemic colitis. This chapter reviews the pathogenesis, diagnosis, and management of bleeding associated with these two conditions. The chapter is from a textbook in which leading experts in the fields of gastroenterology, surgery, and radiology comprehensively review the pathophysiology, diagnosis, management, and treatment of acute bleeding disorders of the GI tract. The authors of this chapter note that acute diverticular bleeding is the most common cause of lower GI bleeding. Most patients are otherwise asymptomatic at presentation, and bleeding ceases spontaneously 70 to 80 percent of the time. Ischemic colitis is the most common form of intestinal ischemic injury, most often occurring in the left side of the colon. Colonoscopy is the diagnostic procedure of choice since it allows direct visualization of the mucosa and tissue sampling. Management is usually merely supportive, consisting of bowel rest and intravenous fluid and antibiotics, with most patients recovering in 24 to 48 hours. 2 figures. 39 references.
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Bladder, Urethra, Renal Pelvis, and Ureter. In: MacLennan, G.T.; Resnick, M.I.; Bostwick, D.G.. Pathology for Urologists. New York, NY: Elsevier Science, Inc. 2003. p. 33-79.
The renal pelvis, ureter, bladder, and urethra are muscular structures, are all lined by urothelium, and are all involved in the collection and expulsion of urine. This chapter on the bladder, urethra, renal pelvis, and ureter is from a pathology textbook that explores the full range of urology, including congenital, hereditary, inflammatory, degenerative, and benign and malignant neoplastic disorders found in the urogenital system. The chapter includes full-color photographs of gross and microscopic pathologic specimens, representing virtually all of the common and rare entities seen in practice. After an introductory section on anatomy and histology, the chapter covers congenital anomalies of the bladder, inflammatory and reactive conditions, acute and chronic cystitis, interstitial cystitis, postoperative spindle cell nodule, urothelial hyperplasia, reactive changes in the urothelium, squamous metaplasia, nephrogenic metaplasia, miscellaneous benign lesions, urothelial neoplasms, papilloma, adenocarcinoma, leiomyoma, hemangioma, neurofibroma, granular cell tumor, bladder sarcomas, hematopoietic malignancies, melanoma, pheochromocytoma, congenital urethral polyp, prostatic-type urethral polyp, urethral diverticulum, urethral caruncle, nephrogenic metaplasia, amyloidosis, malakoplakia, condyloma acuminata, congenital malformations of the renal pelvis and ureter, squamous metaplasia, benign epithelial neoplasms, carcinoma of the ureter and renal pelvis, and soft tissue tumors. Each photograph is accompanied by a descriptive text section. The text also includes explanations of the most current neoplasm classification and staging systems. 130 figures. 2 tables.
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Diverticular Disease of the Colon. In: Textbook of Gastroenterology. 4th ed. [2-volume set]. Hagerstown, MD: Lippincott Williams and Wilkins. 2003. p. 1843-1863.
A diverticulum is a sac-like protrusion of the colonic wall. The spectrum of diverticular disease encompasses diverticulosis, diverticulitis, and diverticular bleeding. This chapter on diverticular diseases of the colon is from a comprehensive gastroenterology textbook that provides an encyclopedic discussion of virtually all the disease states encountered in a gastroenterology practice. The authors of this chapter initially discuss the common epidemiology, etiology (cause), pathogenesis, pathophysiology, and natural history of diverticular diseases of the colon. A detailed discussion of the clinical presentation, diagnosis, and treatment follows, concentrating on the specific diverticular diseases and addressing special situations dictating a more individualized approach. The chapter is illustrated with black-and-white reproductions of imaging studies and drawings. 19 figures. 2 tables. 117 references.
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Diverticular Disease. In: PDxMD. PDxMD Gastroenterology. St. Louis, MO: Elsevier Science. 2003. p. 167-191.
Diverticulosis is a disorder of the digestive tract, consisting of sac-like outpouchings of mucosa and submucosa through the muscular layer. Diverticular disease encompasses all aspects and effects of the condition, including diverticulitis (inflammation of the diverticula). This chapter on diverticular disease is from a book on gastroenterology that offers concise, action-oriented recommendations for primary care medicine. The chapter covers summary information and background on the condition, and comprehensive information on diagnosis, treatment, outcomes, and prevention. Specific topics covered include the ICD9 code, urgent action, synonyms, cardinal features, causes (etiology), epidemiology, differential diagnosis, signs and symptoms, associated disorders, investigation of the patient, appropriate referrals and consultations, diagnostic considerations, clinical tips, treatment options, patient management issues, drug therapies, prognosis, complications, and how to prevent recurrence. The information is provided in outline and bulleted format for ease of accessibility. The final section of the chapter offers resources, including related associations, key references, and the answers to frequently asked questions (FAQs). 46 references.
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Diverticular Diseases. In: Bonci, L. American Dietetic Association Guide to Better Digestion. Hoboken, NJ: John Wiley and Sons, Inc. 2003. p. 114-126.
Coping with a gastrointestinal disorder, whether it is irritable bowel syndrome (IBS), gas (flatulence), constipation, heartburn, or another condition, can be embarrassing and debilitating. While medical treatments and prescriptions can offer relief, one of the most important ways patients can help themselves is in their dietary choices. This chapter on diverticular diseases is from a book that describes how patients can self-manage their digestive disorders through dietary choices. Diverticular disease is characterized by the presence of small, bulging, abnormal pouches in the intestinal wall. In this chapter, the author defines diverticular diseases (diverticulosis and diverticulitis), including their symptoms, then discusses the diagnostic tests that are used to confirm diverticular problems, treatment options, the use of nutritional supplements (notably dietary fiber), the impact of diet on diverticular symptoms, foods to choose for diverticulosis, and foods to choose for diverticulitis. The author notes that the treatment for diverticular disease is a combination of specialized diet to increase fecal mass, medications, surgery, stress management, and exercise. Diverticulitis is an acute disease, which means that patients may need to make temporary changes in eating to allow their bodies a chance to heal, but once improvement is seen, patients should go right back on a maintenance eating plan to keep the gut healthy and to decrease the risk of future diverticula forming. 4 figures.
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Diverticulosis and Diverticulitis. Journal of Wound, Ostomy, and Continence Society. 31(2): 75-82. March-April 2004.
This article for ostomy nurses discusses diverticulosis and diverticulitis, common disorders in modern society that represent different places on the spectrum of diverticular disease. Often called a problem of western civilization, diverticular disease is rare in developing countries. The author provides an overview of the epidemiology of diverticular disease, risk factors, and clinical presentation in varying phases. Differential diagnostic testing and comprehensive management from the medical, surgical, and wound, ostomy, and continence nursing perspectives are also addressed. Nurses play a key role in supporting people with diverticular disease and in referring them for appropriate assessment, treatment, and support. 3 tables. 72 references.
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Esophageal Motility Disorders. In: Katzka, D.A. and Metz, D.C., eds. Esophagus and Stomach. Orlando, FL: Mosby, Inc. 2003. p. 49-67.
Motility disorders of the esophagus encompass a wide spectrum of entities characterized by symptoms suspected of being esophageal in origin (e.g., chest pain, painful swallowing) and abnormal esophageal motility patterns. This chapter on esophageal motility disorders is from a textbook on the esophagus and stomach in which the authors focus on differential diagnosis, pitfalls, and evidence-based management approaches. The chapter covers anatomy, the physiology of swallowing, oropharyngeal dysphagia, globus sensation, Zenker's diverticulum, and primary esophageal motility disorders. For each condition, the authors review symptoms, diagnosis, and patient care management (treatment options). The chapter begins with a chapter outline, includes extensive tables and illustrations, and concludes with a list of recommended readings. 6 figures. 1 table. 10 references.
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Esophagus and Stomach. Orlando, FL: Mosby, Inc. 2003. 200 p.
In this textbook, established experts cover all of the essential information on the esophagus and stomach. The book offers thirteen chapters: gastroesophageal reflux disease; other causes of esophagitis; Barrett's esophagus; esophageal motility disorders; transfer dysphagia; rings, webs, stenoses, and diverticula of the esophagus; esophageal cancer; Helicobacter pylori gastritis and other gastric infections; peptic ulcer disease; gastroparesis and other gastric motor abnormalities; non-ulcer dyspepsia; foreign bodies of the upper gastrointestinal tract; and gastric cancer, lymphoma, and carcinoids of the stomach. The authors focus on differential diagnosis, pitfalls, and evidence-based management approaches. Each chapter begins with a chapter outline, includes extensive tables and illustrations, and concludes with a list of recommended readings. A subject index concludes the volume.
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Esophagus: Anatomy and Structural Anomalies. In: Textbook of Gastroenterology. 4th ed. [2-volume set]. Hagerstown, MD: Lippincott Williams and Wilkins. 2003. p. 1148-1165.
This chapter on the anatomy and structural anomalies of the esophagus is from a lengthy, two-volume textbook that integrates the various demands of science, technology, expanding information, good judgment, and common sense into the diagnosis and management of gastrointestinal patients. The authors stress that recognition of pathological alterations in their earliest stages and optimal interpretation of every test of esophageal function and morphology can be accomplished only through awareness of normal anatomy and its variants. Topics covered in this chapter include embryology, adult anatomy, histology, developmental anomalies, pharyngoesophageal diverticula, esophageal diverticula, and esophageal hiatal hernias. 12 figures. 190 references.
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Female Pelvic Health and Reconstructive Surgery. New York, NY: Marcel Dekker, Inc. 2003. 503 p.
This textbook provides comprehensive, authoritative coverage of female pelvic health and reconstructive surgery. The editors compiled contributions from many experts who specialize in the treatment of pelvic floor disorders. The text includes 27 chapters on the epidemiology and etiology of incontinence and voiding dysfunction; diagnostic evaluation of the female patient; bladder physiology and neurophysiological evaluation; diagnosis and assessment of female voiding function; radiological evaluation; urodynamic evaluation of pelvic floor dysfunction; injectable agents for the treatment of stress urinary incontinence in females; transabdominal procedures for the treatment of stress urinary incontinence; transvaginal surgery for stress urinary incontinence; laparoscopic approaches to female incontinence, voiding dysfunction, and prolapse; diagnosis and management of obstruction following anti-incontinence surgery; pediatric dysfunctional voiding in females; nonsurgical treatment of urinary incontinence; sacral nerve root neuromodulation or electrical stimulation; musculoskeletal evaluation for pelvic pain; diagnosis and management of interstitial cystitis (IC); abdominal approach to apical prolapse; the types and choice of operation for repair of vaginal prolapse; colpocleisis for the treatment of vaginal vault prolapse; technique of vaginal hysterectomy; urethral diverticulum; evaluation and management of urinary fistulas; iatrogenic urological trauma; surgical treatment of rectovaginal fistulas and complex perineal defects; pessaries; menopause and hormone replacement therapy; and diagnosis of female sexual dysfunction. Each chapter includes black and white photographs and charts and concludes with a list of references. A subject index concludes the volume.
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Gastroenterology. St. Louis, MO: Elsevier Science. 2003. 623 p.
This book on gastroenterology is from a series that provides the latest on evaluation, diagnosis, management, outcomes and prevention. The book offers concise, action-oriented recommendations for primary care medicine. It includes MediFiles (sections) on acute appendicitis, Budd-Chiari syndrome, celiac disease, cholecystitis, cirrhosis, Crohn's disease, diverticular disease, gastroesophageal reflux disease (GERD) in adults, hemorrhoids, alcoholic hepatitis, viral hepatitis, femoral and inguinal hernia, irritable bowel syndrome, lactose intolerance, Mallory-Weiss syndrome, pancreatitis, peptic ulcer, acute peritonitis, proctitis, pseudomembranous colitis, pyloric stenosis, rectal malignancy, and ulcerative colitis. Each MediFile covers summary information and background on the condition, and comprehensive information on diagnosis, treatment, outcomes, and prevention. Each section concludes with a list of resources.
