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Fistulizing Crohn's Disease: A Case of Mistaken Identity. Practical Gastroenterology. 31(2): 66-71. February 2007.
This article reviews the case of a 23-year old Caucasian female patient who presented 2 months after an acute appendicitis with an isolated rectovaginal fistula, suspected to be a complication of Crohn’s disease. Despite continued medical and surgical therapies, the fistula would not heal and complications of bleeding ensued. After eight hospitalizations, three surgeries, and more than $135,000 in medical expenses over an 18-month period, her disease was discovered to be self-inflicted. The authors describe this case of factitious disorder disguised as Crohn’s disease and highlight the importance of early diagnosis of this frequently missed disorder in order to initiate early and essential psychiatric care. The authors note that Crohn’s disease is a diagnosis based on a combination of physical findings, endoscopic disease, histopathology, and laboratory and radiographic abnormalities. Relying on only a portion of these parameters may lead to an erroneous diagnosis of inflammatory bowel disease (IBD). 4 figures. 2 tables. 10 references.
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Pregnancy in Gastrointestinal Disorders. 2nd ed. Bethesda, MD: American College of Gastroenterology. 2007. 79 p.
This monograph presents updated information about pregnancy in women with gastrointestinal disorders. The monograph offers eight chapters, covering constipation, diarrhea, hemorrhoids, and fecal incontinence; the use of endoscopy in pregnancy; heartburn, nausea, and vomiting during pregnancy; hyperemesis gravidarum and nutritional support, including nutritional requirements, venous access, and monitoring of pregnant patients on total parenteral nutrition (TPN); liver diseases in pregnancy, including the use of imaging studies, the safety of drugs in pregnancy, liver disorders unique to pregnancy, and pregnancy in liver transplant patients; surgical problems in the pregnant patient; and pregnancy in women with inflammatory bowel disease (IBD). The chapter about surgical problems reviews appendicitis, biliary tract diseases, pancreatitis, trauma, intestinal obstruction, splenic artery aneurysms, hepatic lesions, hemorrhoids, inflammatory bowel disease, and colorectal malignancy. Each chapter focuses on bringing readers up to date on the research in the area covered, the recommended treatments, and patient management concerns, notably issues of maternal and fetal safety. Each chapter concludes with a list of 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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Surgical Problems in the Pregnant Patient. IN: Pregnancy in Gastrointestinal Diseases. 2nd ed. Bethesda, MD: American College of Gastroenterology. 2007. pp 54-65.
This chapter about surgical problems in the pregnant patient is from a monograph that presents updated information about pregnancy in women with gastrointestinal disorders. The authors note that up to 1 percent of all pregnant women require surgery. As a general rule, the condition of the mother should always take priority because proper treatment of surgical diseases in the mother will usually benefit the fetus as well as the mother. The chapter focuses on bringing readers up to date on the research in the area covered, the recommended treatments, and patient management concerns, notably issues of maternal and fetal safety. The authors first briefly review the various anatomic and physiologic changes that occur during normal pregnancy that can alter the presentation of conditions that require surgery. Separate sections discuss general guidelines for surgery during pregnancy, appendicitis, biliary tract diseases, pancreatitis and gallstone disease, trauma, intestinal obstruction, splenic artery aneurysms, hepatic lesions, hemorrhoids, inflammatory bowel disease, and colorectal malignancy. The authors stress the importance of a clear treatment plan that avoids procrastination, which can be made after careful review of the history, a physical exam performed with the gravid uterus in mind, and judicious use of radiologic studies. Elective procedures can be delayed until after delivery. 45 references.
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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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Getting Down to the Lower GI Tract. Nursing. 35(11): 20-21. November 2005.
This article helps nurses understand the physiology of the lower gastrointestinal (GI) tract, particularly in patients who are older. The author outlines how aging affects the lower GI tract, reviews common disorders, and explains how nursing interventions can help minimize problems for this patient population. With age, blood flow to the large intestine lessens and intestinal motility and peristalsis decrease. Constipation and fecal impaction can result from a combination of factors, such as decreased mobility, medications, dehydration, poor diet, and limited fiber intake. The author cautions that assessing older patients can be difficult because their symptoms may be vague and they may have more than one coexisting chronic illness. The author outlines age-related differences in GI disorders, including appendicitis, acute abdomen, and lower GI bleeds. The article concludes with guidelines for nursing interventions for older patients with GI problems. One sidebar lists drugs commonly prescribed for older patients that can cause constipation. 2 figures. 4 references.