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Inflammatory Diseases of the Colon, Rectum, Anus, and Perianal Region. In: Stein, E. Anorectal and Colon Diseases: Textbook and Color Atlas of Proctology. New York, NY: Springer-Verlag. 2003. p. 335-398.
This chapter on inflammatory diseases of the colon, rectum, anus, and perianal region is from a multidisciplinary reference book and atlas that covers all aspects of anorectal and colon disease (proctology). Topics include Crohn disease, ulcerative colitis, ischemic (lack of blood flow) colitis, collagenous colitis, pseudomembranous colitis, irritable bowel syndrome (IBS), colitis cystica profunda, solitary rectal ulcer, diverticulosis and diverticulitis, and radiation proctitis. In each section, the author considers etiology, clinical features, diagnosis, therapy, and prognosis. The chapter includes full-color and black-and-white illustrations and photographs, to support the heavily-visual aspects of proctology. Each section concludes with a list of references. 42 figures. 12 tables. 444 references.
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Laparoscopy in Children. Heidelberg, Germany: Springer-Verlag. 2003. 147 p.
Most surgeons are familiar with the techniques of laparoscopic surgery, however, in children there are variations in size and technical approach. This book describes the differences and characteristic aspects of laparoscopy in small children. The book is an atlas of numerous drawings, accompanied by textual descriptions. Technical guidelines are given on how to perform laparoscopy safely, even in small children. Topics include patient selection, anesthesia, insufflation, trocar insertion, instruments, ligating, needle insertion, suturing, adhesiolysis, appendectomy, cholecystectomy (gallbladder removal), cryptorchidism, fundoplication, inguinal hernia, intussusception, liver biopsy, Meckel's diverticulum, ovary, pyloromyotomy, sigmoid resection, splenectomy, varicocele, thoracoscopy, and postoperative care. The aim of the book is to provide surgeons with the knowledge to extend their expertise in adult laparoscopy to children. A subject index concludes the textbook.
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Meckel's Diverticulum. In: Schier, F. Laparoscopy in Children. Heidelberg, Germany: Springer-Verlag. 2003. p.94-99.
Most surgeons are familiar with the techniques of laparoscopic surgery, however, in children there are variations in size and technical approach. This section on laparoscopic treatment for Meckel's diverticulum is from a book that describes the differences and characteristic aspects of laparoscopy in small children. The book is an atlas of numerous drawings, accompanied by textual descriptions. Technical guidelines are given on how to perform the laparoscopic procedure safely, even in small children. The authors note that they use laparoscopy for both diagnosis and treatment of Meckel's diverticulum. Illustrations depict the trocar placement, instruments used, the technique of locating and isolating the diverticulum, and the surgical techniques used for removing the diverticulum. The aim of the book is to provide surgeons with the knowledge to extend their expertise in adult laparoscopy to children. 6 figures.
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Radiological Evaluation. In: Carlin, B.I. and Leong, F.C., eds. Female Pelvic Health and Reconstructive Surgery. New York, NY: Marcel Dekker, Inc. 2003. p. 51-75.
This chapter on radiological evaluation is from a textbook that provides comprehensive, authoritative coverage of female pelvic health and reconstructive surgery. The radiological evaluation of the female pelvic floor disorders includes many examinations and multiple imaging modalities, including conventional radiography, ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Within each modality are different examinations, ranging from general screening studies to specific examinations optimized to address a particular clinical question. The authors focus on the imaging examinations utilized with the most common female pelvic floor pathologies: stress incontinence, urethral diverticulum, urinary fistulas, and pelvic floor relaxation. With each disease entity, the technique and imaging findings are reviewed. 13 figures. 38 references.
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Rings, Webs, Stenoses, and Diverticula of the Esophagus. In: Katzka, D.A. and Metz, D.C., eds. Esophagus and Stomach. Orlando, FL: Mosby, Inc. 2003. p. 87-97.
There are many anatomical abnormalities of the esophagus that may be congenital or acquired. This chapter addresses esophageal rings, webs, stenoses, and diverticula; the chapter is from a textbook on the esophagus and stomach in which the authors focus on differential diagnosis, pitfalls, and evidence-based management approaches. The chapter covers muscular and mucosal esophageal rings; esophageal webs; stenoses, including benign strictures or malignant tumor strictures; and diverticula, including pharyngoesophageal diverticula, midesophageal diverticula, epiphrenic diverticula, and intramural pseudodiverticulosis. The authors review the underlying etiology, clinical manifestations, diagnostic tests, and treatment options for these abnormalities. The chapter begins with a chapter outline, includes extensive tables and illustrations, and concludes with a list of recommended readings. 2 figures. 2 tables. 10 references.
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Small Intestine: Anatomy and Structural Anomalies. In: Textbook of Gastroenterology. 4th ed. [2-volume set]. Hagerstown, MD: Lippincott Williams and Wilkins. 2003. p. 1466-1485.
This chapter on the anatomy and structural anomalies of the small intestine is from a lengthy, two-volume textbook that integrates the various demands of science, technology, expanding information, good judgment, and common sense into the diagnosis and management of gastrointestinal patients. Topics covered in this chapter include gross anatomy, microscopic anatomy, embryology, congenital anomalies, and structural anomalies. Specific anomalies discussed include Meckel diverticulum, duplications, intestinal atresia and stenosis, malrotation, gastroschisis and omphalocele, volvulus, intussusception, and lymphangiectasia. 10 figures. 222 references.
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Urethral Diverticulum. In: Carlin, B.I. and Leong, F.C., eds. Female Pelvic Health and Reconstructive Surgery. New York, NY: Marcel Dekker, Inc. 2003. p. 351-362.
This chapter on urethral diverticulum is from a textbook that provides comprehensive, authoritative coverage of female pelvic health and reconstructive surgery. The authors stress that urethral diverticulum should be considered in the setting of any woman with lower urinary tract symptoms. The clinical suspicion must be high, and effective imaging and other diagnostic techniques do exist to diagnose this condition. The authors discuss the use of urethroscopy, radiology, and urodynamics in the diagnosis of urethral diverticulum. Transvaginal diverticulectomy is the treatment of choice and is highly successful. 4 figures. 2 tables. 49 references.
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Virtual Colonoscopy. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2003. 2 p.
Virtual colonoscopy (VC) uses x rays and computers to produce two- and three-dimensional images of the colon (large intestine). The procedure is used to diagnose colon and bowel disease, including polyps, diverticulosis, and cancer. VC can be performed with computed tomography (CT) or with magnetic resonance imaging (MRI) scans. This fact sheet describes virtual colonoscopy, including the preprocedure activities, and the advantages and disadvantages of VC. One sidebar briefly describes conventional colonoscopy. A final section describes the goals and work of the National Digestive Diseases Information Clearinghouse.
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Abdominal Abscesses and Gastrointestinal Fistulas. In: Feldman, M.; Friedman, L.S.; Sleisenger, M.H. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 7th ed. [2-volume set]. St. Louis, MO: Saunders. 2002. p. 431-445.
The development of an intra-abdominal abscess (IAA, infection) occurs as a result of a host response to intra-abdominal bacterial contamination secondary to, or in conjunction with, various pathologic clinical entities. In 60 to 80 percent of cases, IAA is associated with perforated hollow viscera, whether as a result of inflammatory disease such as appendicitis or diverticulitis, or as a consequence of penetrating or blunt trauma to the abdomen. A fistula is any abnormal anatomic connection between two epithelialized surfaces. Compared with fistulas connected to the skin that are obvious, internal fistulas may be difficult to diagnose. This chapter on abdominal abscesses and gastrointestinal fistulas is from a comprehensive and authoritative textbook that covers disorders of the gastrointestinal tract, biliary tree, pancreas, and liver, as well as the related topics of nutrition and peritoneal disorders. Topics include the pathophysiology, bacteriology, management, and expected outcome of abdominal abscesses; and definitions, classifications, pathophysiology, diagnosis, management, and outcomes associated with gastrointestinal fistulas. A patient care algorithm for the latter is also included. The chapter includes a mini-outline with page citations, full-color illustrations, and extensive references. 11 figures. 8 tables. 115 references.
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Acute Abdominal Pain. In: Edmundowicz, S.A., ed. 20 Common Problems in Gastroenterology. New York, NY: McGraw-Hill, Inc. 2002. p. 93-107.
Acute abdominal pain is a common complaint of patients coming to a primary care physician. A primary objective of the initial patient evaluation is to determine if the presentation requires emergency evaluation and therapy. This chapter on acute abdominal pain is from a book that focuses on the most common gastroenterological problems encountered in a primary practice setting. The chapter is organized to support rapid access to the information necessary to evaluate and treat most patients with this problems. Topics include the prevalence of acute abdominal pain; principal diagnoses, including gastric ulcer, duodenal ulcer, acute cholecystitis, acute pancreatitis, acute small bowel obstruction, acute mesenteric ischemia (lack of blood flow), acute appendicitis, large bowel obstruction, and acute diverticulitis; the typical presentation of each of these conditions; the recommended physical examination and ancillary tests including complete blood cell count, blood chemistry, abdominal x ray, barium radiography, ultrasonography, hepatobiliary scanning, computer tomography (CT) scan, angiography, and endoscopy; treatment options for each of the diagnoses; and clinical errors. The chapter includes an outline for quick reference, the text itself, a diagnostic and treatment algorithm, and selected references. 2 figures. 1 table. 16 references.
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Acute Lower Gastrointestinal Bleeding. In: Edmundowicz, S.A., ed. 20 Common Problems in Gastroenterology. New York, NY: McGraw-Hill, Inc. 2002. p. 123-136.
The typical presentation of lower gastrointestinal (GI) bleeding is the passage of blood in the stool. Approximately 80 percent of patients with GI bleeding will pass blood in some form through the rectum. The lower GI tract accounts for up to one-third of all cases of GI bleeding; the upper tract accounts for the remainder. This chapter on acute lower GI bleeding (LGIB) is from a book that focuses on the most common gastroenterological problems encountered in a primary practice setting. The chapter is organized to support rapid access to the information necessary to evaluate and treat most patients with this problems. Topics include the prevalence of LGIB; its definition and typical presentation; key points in the patient history, including the anatomic level of bleeding, the quantity of blood lost, the etiology of bleeding, and precipitating factors; the physical examination and ancillary tests, including laboratory studies, sigmoidoscopy and anoscopy, colonoscopy, a tagged red blood cell scan, angiography, esophagogastroduodenoscopy, small bowel enteroscopy, and barium studies; etiology (cause), including diverticulosis, angiodysplasia, neoplasia (including cancer), medications, and other causes; treatment options, including the initial resuscitation, specific treatment, endoscopic therapy, angiotherapy, and surgery; patient education issues; common errors in diagnosis and treatment; controversies; and emerging concepts. The chapter includes an outline for quick reference, the text itself, a diagnostic and treatment algorithm, and selected references. 2 figures. 2 tables. 27 references.
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Anatomy, Histology, Embryology, and Developmental Anomalies of the Small and Large Intestine. In: Feldman, M.; Friedman, L.S.; Sleisenger, M.H. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 7th ed. [2-volume set]. St. Louis, MO: Saunders. 2002. p. 1643-1663.
This chapter on the anatomy, histology, embryology, and developmental anomalies of the small and large intestine is from a comprehensive and authoritative textbook that covers disorders of the gastrointestinal tract, biliary tree, pancreas, and liver, as well as the related topics of nutrition and peritoneal disorders. Topics include intestinal anatomy, intestinal histology, embryology of the intestine and pathogenesis of bowel malformations, clinical presentations of anomalies of the gastrointestinal tract, associated malformations, and developmental anomalies of the intestine. The latter section covers abdominal wall defects (omphalocele and gastroschisis), anomalies of rotation and fixation, duplications, Meckel's diverticulum, intestinal atresia, anorectal malformations, anomalies of intrinsic innervation and motility, and microvillous membrane and epithelial defects. The chapter includes a mini-outline with page citations, full-color illustrations, and extensive references. 18 figures. 6 tables. 90 references.
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Cysts and Congenital Biliary Abnormalities. In: Sherlock, S.; Dooley, J. Diseases of the Liver and Biliary System. Malden, MA: Blackwell Science, Inc. 2002. p.583-596.
Cystic lesions of the liver and bile ducts are increasingly being diagnosed. This chapter on cysts and congenital biliary abnormalities is from a textbook that presents a comprehensive and up-to-date account of diseases of the liver and biliary system. The chapter covers fibropolycystic disease, including that found in childhood; adult polycystic disease; congenital hepatic (liver) fibrosis, including congenital intra-hepatic biliary dilatation (Caroli's disease), congenital hepatic fibrosis and Caroli's disease, choledochal cysts, microhamartoma (von Meyenberg complexes), carcinoma (cancer) secondary to fibropolycystic disease, solitary non-parasitic liver cysts, and other cysts; and congenital anomalies of the biliary tract, including absence of the gallbladder, double gallbladder, accessory bile ducts, left-sided gallbladder, Rokitansky-Aschoff sinuses, folded gallbladder, diverticula of the gallbladder and ducts, intra-hepatic gallbladder, congenital adhesions to the gallbladder, floating gallbladder and torsion of the gallbladder, and anomalies of the cystic duct and cystic artery. 15 figures. 3 tables. 49 references.
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Diverticula of the Hypopharynx, Esophagus, Stomach, Jejunum, and Ileum. In: Feldman, M.; Friedman, L.S.; Sleisenger, M.H. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 7th ed. [2-volume set]. St. Louis, MO: Saunders. 2002. p. 359-368.
Diverticula arise as outpouchings from tubular structures. This chapter on diverticula of the hypopharynx, esophagus, stomach, jejunum, and ileum is from a comprehensive and authoritative textbook that covers disorders of the gastrointestinal tract, biliary tree, pancreas, and liver, as well as the related topics of nutrition and peritoneal disorders. Topics include Zenker's diverticula, diverticula of the esophageal body, esophageal intramural pseudodiverticula, gastric (stomach) diverticula, duodenal diverticula, intramural duodenal diverticula, and jejunal diverticula. For each type, the authors consider etiology and pathogenesis, clinical presentation and diagnosis, treatment, and prognosis. The chapter includes a mini-outline with page citations, full-color illustrations, and extensive references. 10 figures. 1 table. 87 references.
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Diverticular Disease of the Colon. In: Feldman, M.; Friedman, L.S.; Sleisenger, M.H. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 7th ed. [2-volume set]. St. Louis, MO: Saunders. 2002. p. 2100-2112.
Diverticular disease of the colon includes a constellation of symptoms that range from mild irregularities in defecatory function to severe bleeding and the consequences of severe intra-abdominal inflammation. This chapter on diverticular disease of the colon is from a comprehensive and authoritative textbook that covers disorders of the gastrointestinal tract, biliary tree, pancreas, and liver, as well as the related topics of nutrition and peritoneal disorders. Topics covered include epidemiology, pathogenesis, pathology, structural abnormalities, functional abnormalities, diverticulosis, diverticular bleeding, and diverticulitis. For each of the latter three conditions, the authors review clinical manifestations, pathogenesis, differential diagnosis, diagnostic studies, and treatment. The chapter includes a mini-outline with page citations, illustrations, and extensive references. 7 figures. 1 table. 95 references.
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Diverticular Disease. In: Corman, M.L.; Allison, S.I.; Kuehne, J.P. Handbook of Colon and Rectal Surgery. Philadelphia, PA: Lippincott Williams and Wilkins. 2002. p.637-653.
This chapter on diverticular disease is from a handbook that addresses the entire range of diseases affecting the colon, rectum, and anus. The authors note that diverticular disease has become progressively more pervasive in the 20th century and virtually epidemic in Western countries. However, probably not more than 10 percent of persons with colonic diverticula have symptoms, and only a small proportion of these ever require surgery. Topics include pathogenesis, etiology, epidemiology, the impact of diet, symptoms and findings, the medical management of acute diverticular disease, differential diagnosis (carcinoma, polyps, Crohn's disease, ulcerative colitis, ischemic colitis), complications (free perforation, phlegmon or abscess, fistulas, hemorrhage), the surgical treatment of acute diverticulitis, elective resection, myotomy, giant colonic diverticulum, diverticular disease of the right colon, diverticular disease of the transverse colon, and solitary cecal ulcer.
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Diverticular Hemorrhage: Pathogenesis, Diagnosis and Management. Practical Gastroenterology. 26(1): 13-14, 19-20, 22. January 2002.
Colonic diverticular bleeding is common cause of lower gastrointestinal tract hemorrhage. This article discusses the pathogenesis (development), diagnosis, and management of diverticular hemorrhage. Diagnostic techniques involved in determining the extent and location of diverticular bleeding include scintigraphy, angiography, and colonoscopy. Therapeutic radiographic options in controlling diverticular bleeding involve the infusion of vasopressin or selective embolization. Recently, the role of colonoscopy has expanded to allow endoscopic hemostasis of bleeding diverticuli. Current options involve electrocoagulation, injection therapy, or endoscopic hemoclipping. Surgery may be required in patients who fail attempts at hemostasis with medical, angiographic, or endoscopic therapy. 1 figure. 35 references.
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Facts and Fallacies About Digestive Diseases. Practical Gastroenterology. 26(6): 76. June 2002.
This brief patient information handout reviews facts and fallacies about digestive diseases. Four false statements are considered: diverticulosis is an uncommon and serious problem; inflammatory bowel disease is caused by psychological problems; cirrhosis (liver scarring) is only caused by alcoholism; and after ostomy surgery, men become impotent and women have impaired sexual function and are unable to become pregnant. Each of these false statements is clarified and the accurate information is provided.
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Flexible Ureteroscopy Comes of Age. Contemporary Urology. 14(6): 32-33,36, 38, 40, 42, 47-50, 53-54. June 2002.
Since its introduction, major milestones in the evolution of flexible ureteroscopy have included the development of reliable active deflection, improved range of deflection, the combination of active and passive segments in the same endoscope, the addition of a throughput channel for irrigation and instrumentation passage, improvement in image resolution and light transmission, miniaturization of endoscopes to 7.5F or smaller, the advent of the holmium-yttrium-aluminum-garnet laser for lithotripsy and upper tract surgery, and the development of 2F to 3F accessory instrumentation. This article, the first in a two part series, brings readers up to date on the use of flexible ureteroscopy. The authors discuss current flexible ureteroscopes, and instrumentation, and clinical results of this procedure, as it is used for urinary tract stones, diagnostic procedures, upper tract tumors, ureteral strictures, and calyceal diverticulum. 1 figure. 6 tables. 36 references.
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Handbook of Colon and Rectal Surgery. Philadelphia, PA: Lippincott Williams and Wilkins. 2002. 931 p.
This handbook provides a more portable version of the larger textbook with the same title: Colon and Rectal Surgery, 4th Edition. The coverage addresses the entire range of diseases affecting the colon, rectum, and anus. A stepwise approach to treatment guides physicians from evaluation to follow up with incisive coverage of symptoms, testing and diagnosis, preparation, medical and surgical management, and postoperative care. Thirty-three chapters cover anatomy and embryology of the anus, rectum, and colon; physiology of the colon; diet and drugs in colorectal surgery; evaluation and diagnostic techniques; flexible sigmoidoscopy and colonoscopy; setting up a colorectal physiology laboratory; analgesia (pain killing) in colon and rectal surgery; hemorrhoids; anal fissure; anorectal abscess; anal fistula; rectovaginal and rectourethral fistulas; anal incontinence; colorectal trauma; management of foreign bodies; disorders of defecation; rectal prolapse, solitary rectal ulcer, syndrome of the descending perineum, and rectocele; pediatric surgical problems; cutaneous conditions; colorectal manifestations of acquired immunodeficiency syndrome (HIV); polypoid diseases; carcinoma (cancer) of the colon; carcinoma of the rectum; malignant tumors of the anal canal; less common tumors and tumorlike lesions of the colon, rectum, and anus; diverticular disease; laparoscopic-assisted colon and rectal surgery; vascular diseases; ulcerative colitis; Crohn's disease and indeterminate colitis; intestinal stomas; enterostomal therapy; and miscellaneous colitides. The handbook includes the same illustrations as the larger text. A subject index concludes the volume.
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Lower Gastrointestinal Bleeding and Ischemic Colitis. Canadian Journal of Gastroenterology. 16(9): 597-600. September 2002.
This article reports on a study that compared the incidence and clinical characteristics of lower gastrointestinal (LGI) bleeding due to ischemic colitis with those with LGI bleeding of other causes. A chart review was performed of patients admitted with LGI bleeding to Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, between July 1, 1997 and January 31, 2000. Of 124 patients with LGI bleeding, 24 cases were due to ischemic colitis, 62 to diverticulosis, 11 to inflammatory bowel disease (IBD), and 27 to all other causes ('others'). The average ages of patients in each group were 66.5, 76.5, 40.5, and 77.5 years, respectively. Patients with ischemic colitis were statistically younger than those with diverticular bleeding and 'others.' Patients with IBD were younger than those in the other three groups. The only statistical difference for vascular disease risks was hypertension, because of its absence from the IBD group. Three patients with ischemic colitis underwent blood transfusions, while 23 with diverticulosis, 15 'others' and none with IBD received blood. Three patients with ischemic colitis and one patient from the 'others' group died. More women (75) than men (49) had LGI bleeding, in total and within each subgroup. Of women with LGI bleeding, many more with ischemic colitis (44.4 percent) than with diverticulosis (3.0 percent), IBD (0 percent) or 'others' (5.6 percent) were taking estrogen. 16 references.
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Meeting the Challenge of Complex Urethral Diverticula. Contemporary Urology. 14(9): 52-54, 59, 62, 64, 66-68, 70. September 2002.
Diverticula (pouches) of the female urethra present one of the more challenging diagnostic and reconstructive problems in urology. Urethral diverticula (UD) are noted for a bewildering variety of clinical presentations, ranging from completely asymptomatic lesions noted incidentally on physical examination or x-ray to very debilitating, painful vaginal masses associated with incontinence, stones, and tumors. This article reviews the diagnosis and management of UD in females with an emphasis on some of the more complicated or challenging aspects of this condition. Topics include anatomy and pathophysiology, presentation and diagnosis, imaging techniques, and surgical considerations. The authors stress that a step-wise approach to the diagnosis and management of UD should result in successful therapy of even the most complicated case. Operative techniques, including creation of a neourethra, may be necessary to restore urethral continuity when there is circumferential extension of the UD. 7 figures. 1 table. 29 references.
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Timing of Prophylactic Surgery in Prevention of Diverticulitis Recurrence: A Cost-Effectiveness Analysis. Digestive Diseases and Sciences. 47(9): 1903-1908. September 2002.
Although surgery is recommended after two or more attacks of uncomplicated diverticulitis, the optimal timing for surgery in terms of cost-effectiveness is unknown. This article reports on a study in which a Markov model was used to compare the costs and outcomes of performing surgery after one, two, or three uncomplicated attacks in hypothetical cohorts of 60 year old patients. Transition state probabilities were assigned values using published data and expert opinion. Costs were estimated from Medicare reimbursement rates. Surgery after the third attack is cost saving, yielding more years of life and quality adjusted life years at a lower cost than the other two strategies. The results were not sensitive to many of the variables tested in the model or to changes made in the discount rate. The authors conclude that performing prophylactic resection after the third attack of diverticulitis is cost saving in comparison to resection performed after the first or second attacks and remains cost-effective during sensitivity analysis. 1 figure. 3 tables. 34 references.
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Understanding Diverticular Disease. Ostomy Quarterly. 39(2): 56-57. Winter 2002.