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Appendicitis. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2004. 6 p.
Appendicitis is an inflammation of the appendix, a small, tube-like structure attached to the first part of the large intestine (the colon). The appendix has no known function and removal of the appendix appears to cause no change in digestive function. This fact sheet describes appendicitis and its management, addressing the causes, symptoms, diagnosis, treatment, and complications of this condition. The fact sheet emphasizes that appendicitis is considered a medical emergency. Symptoms of appendicitis include pain in the abdomen, loss of appetite, nausea, vomiting, constipation or diarrhea, inability to pass gas, low-grade fever, and abdominal swelling. Physical examination, laboratory tests, and imaging tests are used to diagnose appendicitis. Acute appendicitis is treated by surgery to remove the appendix. The most serious complication of appendicitis is rupture, which can lead to peritonitis and abscess. A final section describes the goals and work of the National Digestive Diseases Information Clearinghouse. 1 figure.
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Common Pediatric Gastrointestinal Disorders. In: Kelly, K.A.; Sarr, M.G.; Hinder, R.A., eds. Mayo Clinic Gastrointestinal Surgery. St. Louis, MO: Elsevier Science. 2004. p. 699-721.
With the exception of appendicitis, most pediatric surgical gastrointestinal disorders are uncommon and diverse. This chapter on pediatric gastrointestinal disorders is from a book that focuses on the major diseases treated by gastrointestinal surgeons, from the esophagus to the anal canal. The text has a clinical orientation and a major emphasis on practical applications as they are applied at the Mayo Clinic. The authors of this chapter note that the challenge with children who present with abdominal pain is to arrive at a diagnosis in a timely fashion yet use the least invasive and most efficient means of investigation. The authors describe a simplified diagnostic algorithm that concentrates on the age of the patient and the symptoms of abdominal pain and emesis. Age groups are created by a 'rule of threes' that is reasonable accurate but also simple and direct for categorizing patients into different risk groups suggesting certain surgical disorders. The authors describe the common gastrointestinal disorders by age and provides a systematic description of pediatric surgical gastrointestinal disorders and their treatment. The most common pediatric surgical diseases and procedures are discussed, and some rare conditions are included for completeness and to illustrate recent major advances in surgical therapy. The chapter is illustrated with line drawings. 10 figures. 75 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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Acute Appendicitis. In: PDxMD. PDxMD Gastroenterology. St. Louis, MO: Elsevier Science. 2003. p. 1-14.
Acute appendicitis is characterized by central abdominal pain usually lasting several hours, with brief cessation, followed by migration of pain to the right lower quadrant in a more constant, more localized form. Nausea, anorexia (lack of appetite), and fever are common. Delayed diagnosis may result in perforation, peritonitis, and greatly increased morbidity and mortality. This chapter on acute appendicitis 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). 8 references.
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Appendectomy Is Followed by Increased Risk of Crohn's Disease. Gastroenterology. 124(1): 40-46. 2003.
Appendectomy is associated with a low risk of subsequent ulcerative colitis (UC, a type of inflammatory bowel disease). This article reports on a study of the risk of Crohn's disease (a second type of inflammatory bowel disease) after appendectomy. The authors followed-up 212,218 patients with appendectomy before age 50 years and a cohort of matched controls, identified from the Swedish Inpatient Register and the nationwide Census, for any subsequent diagnosis of Crohn's disease. An increased risk of Crohn's disease was found for more than 20 years after appendectomy, with incidence rate ratio 2.11 after perforated appendicitis, 1.85 after nonspecific abdominal pain, 2.15 after mesenteric lymphadenitis, 2.52 after other diagnoses. After nonperforated appendicitis, there was an increased risk among women but not among men. Patients operated on before age 10 years had a low risk. Crohn's disease patients with a history of perforated appendicitis had a worse prognosis. 2 figures. 5 tables. 29 references.
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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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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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Abdominal Pain. In: Reisman, A.B.; Setevens, D.L., eds. Telephone Medicine: A Guide for the Practicing Physician. Philadelphia, PA: American College of Physicians. p. 107-122.