Diverticular disease is a condition where the diverticula form in the colon; it is associated with abdominal pain and disturbed bowel habits. The symptoms are caused by intestinal muscle spasms, not from an inflammation of the diverticula. Diverticulosis is the presence of diverticula in the colon with no symptoms. This newsletter article helps readers with ostomies understand diverticular disease. Diverticular disease is very common in the United States; roughly half of Americans develop diverticula by the age of 60 and nearly all of those over 80 do. Most people with diverticula have no complications. Unless a diverticulum becomes inflamed, it will produce no symptoms (including pain). The article considers the causes of diverticular disease, the symptoms, the causes of diverticulitis (inflammation), treatment strategies for diverticulitis, and the prevention of diverticular disease. A diet high in fiber may prevent the development of diverticula within the colon and may lessen the symptoms associated with diverticular disease. Most cases of diverticulitis respond to medical treatment. Surgery is reserved for patients with recurrent bouts of diverticulitis or when complications arise. 2 figures.
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Adult Onset Nocturnal Enuresis. Journal of Urology. 165(6 Part 1): 1914-1917. June 2001.
This article reports on a study that determined the etiology and prognostic significance of adult onset nocturnal enuresis (bedwetting) with absent daytime incontinence. The authors note that adult onset nocturnal enuresis not associated with daytime incontinence is uncommon and that there is a lack of information about its incidence, significance, evaluation, and treatment. The authors present a retrospective evaluation of this condition based on a database review of 3,277 consecutive patients referred for the evaluation of lower urinary tract symptoms. Patients with daytime incontinence were excluded from the study. Evaluation consisted of history, physical examination, American Urological Association (AUA) symptom score, voiding diary, uroflowmetry (measurement of urination), estimation of postvoid residual urine, video urodynamics, cystoscopy, and radiographic evaluation of the upper urinary tract. Of 3,277 patients, 8 (0.02 percent) had adult onset nocturnal enuresis without daytime incontinence as a primary complaint. Average AUA symptom score was 12.6 (range 3 to 25), average maximum urine flow was 8.5 milliliters per second (range 5 to 15), and average postvoid residual urine (urine remaining in the bladder after urination) was 350 milliliters (range 50 to 489). All patients were men with severe prostatic or vesical neck obstruction as well as bilateral or unilateral hydronephrosis (extra urine retention in the kidneys) in 63 percent, a bladder diverticulum in 38 percent, vesicoureteral reflux (return of urine from bladder back through the ureters to the kidneys) in 50 percent, and low bladder compliance in 50 percent. Transurethral prostatic resection (TURP) was recommended to all patients, but only 5 agreed. The other 3 cases were managed by alpha adrenergic antagonists, including 2 by adjunctive clean intermittent self catheterization. In all patients who underwent TURP, symptoms resolved. 2 figures. 1 table. 12 references.
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Diagnosis and Therapy of the Female Urethral Diverticula. International Urogynecology Journal. 12(1): 51-57. February 2001.
This article reviews the various diagnostic and therapeutic modalities currently in use for female urethral diverticula. Female urethral diverticula (a pouchlike herniation) have always been considered rare. Various radiographic techniques have been reported, but only voiding cystourethrography (VCUG) and positive pressure urethrography (PPU) are currently utilized. Urethroscopy is another suitable technique for diagnosis. Various sonographic (ultrasound) techniques have been proposed, but their sensitivity is improved only by the transvaginal approach and magnetic resonance imaging (MRI). Various treatment methods have been proposed. The standard operative approach is surgical, through the vagina. The techniques currently in use to treat urethral diverticula are the Spence procedure, the typical urethral diverticulectomy, and the Tancer partial ablation technique. A full history and physical examination are the first step in screening. When the diagnosis is suspected, ultrasound and radiological imaging is necessary. Symptomatic and very large diverticula must be treated in the easiest way possible. The best treatment, except for complicated and infected diverticula, is excision. 1 table. 61 references.
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Diverticular Disease in the Elderly. Gastroenterology Clinics of North America. 30(2): 475-496. June 2001.
The term diverticular disease refers to the entire spectrum of asymptomatic to symptomatic disease associated with colonic diverticula (a pouch or sac created by herniation of the lining of mucus membrane in the intestine). Diverticulosis is the presence of one or more diverticula; diverticulitis is diverticulosis with clinical symptoms and evidence of inflammation. This article, from a special issue on gastrointestinal (GI) disorders in the elderly, addresses diverticular disease, a condition of special significance in the elderly. The incidence and severity of diverticular disease increases with age. Elderly patients often present with complicated diverticular disease, and because of their advanced age, poor ability to provide a history, and muted symptoms and signs, the diagnosis is particularly difficult to make. Consequently, great demands are placed on the physician to diagnose and treat diverticular disease in this population. In the past, advanced age made conservative therapy the standard of care for most patients; however, recent endoscopic, radiologic, and surgical advances have helped define more definitive therapies for patients with complicated diverticular disease. Complications of diverticulitis can include abscess, fistula (an opening between the colon and surrounding structures), obstruction, free perforation, and diverticular hemorrhage. Treatment strategies include bed rest, oral broad spectrum antibiotics, bowel rest, and oral hydration for uncomplicated diverticulitis; complicated diverticulitis generally requires surgery in addition to these primary care strategies. Lack of improvement with medical management may indicate a peridiverticular abscess. Recurrent diverticulitis is less likely to respond to medical management. Elective surgery should be considered after the second attack. 4 figures. 1 table. 82 references.
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Diverticulosis and Diverticulitis: Understanding and Managing Two Common Colon Problems. [Diverticulosis y Diverticulitis: Como Entender y Controlar Problemas Comunes del Colon]. San Bruno, CA: StayWell Company. 2001. 7 p.
This patient education brochure describes two common colon problems: diverticulosis and diverticulitis. Written in nontechnical language, the brochure defines diverticulosis as small pouches in the colon wall; diverticulitis is a more serious problem that occurs when these pouches become infected or inflamed. Although aging may contribute to colon problems, food choices are the primary concern for the health of one's colon. A low fiber, high fat diet can lead to an unhealthy colon. The brochure describes how pressure can cause pouches in the colon and then the conditions that can lead to diverticulitis. Symptoms often include pain, fever, chills, cramping, bloating, constipation, or diarrhea. Diet changes or medications may be enough to bring relief; in severe cases, surgery may be needed. The diagnosis will include the patient's history, a medical exam, and diagnostic tests, including barium enema, sigmoidoscopy, and colonoscopy. The two keys to controlling diverticulosis are dietary fiber (roughage) and liquid. Fiber absorbs water as it travels through the colon, helping the stool stay soft and move smoothly with less pressure. Eating more high fiber foods and drinking more liquids can often keep diverticulosis in check. If diverticulitis symptoms are mild, the treatment may begin with a temporary liquid diet and oral antibiotics. If the diverticulitis is severe, the patient may need bed rest, hospitalization, and intravenous (IV) antibiotics and nutrients. Surgery may be indicated in some cases and the brochure outlines the typical colon surgery resection that is used. The brochure concludes by reminding readers of the importance of dietary fiber and lists common foods that are high in fiber. The brochure is illustrated with full color line drawings and is available in English or Spanish. 19 figures.
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Female Urology and Incontinence. In: Weiss, R.M.; George, N.JR.; O'Reilly, P.H. Comprehensive Urology. Orlando, FL: Mosby, Inc. 2001. p. 477-492.
Urinary incontinence (involuntary loss of urine) is most frequently related to bladder or urethral dysfunction. Characteristics that promote continence include maintenance of normal bladder pressure to volume relations, absence of uninhibited bladder contractions, reasonable bladder emptying, satisfactory intrinsic closure capabilities of the urethra, and functional support structures that maintain the urethra in its normal retropubic position. This chapter on female urology and incontinence is from a comprehensive urology textbook. The authors address the typical female urologic entities, with a particular focus on incontinence, with the exception of those (interstitial cystitis, urinary tract infection, and fistulae) that are covered elsewhere in the text. Topics include the epidemiology and pathogenesis of urinary incontinence (UI), bladder dysfunction, overflow incontinence, stress UI, pelvic prolapse, urethral diverticulum, and other vaginal wall masses. The chapter is illustrated with full-color drawings and photographs. 21 figures. 59 references.
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Flexible Sigmoidoscopy. American Family Physician. 63(7): 1375-1380. April 1, 2001.
Flexible sigmoidoscopy remains a common tool used for the periodic screening of colorectal cancer. This article reminds family care physicians of the recommendations for the use of flexible sigmoidoscopy. Most organizations recommend screening at three to five year intervals beginning at age 50 for persons with average risk. Extensive training in endoscopic maneuvering, colorectal anatomy, and pathologic recognition is required. Most physicians report comfort performing the procedure unsupervised after 10 to 25 supervised sessions. The procedure itself involves the insertion of the sigmoidoscope through the anus and distal rectum and advancement of the scope tip to an average depth of 48 to 55 centimeters in the sigmoid colon. Once the sigmoidoscope has been appropriately advanced, the scope is slowly withdrawn, allowing for the inspection of colon mucosa during withdrawal. Polyps less than 5 millimeters in diameter should be biopsied. Polyps 5 to 10 millimeters or greater can be assumed to be adenomatous, and follow up colonoscopy for complete polypectomy is required. Diverticulosis, hemorrhoids, nonspecific colitis and pseudomembranes may also be encountered during inspection. Use of preprocedural benzodiazepines can be helpful in reducing patient discomfort. 2 figures. 10 references.
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Flexible Sigmoidoscopy: A Pictorial Atlas. Patient Care. 35(18): 13-27. September 30, 2001.
Endoscopy continues to play an important role in colorectal screening. It is important to identify the members of those families that are at high risk for colon cancer and diligently screen them using colonoscopy. This article helps readers update their clinical skills regarding colorectal screening with direct instruction and a full color pictorial atlas. The author notes that the entire 360 degrees of the colon wall in each segment should be scrutinized as the instrument is slowly and deliberately withdrawn. In order to maximize the depth of insertion, it is important to minimize overinflation of the colon. The majority of pathologies seen in primary care are diverticulosis, hemorrhoids, and polyps. Approximately 95 percent of all colorectal cancers arise from benign polyps. Some experts recommend colonoscopy for all average risk persons older than 50. Mixed screening strategies may be employed more frequently in the future, or it may be appropriate to switch strategies as people age. Performing flexible sigmoidoscopy can be time intensive for a busy primary care physician. Experts have suggested that nurse practitioners and physician assistants be trained so that more patients can be screened (one sidebar summarizes this concept). 9 figures. 12 references.
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Hemorrhoids and More: Common Causes of Blood in the Stool. Digestive Health and Nutrition. 3(4): 24-26. July-August 2001.
Most rectal bleeding is caused by hemorrhoids, which usually can be simply and effectively treated. This article reviews the many other conditions, including some serious disorders, that can cause blood in the stool. The author reminds readers that bleeding from any part of the nearly 40 foot long digestive tract can cause blood in the stool. Accurate and timely diagnostic tests are important to determine the cause of any bleeding. Bleeding higher up in the gut, from the esophagus or stomach, can result in stools with a black, tarry appearance. Bleeding from the lower end, such as the colon, or in large amounts, can appear as pure blood, blood clots, or as blood mixed with or streaking the stool. Another kind of blood, occult or hidden blood, may not be visible at all. A number of prescription and over the counter (OTC) medications can cause bleeding in the stomach and small intestine. The blood thinning drug warfarin also can induce bleeding in the intestine, as can some antibiotics. Other causes of bleeding can include ulcers, gastritis (inflammation of the stomach lining), ulcerative colitis, Crohn's disease, polyps (small growths inside the intestine), diverticular disease, abnormalities in the blood vessels (vascular anomalies), anal fissures (tears) and fistulas (abnormal openings between the anal canal and other organs, such as the bladder), and abscesses (pockets of infection. The author reiterates the importance of timely diagnosis, including a thorough patient history and evaluation of symptoms. Diagnostic tests can include blood tests, digital rectal examination, endoscopy, colonoscopy, sigmoidoscopy, fecal occult blood test, barium x rays, angiography (x rays of blood vessels), and nuclear scanning. Treatment depends on the source and extent of the bleeding.
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Inflammatory Bowel Disease in the Elderly. Gastroenterology Clinics of North America. 30(2): 409-426. June 2001.
Roughly 15 percent of all patients with inflammatory bowel disease (IBD) first develop symptoms after age 65. As the number of elderly in the population continues to grow, clinicians should see a greater number of elderly IBD patients. This article, from a special issue on gastrointestinal (GI) disorders in the elderly, addresses IBD in the older patient. In general, the presenting features of IBD are similar to those encountered in younger patients, but the broad differential diagnosis of colitis in the elderly can make definitive diagnosis more challenging. Despite many advances in cellular and molecular biology, the precise cause of IBD is elusive. The elderly are particularly susceptible to GI infection, suggesting a possible compromise of the mucosal immune system with age. The presentation and course of both ulcerative colitis (UC) and Crohn's disease (CD) in older patients is similar to that in younger patients. Differential diagnosis can include infection, ischemic colitis, diverticular disease, microscopic colitis, medications, and other conditions (lymphoma, radiation enterocolitis, vasculitis, amyloidosis). Whereas most therapies for IBD have not been studied specifically in the elderly, as a general rule, medical and surgical treatment options are the same irrespective of age. The authors stress that osteoporosis (abnormal loss of bone density), a condition generally associated with aging, should be managed aggressively in patients with IBD because many older persons already have a substantial baseline risk for accelerated bone loss. 1 figure. 2 tables. 123 references.
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Laparoscopically Assisted Bowel Resection. In: Bayless, T.M. and Hanauer, S.B. Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario: B.C. Decker Inc. 2001. p. 453-455.
This chapter on laparoscopically assisted bowel resection is from the second edition of a book devoted to the details of medical, surgical, and supportive management of patients with Crohn's disease (CD) and Ulcerative Colitis (UC), together known as inflammatory bowel disease (IBD). Laparoscopic resection for inflammation makes good sense, but has inherent technical challenges. The most common indications for bowel resection related to inflammation are diverticulitis and inflammatory bowel disease (IBD). Inflammation can make dissection difficult and potentially dangerous. Acute indications include bleeding, obstruction, and, rarely, perforation. More chronic indications include fistulization, chronic obstruction, and perianal abscess. Since societal costs can be significant in terms of insurance expenditure for an in patient and time lost to business, a laparoscopically assisted approach may benefit some patients with Crohn's disease (and their health care provider). This approach is appropriate for virtually all patients with Crohn's disease. The only exceptions are those with known phlegmons, multiple strictures, or complex fistulae (abnormal passageways). However, the procedure is safe only if the surgeon is willing to convert to a standard surgical technique when difficulty is encountered or when the dissection becomes potentially dangerous. Obviously, no rules can be offered in this regard, since it depends upon the individual combination of the patient's diseased bowel state, the surgeon's skill level, and the sophistication of the surgeon's tools. In general, a laparoscopically assisted procedure is appropriate for nutritionally sound patients who have obstruction or intractable disease without complications. 7 references.
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Lateral Approach to Laparoscopic Sigmoid Colon Resection. Journal of the American College of Surgeons. 193(1): 105-108. July 2001.
Laparoscopic sigmoid colon resection has been traditionally performed using an anterior (front) approach with the patient placed in a modified lithotomy position. In this article, the authors report their experience and describe their technique for laparoscopic sigmoid colon resection using a lateral approach. The lateral position provides excellent visualization of the splenic flexure, and the entire left colon can be moved easily without the need for excessive retraction. This position allows gravity to aid in the retraction of the left colon. Once the lateral peritoneal reflection is incised, the left colon falls away from the retroperitoneum, exposing the ureter and the gonadal vessels on the lateral side and the mesenteric vessels, including the inferior mesenteric artery and vein, on the medial side. In addition, the cosmetic results of this approach are superior to those of the anterior approach. The authors report on 8 sigmoid colon resections that were performed using the laparoscopic lateral approach. The patients were eight men with ages ranging between 32 and 70 years (average 48.5 years). All procedures were performed for diverticular disease. Mean operative time was 152 minutes (range 125 to 216 minutes). Of the eight patients, three had the procedure using only three trocars, and five patients required the placement of four trocars. None of the patients required an open procedure. 4 figures. 4 references.
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Liver Abscesses and Hydatid Disease. In: Beckingham, I.J., ed. ABC of Liver, Pancreas and Gallbladder. London, UK: BMJ Publishing Group. 2001. p.29-32.
Liver abscesses are caused by bacterial, parasitic, or fungal infection. This chapter on liver abscesses and hydatid disease is from an atlas of the liver, pancreas and gallbladder. Topics include the etiology, microbiology, clinical features, laboratory investigations, and treatment of pyogenic liver abscesses; the pathogenesis, clinical presentation, diagnosis and treatment of amoebic liver abscess; and the presentation, diagnosis, treatment of hydatid disease (caused by the dog tapeworm) in humans. Most patients with pyogenic abscesses will require percutaneous drainage and antibiotics. A cause can be identified in 85 percent of cases of liver abscess, most commonly gallstones, diverticulitis, or appendicitis. The chapter concludes with summary points of the concepts discussed. 8 figures. 4 table. 3 references.
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Meckel's Diverticulum in Crohn's Disease. Canadian Journal of Gastroenterology. 15(5): 308-311. May 2001.
This article discussed Meckel's diverticulum, a congenital (present at birth) abnormality of the distal ileum (the far section of the small intestine, which opens into the large intestine) associated with failed vitelline duct (the umbilical duct) closure. The article focuses on Meckel's diverticulum in patients with Crohn's disease. Detailed pathological studies have estimated its frequency to be about 2 percent of the general population, and it has been anecdotally recorded in patients with Crohn's disease. Most patients with Crohn's disease have imaging studies of the small intestine during the course of their disease, and often, an intestinal resection. Thus, it seems possible to estimate the prevalence of Meckel's diverticula in Crohn's disease. In addition, patient characteristics may be important, especially if management of Crohn's disease is altered. The author reports on a series of 877 patients with Crohn's disease, of whom 10 (approximately 1 percent) had a Meckel's diverticulum diagnosed (6 men, 4 women). All were diagnosed with Crohn's disease before age 50 years and seven were diagnosed before age 30 years. There were five with ileocolonic disease, two with colon only disease, and three with ileum only disease. The clinical behavior of five patients could be classified as penetrating and two as stricturing. A total of 311 patients had an ileocolonic resection, including eight (about 2 percent) with a Meckel's diverticulum. In contrast to some case reports, no heterotopic mucosa was detected and the Meckel's diverticulum was incidental and, apparently, an unexpected finding. In each case, the diverticulum was not involved with Crohn's disease but was included in the ileal resection. These results suggest that the overall prevalence of a Meckel's diverticulum is not increased in Crohn's disease patients, but may result in resection of additional small intestine. 1 table. 20 references.
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Meckel's Diverticulum. Journal of the American College of Surgeons. 192(5): 658-662. May 2001.
This article reviews the condition of Meckel's diverticulum (MD), a diverticulum in the small intestine. An average MD is approximately 3 centimeters long, with nearly 90 percent ranging from 1 to 10 centimeters. MD is considered the most prevalent congenital (present at birth) anomaly of the gastrointestinal tract, affecting 2 percent of the general population. MD may be more common in patients with Crohn's disease than in the general population. The total lifetime complication rate has been reported to be around 4 percent. Most patients with MD are asymptomatic, but in those that develop symptoms, it has been estimated that more than 50 percent are less than 10 years of age. Long, narrow based diverticula are thought to be more prone to obstruction or inflammation; short, large based diverticula are subject to foreign body entrapment. The location of an MD does not appear to affect the complication rate. Bleeding occurs in more than 50 percent of symptomatic MD in patients less than 18 years old. Surgical treatment of MD may be by open or laparoscopic procedures. Principles of resection include the removal of MD and associated bands, and small bowel management. Laparoscopic treatment of MD has been increasingly reported, with techniques including intraabdominal wedge resection or extracorporeal or intracorporeal bowel segment resection. The authors conclude that because the risk of complications of an MD has not been found to decrease with age, the benefits of surgery outweigh its attending morbidity and mortality. 3 tables. 36 references.
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Nonsteroidal Anti-Inflammatory Drugs, Enterocolonic Ulceration, and Inflammatory Bowel Disease. In: Bayless, T.M. and Hanauer, S.B. Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario: B.C. Decker Inc. 2001. p. 625-629.
Nonsteroidal antiinflammatory drugs (NSAIDs) cause damage through the gastrointestinal tract. This chapter on NSAIDS, enterocolonic (small bowel) ulceration and inflammatory bowel disease (IBD) is from the second edition of a book devoted to the details of medical, surgical, and supportive management of patients with Crohn's disease (CD) and ulcerative colitis (UC), together known as IBD. The authors outline an approach to treatment of the damage of NSAIDs to the small bowel and the management of patients with IBD who require NSAIDs. The authors caution that the use of NSAIDs in patients with IBD is challenging because the drugs may cause relapse of disease. Specific issues addressed include iron deficiency anemia, hypoalbuminemia (reduced levels of protein in the blood), strictures (narrowing of the intestine), NSAID induced colon damage, and the use of NSAIDs in patients with IBD. Rarely, NSAIDs actually cause colitis, but their use is associated with an enhanced risk of appendicitis in the elderly and diverticular complications (fistulae and abscesses). 6 references.
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Pubovaginal Sling Surgery for Simple Stress Urinary Incontinence: Analysis by an Outcome Score. Journal of Urology. 165(5): 1597-1600. May 2001.
This article reports on a study that assessed the results of pubovaginal sling surgery in women with simple stress urinary incontinence (SUI) using strict subjective and objective criteria. Simple incontinence was defined as sphincteric (bladder opening) incontinence with no concomitant urge incontinence, pipe stem or fixed scarred urethra, urethral or vesicovaginal fistula, urethral diverticulum, grade 3 or 4 cystocele, or neurogenic bladder. A total of 67 consecutive women (mean age 56 years plus or minus 11 years) who underwent pubovaginal sling surgery for simple sphincteric incontinence were prospectively followed for 12 to 50 months. Cure was defined as no urinary loss due to urge or stress incontinence, as documented by 24 hour diary and pad test, with the patient considering herself cured. Failure was defined as poor objective results with the patient considering surgery to have failed. Of the 67 patients, 46 (69 percent) had type II and 21 (31 percent) had type III incontinence. Preoperative diary and pad tests revealed a mean of 5.9 (plus or minus 3.6) stress incontinence episodes and a mean urinary loss of 91.8 grams (plus or minus 81.9 grams) per 24 hours. There were no major intraoperative, perioperative, or postoperative complications. Two patients (3 percent) had persistent minimal stress incontinence and 7 (10 percent) had new onset urge incontinence within 1 year after surgery. Overall using the strict criteria of the outcome score, 67 percent of the cases were classified as cured, and the remaining 33 percent were classified as improved. The degree of improvement was defined as a good, fair, and poor response in 21 percent, 9 percent, and 3 percent, respectively. Midterm outcome results defined by strict subjective and objective criteria confirm that the pubovaginal sling is highly effective and safe surgery for simple sphincteric incontinence. A followup of more than 5 years is required to establish the long term durability of this procedure. 2 tables. 11 references.
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Review of the Causes of Lower Gastrointestinal Tract Bleeding in Children. Gastroenterology Nursing. 24(2): 77-83. March-April 2001.