This chapter on abdominal pain is from a reference book for practicing physicians who are providing information for their patients over the telephone. The author notes that abdominal pain is one of the more challenging medical complaints to evaluate over the telephone. The chapter summarizes key points, then outlines an approach to acute abdominal pain and to chronic abdominal pain that has acutely changed in the adult patient. Topics include epidemiology, utility of early diagnosis, early diagnosis in the elderly, the general approach to the telephone evaluation, determining whether the patient requires emergency evaluation, small bowel obstruction, acute appendicitis, acute cholecystitis (gallbladder infection, often due to gallstones), ectopic pregnancy, dyspepsia, biliary colic, what to tell the patient, and what to document. The author stresses that the telephone physician should have a lower threshold for in-person evaluation of elderly patients with any acute abdominal pain because older patients are more likely to present late in the course of their illness and to have a poor clinical outcome. Abdominal pain in the setting of significant bleeding, trauma, or recent abdominal surgery should prompt a referral to the emergency room without delay. For patients in whom the disposition is not clear, the physician should consider calling back within a few hours to reassess the symptoms for resolution or progression. A patient care diagnostic algorithm is provided. 1 figure. 38 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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Appendicitis. 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. 2089-2099.
Appendicitis is the most common acute abdominal emergency seen in developed countries. This chapter on appendicitis 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 historical perspective, epidemiology, anatomy and embryology, pathology, pathogenesis, diagnosis, clinical presentation, diagnostic accuracy, complications, treatment, and anticipated treatment outcomes. Simple acute appendicitis is associated with excellent outcomes. Morbidity and mortality attributable to appendicitis increase markedly with complicated and in particular, perforated appendicitis. The treatment of acute appendicitis remains appendectomy. The chapter includes a mini-outline with page citations, illustrations, and extensive references. 4 figures. 2 tables. 80 references.
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Appendicitis: Should Diagnostic Imaging Be Performed if the Clinical Presentation is Highly Suggestive of the Disease?. Gastroenterology. 123(4): 992-998. October 2002.
This article reports on a study that investigated whether diagnostic imaging is required if the clinical presentation suggests acute appendicitis with high probability. On the basis of clinical findings, 350 consecutive patients with clinical suspicion of acute appendicitis were prospectively divided into 3 groups as follows: low, intermediate, and high probability of having appendicitis. All patients then underwent diagnostic ultrasonography. The clinical likelihood of appendicitis and the ultrasonography results were correlated with the definite diagnoses. In the patients with clinically low probability of having appendicitis, appendicitis was present in 10 percent (11 of 109 patients), and, in those with intermediate probability, appendicitis was present in 24 percent (23 of 97 patients). Patients with clinically high probability of having appendicitis had appendicitis in 65 percent (94 of 144 patients), an alternative diagnosis in 18 percent (26 of 144 patients), and no specific definitive diagnosis in 17 percent (24 of 144 patients). The authors conclude that even in patients with clinically high probability of acute appendicitis, diagnostic imaging should be performed because it accurately depicts a high percentage of normal appendices and differential diagnoses. 1 figure. 5 tables. 37 references.
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Factors Associated with Conversion to Laparotomy in Patients Undergoing Laparoscopic Appendectomy. Journal of the American College of Surgeons. 193(3): 298-305. March 2002.
Laparoscopic appendectomy (LA) has been increasingly adopted for its advantages over the open technique, but there is a possibility of conversion to open appendectomy (OA) if complications occur or the extent of inflammation of the appendix prohibits successful dissection. This article reports on a study undertaken to identify the preoperative predictors for conversion from laparoscopic to open appendectomy. The authors retrospectively reviewed the medical records of 705 consecutive patients who underwent surgery for suspected appendicitis (inflamed appendix). LA was attempted in 595 patients by 25 different surgeons. Conversion to OA occurred in 58 of these 595 patients (9.7 percent). The most common reason for conversion was dense adhesions due to inflammation, followed by localized perforation and diffuse peritonitis. Based on 261 patients evaluated by CT scan preoperatively, significant factors associated with conversion to OA were age, diffuse tenderness on physical examination, and a surgeon with less experience. The presence of significant fat stranding associated with fluid accumulation, inflammatory mass, or localized abscess in CT scan also significantly increased the possibility of conversion. 5 tables. 38 references.
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Factors Associated with Conversion to Laparotomy in Patients Undergoing Laparoscopic Appendectomy. Journal of the American College of Surgeons. 193(3): 298-305. March 2002.