Bleeding may occur anywhere along the gastrointestinal (GI) tract, which covers a large surface area and is highly vascularized. Pediatric patients who present with blood in their stools (bowel movements) are a special challenge for the health care team. Seeing blood in the child's stools, the caregiver and child may become extremely anxious, fearing a devastating diagnosis. This article reviews the causes of lower GI tract bleeding in children. The differential diagnosis of this symptoms in infants and children includes numerous possibilities ranging from benign disorders, which require little or no treatment at all, to serious diseases that require immediate intervention. A complete history, including progression, duration, frequency, and severity of symptoms, is essential in assessing GI bleeding. Associated symptoms that help define the diagnosis include vomiting, diarrhea, constipation, abdominal pain, anorexia (lack of appetite), rash, joint pain or swelling, weight loss, fever, irritability, history of GI bleeding, or history of hematological or immunological disorders. Constipation with fissure (a tear in the anus) formation is the most common cause for rectal bleeding in toddlers and school age children. Infection is one of the more common causes of bleeding from the lower GI tract; infections can be due to Salmonella, Shigella, Campylobacter jejuni; Yersinia enterocolitica, Escherichia coli, Clostridium difficile, or Entamoeba histolytica. Other causes include swallowed blood, hemorrhoids, inflammatory bowel disease (IBD), intussusception (a portion of the bowel turns in on itself, creating an obstruction), polyps, lymphonodular hyperplasia, Meckel's diverticulum, allergic colitis, Henoch Schonlein purpura, hemolytic uremic syndrome (HUS), enterocolitis, child sexual abuse, and Munchausen syndrome by proxy.
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Trials of the Aging Gut. Digestive Health and Nutrition. 3(6): 16-18. November-December 2001.
This health education article reviews the impact of aging on the gastrointestinal (GI) tract, notably in the areas of motility (movement through the system) and absorption of nutrients. Both men and women report problems with constipation, diarrhea, and fecal incontinence with greater frequency after age 50 and an increased number of potentially serious diseases, such as diverticulosis and colon cancer. Most of the GI changes that occur in older individuals can be pinned on small physiological changes and responses within the GI tract itself, on medications that must be taken for other conditions such as heart disease or depression, and on gastrointestinal diseases that occur in greater numbers after age 50. A lesser number of people have consequences of other diseases that either make them less mobile and prone to constipation or that affect the nerves of the intestinal system, such as diabetic neuropathy (nerve damage associated with diabetes mellitus). The GI tract of older individuals may not have the same ability to absorb nutrients, such as vitamin B12 (which helps the body to produce blood cells) and calcium (which helps maintain bone density). The author also considers the issues of malnutrition, swallowing disorders and choking, fecal incontinence, constipation, lack of fiber in the diet, drug side effects, diverticular diseases, gallbladder disease, and cancer of the colon or rectum. The article concludes with five related websites for readers who want additional information.
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Urethral Diverticula: Evolving Diagnostics and Improved Surgical Management. Current Urology Reports. 2(5): 373-378. October 2001.
Urethral diverticula in females remain problematic from both diagnostic and therapeutic standpoints. Recent developments in pelvic imaging with computed tomography (CT scan), sensitive ultrasonography, and magnetic resonance imaging (MRI) have greatly advanced diagnostic accuracy and improved the clinician's ability to stage lesions as to location, size, and coexistent pathology. Coupled with improved recognition has come advancements in surgical technique, reflective of improved understanding of urethral anatomy and function. Better use of concomitant procedures, such as pubovaginal sling or soft tissue interposition, has continued a steady trend toward improved surgical outcomes when considering urethral function and urinary continence. This article reviews these mutually complementary trends. 4 figures. 16 references.
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Use of Endoscopy in Patients with Gastrointestinal Motility Problems. Journal of Clinical Gastroenterology. 33(3): 185-190. 2001.
Gastrointestinal motility (movement) disorders are a commonly encountered problem. Although some are associated with organic alterations, others are defined by their symptoms, and no anatomic or histological organic changes are to be found. In most cases, the etiology (cause) is completely unclear. This article reviews the use of endoscopy in patients with gastrointestinal motility problems. Endoscopy, with the option of obtaining biopsies for histopathologic evaluation, plays the most important role in the diagnostic workup, as it can exclude such lesions as tumors, ulcers, inflammatory processes, and diverticula and it helps to define the grade and extent of motility-associated diseases (such as gastroesophageal reflux disease or GERD). Furthermore, endoscopic interventional procedures offer sufficient treatment of several motility-related disorders, including achalasia, GERD, and secondary constipation. The authors discuss the use of endoscopy for cricopharyngeal dysfunction, spastic disorders of the esophagus, achalasia, GERD, gastroparesis (delay in gastric emptying, often a complication of diabetes mellitus), functional dyspepsia (heartburn), irritable bowel syndrome (IBS), and chronic constipation. 6 figures. 57 references.
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Why Certain Foods May Be Upsetting Your Stomach. Digestive Health and Nutrition. 3(3): 28-30. May-June 2001.
Special diets, specifically those intended to alleviate disease symptoms (as opposed to those for weight reduction), are a way of life for many individuals with gastrointestinal (GI) illnesses such as irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), peptic ulcers, diverticulosis, celiac sprue, gallbladder disease, and inflammatory bowel disease (IBD, including Crohn's disease and ulcerative colitis). This article reviews this phenomenon of avoiding or incorporating certain foods to alleviate the symptoms of GI diseases. The author stresses the fact that each person's diet will vary, even when they have the same disease, because certain foods may affect people differently. Many physicians recommend avoiding certain foods but ultimately leave the patient to experiment with trial and error. While diets vary from condition to condition, all diets should have the common goal of maintaining good health and proper weight through a diet rich in fruits and vegetables, moderate in the consumption of alcohol, and low in fat. The article concludes with a list of websites for additional information.
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Acute Abdominal Pain in the Elderly: Guide to a Cost-Effective Work-Up. Consultant. 40(1): 25-27, 31-35, 39. January 2000.
This article explains how physicians can use an 11 question analysis to get an immediate bearing on the source of a patient's abdominal pain. The authors focus on acute abdominal pain in the elderly. Clues to diagnosis include location and characteristics of the pain, as well as patterns of radiation; color, content, and volume of vomitus; stool consistency, frequency, and color. Every abdominal examination should be followed by a rectal examination and, in women, a vaginal examination. Laboratory studies usually include serum electrolyes, glucose and amylase levels, liver and kidney function tests, and a complete blood count with differential analysis. Guidelines are available to help determine the need for hospitalization based on test results. Radiographic films and ultrasonography (now available at bedside) are often enough to confirm diagnoses, but CT scan and MRI (magnetic resonance imaging) also play important roles. The authors review cost effective approaches for suspected appendicitis, bowel obstruction, diverticulitis, peptic ulcer disease, mesenteric ischemia, pancreatitis, and biliary disease. 5 figures. 4 tables. 15 references.
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Controversies in the Investigation and Treatment of Lower Gastrointestinal Bleeding. Practical Gastroenterology. 24(1): 42, 52, 54, 58. January 2000.
Lower gastrointestinal (GI) bleeding may be intermittent, self limited, or produce a life threatening emergency. There are several options for diagnostic evaluation, but the location and etiology of the bleeding source may remain elusive. In this article, the authors review the diagnostic and treatment options and provide recommendations for developing an organized patient algorithm. The majority of patients with lower GI hemorrhage will stop bleeding during resuscitation. Once the bleeding has stopped, investigation of the source of the bleed usually proceeds with routine endoscopic and radiological studies, followed by elective segmental resection, if indicated. In patients where it is impossible to determine the precise location and etiology, both patient and physician must await the next bleeding episode. Patients who present with lower GI bleeding are usually adults older than 50 years. The most common etiologies of lower GI bleeding include diverticulosis, vascular ectasia, ischemic colitis, inflammatory bowel disease (IBD), and neoplasm (cancer). Diagnostic options include colonoscopy, traditional imaging techniques (CT scan or contrast studies), nuclear scintigraphy, or mesenteric angiography. Colonoscopy and mesenteric angiography both offer the means for potentially controlling the hemorrhage whereas scintigraphy does not. Colonoscopy can provide the means to treat bleeding lesions through electrocautery, epinephrine injection, or sclerotherapy. Angiography can provide access for vasopressin infusion or embolization. The unstable patient without a determined site of bleeding represents the most challenging dilemma, as blind total abdominal colectomy is associated with potential rebleeding from the small intestine and significant morbidity and mortality. 26 references.
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Coping with the Pain and Annoyance of Hemorrhoids. Digestive Health and Nutrition. p. 20-23. January-February 2000.
This article helps readers understand and cope with hemorrhoids. The author describes how to distinguish between types of hemorrhoids, how to recognize the possible symptoms, and what treatment options are available. Following is a description of typical hemorrhoidal bleeding (bright red blood on the toilet tissue or in the toilet water); readers are encouraged to consult with a health care provider for even relatively minor rectal bleeding. Hemorrhoids are then defined in terms of their location. Internal hemorrhoids arise from blood vessels that lie up to 2 inches inside the anus, and external hemorrhoids form under the anal skin. Internal hemorrhoids, which are not usually seen or felt unless they protrude downward outside the anus, can cause other symptoms, including a feeling of fullness in the rectum (particularly after passing stool) or deep itching (pruritus). The author explores possible reasons why some people develop hemorrhoids, including certain working conditions (such as lots of sitting), weak muscles within the bowels, low fiber diets (which can result in straining with defecation), and pregnancy. Diagnostic tests can rule out other possible causes of rectal bleeding, including anal fissure, Crohn's disease or ulcerative colitis (inflammatory bowel diseases), Meckel's diverticulum, and cancer or noncancerous polyps in the bowel. Treatment options are reviewed, from lifestyle and dietary changes to topical therapy, to surgical treatments (rubber band ligation, laser treatment, and sclerosing injections).
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Digestive Diseases and Disorders Sourcebook. Detroit, MI: Omnigraphics. 2000. 300 p.
This sourcebook provides basic information for the layperson about common disorders of the upper and lower digestive tract. The sourcebook also includes information about medications and recommendations for maintaining a healthy digestive tract. The book's 40 chapters are arranged in three major parts. The first section, Maintaining a Healthy Digestive Tract, offers basic information about the digestive system and digestive diseases, information about tests and treatments, and recommendations for maintaining a healthy digestive system. The second section, Digestive Diseases and Functional Disorders, describes nearly 40 different diseases and disorders affecting the digestive system. These include appendicitis, bleeding in the digestive tract, celiac disease, colostomy, constipation, constipation in children, Crohn's disease, cyclic vomiting syndrome, diarrhea, diverticulosis and diverticulitis, gallstones, gas in the digestive tract, heartburn (gastroesophageal reflux disease), hemorrhoids, hernias, Hirschsprung's disease, ileostomy, indigestion (dyspepsia), intestinal pseudo-obstruction, irritable bowel syndrome (IBS), IBS in children, lactose intolerance, Menetrier's disease, rapid gastric emptying, short bowel syndrome, ulcerative colitis, ulcers, Whipple's disease, and Zollinger Ellison syndrome. The final section offers a glossary of terms, a subject index and a directory of digestive diseases organizations (which includes website and email addresses as available). Material in the book was collected from a wide range of government agencies, nonprofit organizations, and periodicals.
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Diseases and Conditions of the Digestive System. In: Frazier, M.S.; Drzymkowski, J.W.; Doty, S.J. Essentials of Human Diseases and Conditions. 2nd ed. Philadelphia, PA: W.B. Saunders Company. 2000. p. 214-255.
This chapter, from a comprehensive text on human diseases and conditions, familiarizes readers with the various conditions that can afflict the alimentary canal and the accessory organs of the digestive system. Gastrointestinal (GI) problems are common and often cause anxiety because of the way in which they interfere with a sense of well being. The 'gut' is also often associated with emotional responses. The chapter covers the processes of normal digestion and absorption; the importance of normal teeth and a normal bite; the presenting symptoms of temporomandibular joint (TMJ) syndrome; the etiology of herpes simple compared to the etiology of candidiasis (thrush); complications of esophageal varices; the pathology and etiology of peptic ulcers; the diagnosis of gastric cancer; hiatal and other types of abdominal hernias; the pathology involved in Crohn's disease and ulcerative colitis; the etiology of gastroenteritis; functional and mechanical obstruction of the bowel; intestinal obstruction; diverticulosis versus diverticulitis; the treatment of colorectal cancer; the relationship between broad spectrum antibiotics and pseudomembranous enterocolitis; the causes of inflammation of the peritoneum; the symptoms and signs of cirrhosis of the liver; the etiology, transmission, and prevention of hepatitis A and hepatitis C; the clinical picture of biliary colic and acute pancreatitis; the manifestations of malnutrition and malabsorption; the diagnostic criteria for celiac disease (gluten intolerance); the different presentations of anorexia nervosa and bulimia; and the components of a successful weight loss program. Each of the topics includes a brief discussion of symptoms and signs, etiology (causes), diagnosis, and treatment. The chapter is illustrated with line drawings and concludes with a list of review questions. A brief list of related information resource organizations is also included. 25 figures. 1 table.
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Diverticular Disease. In: King, J.E., ed. Mayo Clinic on Digestive Health. Rochester, MN: Mayo Clinic. 2000. p. 125-132.
Diverticular disease is the general term for the development of small, bulging pouches in the digestive tract. The most common site for diverticula is the large intestine (colon), particularly the lower part of the colon called the sigmoid colon. This chapter on diverticular disease is from a comprehensive guidebook from the Mayo Clinic that focuses on a variety of digestive symptoms, including heartburn, abdominal pain, constipation, and diarrhea, and the common conditions that are often responsible for these symptoms. Written in nontechnical language, the book includes practical information on how the digestive system works, factors that can interfere with its normal functioning, and how to prevent digestive problems. This chapter first reviews the key signs and symptoms of diverticular disease, including pain in the lower left abdomen, abdominal tenderness, fever, nausea, and constipation or diarrhea. The authors describe the two forms of diverticular disease: diverticulosis, which refers to the presence of diverticula in the digestive tract, and is very common; and diverticulitis, which is inflammation or infection in a diverticulum. Three factors seem to contribute to diverticula: weak spots in the colon wall, aging, and too little dietary fiber. Because diverticula usually do not cause problems, most people first learn they have diverticulosis during routine screening exams for colorectal cancer or during tests for another intestinal condition. Treatment begins with self care strategies, including increasing the amount of fiber in one's diet, drinking plenty of fluids, avoiding constipation, and exercising regularly. The authors outline how to know when medical care is necessary for diverticular disease, and review the care that may be provided, including rest and a restricted diet, antibiotics, painkillers (analgesics), and surgery. The chapter concludes by reminding readers that there is no evidence that diverticular disease increases one's risk of colon or rectal cancer; however, diverticular disease can make cancer more difficult to diagnose. 1 figure.
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Diverticulitis: A High-Fiber Diet May Prevent This Ailment. Mayo Clinic Women's Healthsource. 4(11): 6. November 2000.
This article, from a general health newsletter, offers suggestions for avoiding diverticulitis (infection of pockets of the colon) through the use of a high fiber diet. Diverticulosis, a condition that develops with aging, seems to be due to weakening and bulging of the colon wall that results in the pockets or pouches called diverticula. Some people with diverticulosis develop diverticulitis, a serious condition of infection or inflammation in the colon that needs prompt treatment. Symptoms of diverticulitis range from mild crampy abdominal pain to severe pain, nausea, and fever. Mild attacks can be treated at home with an antibiotic and a low fiber diet (to rest the colon). If the antibiotics do not work or if the physician suspects an obstruction or perforation of the colon wall, the patient will require treatment in the hospital. Eating a high fiber diet may help prevent diverticulosis or slow its progression. It is suspected, but unproven, that eating a high fiber diet can prevent diverticulitis. To help minimize pressure within the colon, the author advises readers to eat a varied diet rich in fiber, drink eight or more cups of liquid a day, and move the bowels whenever the urge is present (do not delay defecation). One sidebar offers brief specifics on how to increase the fiber in one's diet, including what items to note on food labels (at least 5 grams of fiber per serving, and ingredients including wheat bran, whole wheat, cracked wheat, barley, brown rice, bulgur).
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Feeling Good About Your Medical Care. In: Bolen, B.B. Breaking the Bonds of Irritable Bowel Syndrome: A Psychological Approach to Regaining Control of Your Life. Oakland, CA: New Harbinger Publications, Inc. 2000. p.29-43.
Irritable bowel syndrome (IBS) consists of recurrent episodes of abdominal pain related to altered bowel habit, which may consist of predominantly constipation or diarrhea, or an alternation between the two. This chapter on feeling good about one's medical care is from a book in which the author encourages an open discussion of the symptoms and feelings that accompany irritable bowel syndrome (IBS). Charts and worksheets help readers track the relationship between unpleasant symptoms and external triggers such as foods, stressful events, emotional states, and certain thoughts. Coping skills, such as relaxation exercises and assertiveness techniques, teach readers how to manage their stress more effectively and help them break free of the restrictions placed upon them by the disruptiveness of this digestive disorder. This chapter discusses how to locate a health care provider, how to establish a good relationship between patient and doctor, reasonable expectations of one's health care provider, how to be assertive in health care matters, what to expect during the first and subsequent visits to the doctor, diagnostic tests (sigmoidoscopy, barium enema, colonoscopy), other diseases that might be considered during diagnosis (inflammatory bowel diseases, diverticular disease, and colon cancer), treatments that may be utilized (dietary changes, medication), and prognosis. Throughout the chapter, the author emphasizes the importance of educating oneself and taking an active role in one's own disease management. 1 figure.
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Fiber-Restricted Diet. In: American Dietetic Association. Manual of Clinical Dietetics, Sixth Edition. Chicago, IL: American Dietetic Association. 2000. p.703-707.
This chapter describing a fiber-restricted diet is from a comprehensive manual of clinical dietetics designed to help dietitians, physicians, and nurses deliver quality nutrition care. The chapter includes the purpose of the fiber-restricted diet, the indications for use, a description of the diet, meal planning approaches, and a discussion section. The fiber-restricted diet is used to reduce the frequency and volume of fecal output while prolonging intestinal transit time; and to prevent blockage of a stenosed gastrointestinal tract. The diet can be used during acute phases of ulcerative colitis, Crohn's disease, and diverticulitis and when stenosis (narrowing) of the intestine occurs. The diet may also be used preoperatively to minimize fecal volume and residue and postoperatively during the progression to a general diet. 1 table. 18 references.
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Gastrointestinal Bleeding in Infancy and Childhood. Gastroenterology Clinics of North America. 29(1): 37-66. March 2000.
Gastrointestinal (GI) bleeding is an alarming problem in children. Although many causes of GI bleeding are common to children and adults, the frequency of specific causes differs greatly, and some lesions, such as necrotizing enterocolitis or allergic colitis, are unique to children. This article reviews the spectrum of GI bleeding in infants and children. The author discusses the causes (etiology), diagnostic evaluation, and management, and highlights the differences with adult medicine. The more common causes of upper GI bleeding in children are ulcer and gastritis, esophagitis, and varices (enlarged veins or arteries). A detailed history and careful physical examination accompanied by limited laboratory studies may identify the underlying cause and predict the severity of gastrointestinal hemorrhage. Endoscopy is the preferred diagnostic procedure because it is sensitive and specific and, for some lesions, provides the means for immediate treatment. Medical therapy (drugs) is similar for adults and children, differing mostly in the dosage of medications. One table lists pediatric doses for medications commonly used in upper gastrointestinal bleeding. Endoscopic therapy may be used in children with an actively bleeding focal lesion or with a lesion at high risk of rebleeding. Surgery is reserved for bleeding that is uncontrollable by less invasive interventions. The latter part of the article reviews lower GI bleeding, noting that age is an important factor in diagnosis of etiology (cause). Colonoscopy is the preferred diagnostic modality for rectal bleeding. The article concludes with a brief description of small bowel hemorrhage, usually due to Meckel's diverticulum (a congenital anomaly), duplications of the bowel, or idiopathic necrotizing enteritis. 4 figures. 3 tables. 212 references.
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Gastrointestinal Bleeding in Older People. Gastroenterology Clinics of North America. 29(1): 1-36. March 2000.
Aging is associated with an increased rate of comorbidity, greater medication use, and atypical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding makes the evaluation and management of gastrointestinal bleeding in older people a special and increasingly common clinical challenge. In this article, the unique features and common causes of upper and lower gastrointestinal bleeding in older people are reviewed. The hospital course of elderly patients with upper gastrointestinal bleeding appears to be similar to that of younger patients with respect to the use of endoscopic therapy for bleeding and rebleeding, need for general anesthesia for endoscopy, rates of admission to an intensive care unit, blood transfusion requirements, frequency of surgery, and duration of hospital stay. The authors consider some important management issues including hemodynamic resuscitation, anticoagulation, and endoscopic and surgical therapy. The authors review specific upper gastrointestinal bleeding lesions, including esophagitis and gastritis, peptic ulcer disease (particularly that caused by nonsteroidal antiinflammatory drugs), and variceal bleeding; and specific lower gastrointestinal bleeding lesions, including colonic diverticula, angiodysplasia, colonic ischemia, and inflammatory bowel disease. The authors also conclude that planning for care beyond the acute bleeding episode in this population is critical and involves an understanding of the importance of rehabilitation and community based services and involvement of a caregiver. 11 tables. 153 references.
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High-Fiber Diet. In: American Dietetic Association. Manual of Clinical Dietetics, Sixth Edition. Chicago, IL: American Dietetic Association. 2000. p.709-717.
This chapter describing a high-fiber diet is from a comprehensive manual of clinical dietetics designed to help dietitians, physicians, and nurses deliver quality nutrition care. The chapter includes the purpose of the high-fiber diet, the indications for use, a description of the diet, meal planning approaches, and a discussion section. The high-fiber diet is used to increase fecal bulk and promote regularity, to normalize serum lipid (fats) levels, and to blunt postprandial (after a meal) blood glucose response. A high-fiber diet can be used in the prevention or treatment of various gastrointestinal, cardiovascular, and metabolic diseases and conditions including diverticular disease, cancer of the colon, diabetes mellitus, endometrial cancer, constipation, irritable bowel syndrome, Crohn's disease, hypercholesterolemia, and obesity. 2 tables. 20 references.
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House Call. Digestive Health and Nutrition. p. 26-27. May-June 2000.
This column is a regular feature in Digestive Health and Nutrition; in each issue, the medical editor and associate editors answer reader questions about gastroenterological concerns. This entry addresses six topic areas: the outward symptoms of hepatitis C, diarrhea and gas with weight loss (possibly triggered by the use of herbal remedies), chronic hepatitis C, tests to monitor liver cancer, posttherapy complications of antibiotics, and uncontrollable weight loss. Chronic hepatitis C infection can result in cirrhosis (scarring) of the liver with ascites (fluid in the abdominal cavity) and low clotting factors, leading to easy bruising. Low response to the hepatitis C drugs is disappointing, but they should still be tried, since some responses are dramatic. In some patients, chronic hepatitis C may lead to cirrhosis followed by liver failure or the development of primary liver cancer (hepatocellular carcinoma), usually after 20 to 40 years of infection. It is generally recommended that patients with hepatitis C and cirrhosis undergo semiannual testing with ultrasound and alphafetoprotein. There are many herbs that can cause diarrhea, but in almost all cases the diarrhea stops when the patient stops taking the herbal remedy. Antibiotics can themselves cause diarrhea (notably the antibiotic induced infection Clostridium difficile). Ciprofeoxacin and metronidazole may help chronic diarrhea if the condition is due to bacterial overgrowth secondary to a blind loop syndrome, small intestinal diverticulosis, or a stagnant small intestine. The author concludes that weight loss is not a symptom of irritable bowel syndrome and usually indicates another condition.
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Inflammatory Bowel Disease in the Elderly. In: Williams, C.N., et al., eds. Trends in Inflammatory Bowel Disease Therapy 1999. Boston, MA: Kluwer Academic Publishers. 2000. p. 96-104.