Laparoscopic appendectomy (LA) has been increasingly adopted for its advantages over the open technique, but there is a possibility of conversion to open appendectomy (OA) if complications occur or the extent of inflammation of the appendix prohibits successful dissection. This article reports on a study undertaken to identify the preoperative predictors for conversion from laparoscopic to open appendectomy. The authors retrospectively reviewed the medical records of 705 consecutive patients who underwent surgery for suspected appendicitis (inflamed appendix). LA was attempted in 595 patients by 25 different surgeons. Conversion to OA occurred in 58 of these 595 patients (9.7 percent). The most common reason for conversion was dense adhesions due to inflammation, followed by localized perforation and diffuse peritonitis. Based on 261 patients evaluated by CT scan preoperatively, significant factors associated with conversion to OA were age, diffuse tenderness on physical examination, and a surgeon with less experience. The presence of significant fat stranding associated with fluid accumulation, inflammatory mass, or localized abscess in CT scan also significantly increased the possibility of conversion. 5 tables. 38 references.
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Identification of Pancreatitis in the Ambulatory Setting. Gastroenterology Nursing. 24(1): 20-22. January-February 2001.
Acute pancreatitis can be life threatening and nurse practitioners must know the signs, symptoms, and risk factors for pancreatitis. This article reviews the identification of pancreatitis in the ambulatory setting. The author uses a case study of a 59 year old white woman who presents to the clinic with vague complaints of abdominal pain. Her symptoms began the evening before presentation and are progressively worsening. The author uses this case to illustrate the differential diagnostic process. The most common differential diagnoses for this patient's symptoms include appendicitis, acute pancreatitis, mesenteric ischemia or infarction, perforated gastric or duodenal ulcer, intestinal obstruction, biliary colic, and perhaps even inferior wall myocardial infarction. Making a diagnosis of acute pancreatitis depends on clinical history, physical examination, serum enzyme assays, and radiologic tests. The main goal of treatment for pancreatitis is supportive care, limitation of complications, and prevention of necrosis (tissue death) of the pancreas. In the case example, the patient's pancreatitis was thought to be caused by a mixture of estrogen and an ACE inhibitor. Although alcohol consumption and gallstones are the most frequent causes of pancreatitis in the general population, mediations are now being recognized as important causative agents that are often overlooked. The author reiterates that early recognition and treatment of acute pancreatitis can reduce suffering and serious complications for the patient. 3 tables. 7 references.
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Is the Appendix a Vestigial Organ? Its Role in Ulcerative Colitis. Gastroenterology 121(3): 730-737. September 2001.
This article summarizes a research study that considers the role of the appendix in ulcerative colitis (UC, a type of inflammatory bowel disease), including the possible role of appendectomy (removal of the appendix) in protecting against UC. The author briefly reviews the research in this area, then focuses on one particular study that was reported in the New England Journal of Medicine in 2001 (Andersson, R.E., et al, Volume 344). The investigators in that study conclude that the inflammatory response leading to an appendectomy rather than the removal of the appendix was the significant clinical factor negatively associated with developing UC at a later date. The absence of this protective effect in older patients with appendicitis also suggests that the immune mechanisms resulting in appendicitis in these patients may differ from those resulting in appendicitis before the third decade. The author then appends a lengthy commentary exploring the ramifications of these results. The author concludes that in the absence of evidence supporting a more causal role for the appendix, adoption of therapeutic appendectomy as a strategy to affect the incidence or clinical course of UC is premature, despite recent case reports suggesting clinical improvement and reduction in mucosal inflammatory mediators after appendectomy. Numerous studies are referred to in the text of this article.
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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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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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Prevalence of Appendectomy Among Ulcerative Colitis Patients and Their Relatives. European Journal of Gastroenterology and Hepatology. 13(10): 1231-1233. October 2001.
It has been suggested that appendectomy (removal of the appendix) may protect against ulcerative colitis (UC). However, the incidences of appendectomy and UC in developed countries have diverged over the last 50 years, possibly as a consequence of environmental factors. This study was undertaken to determine whether the incidence of appendectomy is lower in patients with UC than in the general population. Patients with UC (n = 153), their relatives (n = 116), and members of the general population (n = 306) that had been matched for age, sex, and educational status were studied. Six percent of UC patients had undergone appendectomy. The corresponding figure for non family controls was 20 percent. The rate of appendectomy within families (cases plus siblings) was 17 of 269 patients (6.3 percent) and was similar to that for UC patients alone. A negative association between appendectomy and UC exists in our patients with UC. In addition, the appendectomy rate in families of UC patients was lower than that in the general population, possibly implying that common environmental and genetic factors could play an important role in the divergent incidences of appendicitis and UC over the last 50 years. 2 tables. 18 references.