Inflammatory bowel disease (IBD) characteristically presents in early adulthood, but a second incidence peak is observed in the sixth to eighth decade of life. This chapter on IBS in the elderly is from a monograph that reprints the presentations given at the Trends in Inflammatory Bowel Disease Therapy Symposium, held in Vancouver, British Columbia, Canada, in August 1999. The general objective of the conference was to provide an update in the etiology, pathogenesis, and treatment of inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD). In this chapter, the authors note that UC presenting in older patients tends to show a preference for distal involvement, with the initial attack often being more severe than in younger patients. The response to medical management, risk of extension and requirement for surgery, however, are similar to younger patients. The treatment options are also similar, although the risk of complications related to prolonged steroid use (including hyperglycemia, hypertension, and osteoporosis) may be higher and the use of immunosuppressive agents may be associated with a higher risk of infection. A small increase in mortality occurs postoperatively and seems more often related to comorbid disease rather than to UC. For CD in older patients, the spectrum of clinical presentations, including extraintestinal manifestations and perianal disease, is no different from a younger population, with the exception of a higher incidence of Crohn's colitis and a lower rate of surgery. However, in elderly Crohn's colitis patients who require surgery either due to disease severity or complications, postoperative mortality (death) and complication rates related to surgery may be higher. The overall mortality rate in elderly patients with CD is, however, not different from the general population. Important differential or coexistent diagnoses in the evaluation of elderly patients with possible IBD include ischemic colitis, diverticulitis, neoplasms, infectiou causes (Clostridium difficile and Escherichia coli 0157:H7), and nonsteroidal antiinflammatory drug (NSAID) related fibrosis. The authors conclude that, with certain exceptions, the presentation, clinical course, and response to therapy for elderly patients presenting with IBD tend to be comparable to a younger population. 49 references.
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Mayo Clinic on Digestive Health. Rochester, MN: Mayo Clinic. 2000. 194 p.
This comprehensive guidebook from the Mayo Clinic focuses on a variety of digestive symptoms, including heartburn, abdominal pain, constipation, and diarrhea, and the common conditions that are often responsible for these symptoms. Written in nontechnical language, the book includes practical information on how the digestive system works, factors that can interfere with its normal functioning, and how to prevent digestive problems. After two introductory chapters in which the authors review the anatomy and physiology of the digestive tract and practical suggestions for maintaining a healthy digestive tract, the book includes 12 chapters on symptoms, common diagnostic tests, gastroesophageal reflux disease (GERD), ulcers and stomach pain, irritable bowel syndrome, Crohn's disease and ulcerative colitis (together called inflammatory bowel disease or IBD), celiac disease, diverticular disease, gallstones, pancreatitis, liver disease, and cancer. Each chapter on a specific condition reviews the symptoms, diagnosis, risk factors, prognosis, and treatment options for that condition. The book concludes with a list of resource organizations through which readers can obtain more information, and a subject index.
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Meckel's Diverticulum. American Family Physician. 61(4): 1044. February 15, 2000.
Meckel's diverticulum is a true intestinal diverticulum (pouch) that is the most prevalent congenital (present from birth) abnormality of the gastrointestinal tract. This brief patient education handout reviews the diagnosis and management of Meckel's diverticulum. The handout notes that most people who have a Meckel's diverticulum have no problems. However, complications can include bleeding in the gastrointestinal tract and intestinal blockage. The symptoms of these complications can include stomach pain, vomiting, fever, constipation, and swelling of the stomach. Currently, there is no safe, simple way to test for Meckel's diverticulum. When this condition causes complications, it can be diagnosed by taking special x-rays of the intestines. Sometimes the treatment includes surgery to remove the diverticulum and repair the intestine. This patient education handout appears in the same issue as an article for physicians on the care of patients with Meckel's diverticulum.
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Meckel's Diverticulum. American Family Physician. 61(4): 1037-1042. February 15, 2000.
Meckel's diverticulum is a true intestinal diverticulum (pouch) that is the most prevalent congenital (present from birth) abnormality of the gastrointestinal tract. This article reviews the diagnosis and management of Meckel's diverticulum. The authors stress that the diagnosis of this condition is often difficult because it may remain completely asymptomatic, or it may mimic such disorders as Crohn's disease, appendicitis, and peptic ulcer disease. Ectopic tissue, found in approximately 50 percent of cases, consists of gastric (stomach) tissue in 60 to 85 percent of cases and pancreatic tissue in 5 to 16 percent of cases. The diagnosis of Meckel's diverticulum should be considered in patients with unexplained abdominal pain, nausea and vomiting, or intestinal bleeding. Major complications include bleeding, obstruction, intussusception, diverticulitis (infection), and perforation. The most useful method of diagnosis is with a technetium 99m pertechnetate scan, which is dependent on uptake of the isotope in heterotopic tissue. Management is by surgical resection. A patient education handout on Meckel's diverticulum is included in the same issue. 1 figure. 1 table. 35 references.
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Ostomy. In: American Dietetic Association. Manual of Clinical Dietetics, Sixth Edition. Chicago, IL: American Dietetic Association. 2000. p.421-424.
Medical nutrition therapy (MNT) is used for patients who have had a surgical ileostomy or colostomy to minimize the risk of obstruction, to prevent fluid and electrolyte imbalances, to reduce excessive output, and to minimize gas and unpleasant odors. This chapter on nutrition care for patients with an ostomy is from a comprehensive manual of clinical dietetics designed to help dietitians, physicians, and nurses deliver quality nutrition care. The chapter includes the purpose of nutrition care, the indications for use, a description of the diet, meal planning approaches, a definition of the disease or condition, and a discussion section. Conditions most commonly associated with ostomy placement include Crohn's disease, diverticulitis, ulcerative colitis, colorectal cancer, familial polyposis, intestinal trauma, bowel ischemia, and radiation enteritis. One chart summarizes food selection guidelines for people with ostomies. 1 table. 4 references.
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Peritoneal Dialysis: Its Indications and Contraindications. Dialysis and Transplantation. 29(2): 71-77. February 2000.
Global utilization of peritoneal dialysis ranges from 6 to 91 percent of the people on dialysis in various parts of the world; in the United States, approximately 14 percent of the patients with end stage renal disease (ESRD) use peritoneal dialysis. This article reviews the indications and contraindications for chronic peritoneal dialysis (PD), provides evidence when available, and offers recommendations based on the experiences of the authors. Strong indications for PD include situations such as vascular access failure and intolerance to hemodialysis (HD); medical preferences such as congestive heart failure, prosthetic valvular disease, and children aged 0 to 5 years; and social situations such as patient preference and living far from a dialysis clinic. The situations where PD is preferred include bleeding tendencies, multiple myeloma (bone tumors), labile diabetes (hard to control), chronic infections, possibility of transplantation in the near future, age between 6 and 16 years, needle anxiety, and active lifestyle. Situations where PD is not preferred but is still possible with some special considerations include obesity, multiple hernias, severe backache, multiple abdominal surgeries, impaired manual dexterity, blindness, less than ideal home situation, and depression. Relative contraindications (reasons not to use the technique) for PD include patients with severe malnutrition, multiple abdominal adhesions, ostomies, proteinuria greater than 10 grams per day, advanced COPD (chronic pulmonary disease, usually attributed to smoking), ascites (fluid accumulation), upper limb amputation with no help at home, poor hygiene, dementia, and homelessness. PD is contraindicated in patients with documented Type II ultrafiltration failure, severe inflammatory bowel disease (IBD), active acute diverticulitis, abdominal abscess, active ischemic bowel disease, severe active psychotic disorder, marked intellectual disability, and the third trimester of pregnancy. In most of the remaining situations, either HD or PD is equally preferred. The authors conclude that in order to take full advantage of the advances that have occurred over the past decade, successful PD requires committed and knowledgeable physicians and nurses, and a center with at least 20 to 25 patients on this modality. 1 table. 30 references.
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Prescription Medications That Can Be Harmful to the Digestive System. Digestive Health and Nutrition. p. 26-29. September-October 2000.
This article reviews the possible negative impact of prescription medications on the digestive system. Drugs that are swallowed enter the body through the gastrointestinal (GI) tract, making it an easy target for side effects. However, injected or infused drugs can also upset the GI tract. Sometimes taking the drug with food will decrease GI side effects; however, food can interfere with the actions of some medications. Nonsteroidal antiinflammatory drugs (NSAIDs) are very effective in helping to reduce the inflammation and pain caused by arthritis and other conditions, however, they increase the risk of ulcers when taking long term. Damage also can occur in the small and large intestine due to the prolonged use of NSAIDs. The drugs can bring about a relapse of inflammatory bowel disease (IBD) and they may cause a rare condition called collagenous colitis or cause diverticula pouches in the colon wall to bleed or perforate. Diarrhea is another common and potentially serious side effect of some prescription drugs; antibiotics, in particular, often cause diarrhea. Other drugs that cause diarrhea, include chemotherapy cancer drugs, magnesium-containing antacids, the antiobesity drug Xenical, and some diabetes drugs. In addition, some drugs can slow the motility of the GI tract or can limit activities, resulting in constipation. Other GI problems can include esophageal irritation (from oral pills getting stuck in the esophagus), liver toxicity, and pancreatitis (inflammation of the pancreas). The author concludes by reminding readers that most drugs have the potential for causing GI upset and that patients should work closely with their physicians to monitor side effects. 1 table.
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Surgical Management of Gastrointestinal Bleeding. Gastroenterology Clinics of North America. 29(1): 189-222. March 2000.
The role of surgery in gastrointestinal (GI) bleeding has recently diminished because of the development of effective endoscopic and interventional radiologic therapies. Nevertheless, operation remains an important salvage strategy for failure of less invasive interventions and is required in most patients with bleeding GI neoplasms other than small benign polyps. This article reviews the surgical management of GI bleeding. Operations for upper tract bleeding are often designed to address the specific pathophysiology responsible for the bleeding lesion. Operations for lower GI tract bleeding more commonly entail simple segmental bowel resections that encompass the bleeding lesion. The combined application of endoscopic and laparoscopic techniques now provides a minimally invasive alternative to treat a highly selected group of patients with GI bleeding. The authors review surgical strategies for hemorrhagic gastritis, esophageal and gastric varices, esophageal ulcers and erosions, Mallory-Weiss tears, Dieulafoy's lesion, angiodysplasia, neoplastic lesions, hemobilia, pancreatic pseudocysts and pseudoaneurysms, aortoenteric fistula, diverticular disease, arteriovenous malformations, inflammatory bowel disease (IBD), tumors of the colon and rectum, anorectal disease, and Meckel's and other small intestinal diverticula. The authors conclude that, despite the less frequent need for surgical intervention, traditional operative approaches, such as suture ligation, lesion or organ excision, vagotomy, portasystemic anastomosis, and devascularization procedures, continue to be life saving in many instances. 8 figures. 2 tables. 156 references.
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System Breakdown. Princeton, NJ: Films for the Humanities and Sciences. 2000. (videorecording).
Over the course of a lifetime, up to 100 tons of food will pass through the average American's digestive tract. This videotape is one in a three-part series that explains the workings of the digestive tract, describes selected gastrointestinal disorders, and spotlights a variety of approaches to overall wellness through good nutrition. This program focuses on surgical, pharmaceutical, and nontraditional interventions for people with gastrointestinal distress, including chronic acid reflux, irritable bowel syndrome (IBS), ulcerative colitis, gastroesophageal reflux disease (GERD), and diverticulosis. Diagnosis of intestinal illnesses through stool (fecal) analysis as performed at the Great Smokies Diagnostic Laboratory is featured. Also, nutritionist Keith Ayoob helps the Ayvaliotis family, introduced in the first program, to improve their diet by reducing their dependence on processed and convenience foods. The programs include expert commentary, endoscopic and microscopic imaging, onscreen statistics, and tips from 'Eddie the Enzyme'.
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