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Ulcerative Colitis of the Appendix ('Ulcerative Appendicitis') Mimicking Acute Appendicitis. Canadian Journal of Gastroenterology. 15(3): 201-204. March 2001.
The appendix may be involved in ulcerative colitis (UC, a type of inflammatory bowel disease), in the setting of either diffuse or distal disease, and is usually diagnosed incidentally at the time of proctocolectomy (surgery to treat the UC). This article describes a patient in whom a rare case of 'ulcerative appendicitis' occurring on a background of clinically quiescent (no active symptoms) UC presented with the signs and symptoms of acute appendicitis. Prior to this presentation, the patient's UC was in remission for over 2 years. The patient was treated with laparotomy and the appendix was removed. Pathology showed acute inflammation confined to the mucosa, with neutrophilic crypt epithelial infiltration (cryptitis) and crypt abscesses consistent with appendix involvement by UC. Following appendectomy, the patient made a rapid and uneventful recovery; he was asymptomatic one day after the operation and was discharged home on day 2. Six months later, the colitis remained in complete clinical remission, and there has been no recurrence of right lower quadrant symptoms. The authors suggest that this patient's acute appendiceal pain syndrome derived from a complex interplay of mucosal immune, vascular, and neurogenic factors, driven by a localized, active focus of UC. Appendectomy provided both the diagnosis and the cure of this acute illness. The authors conclude that although rare (and perhaps underrecognized), acute right lower quadrant pain in the setting of clinically quiescent UC may herald active ulcerative appendicitis, rather than typical suppurative appendicitis. 1 figure. 24 references.
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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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Appendicitis in Children: New Insights Into an Old Problem. Patient Care. 34(5): 183-188, 191-195. March 15, 2000.
Acute appendicitis is the most common reason for emergency abdominal surgery in childhood. Despite strong emphasis on early surgical intervention, the morbidity and mortality of acute appendicitis in children remain high. This review article clarifies the symptoms to look for in the patient's history, the signs to assess during the physical examination, and the degree of confidence to place in various laboratory tests and radiologic studies. The authors reiterate that a thorough but speedy evaluation is essential when examining a child with possible appendicitis. Recent studies show that in ambiguous cases, computed tomography (CT scan), especially when performed with rectal contrast, is an excellent adjudicator. The authors review the anatomy and physiology of the appendix, then detail each step of the physical examination. After a discussion of the appropriate laboratory tests, the authors remind readers of the more common pediatric illnesses that mimic appendicitis, including gastroenteritis, constipation, mesenteric adenitis, urinary tract infection (UTI), inflammatory bowel disease (IBD), pelvic inflammatory disease (PID), ovarian cyst, and pneumonia. 8 figures. 2 tables. 22 references.
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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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Evaluation of the Acute Abdomen. Patient Care. 34(12): 26-30, 33-34, 36, 39. June 30, 2000.
Acute abdominal pain is one of the most common medical symptoms, especially in middle aged and older patients. This article reviews the evaluation of the acute abdomen, noting that quick assessment is essential when the patient has abdominal pain that may signal a potentially serious underlying condition. A delay in appropriate treatment can have hazardous consequences. Certain underlying conditions are more likely in different ethnic groups, or in various age groups; demographic information can help narrow the differential diagnosis. The authors caution that symptoms associated with an acute abdominal process need not be particularly painful to be associated with serious conditions. Acute appendicitis, obstruction of the small intestine, and acute inflammation of the gallbladder and pancreas are common causes of acute abdominal pain. The chronology of symptom onset is crucial information and localizing tenderness is an integral part of the physical evaluation. CT (computed tomography) has become a standard tool in the evaluation of acute abdominal pain but should not, and need not, be applied to the majority of patients with this symptom. Patients presenting with abdominal pain who have normal laboratory or radiographic findings can be observed in the emergency department for 4 to 6 hours. Those whose condition has not worsened at that time can be discharged. The authors review the criteria for hospitalization. 4 figures. 2 tables. 8 references.
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Keep Yourself Healthy at Home: A Guide for Adults with Diabetes. South Deerfield, MA: Channing L. Bete Co., Inc. 2000. 60 p.
This illustrated handbook provides adults who have diabetes with information on health care. Section one provides general information about health care, the prevention of health problems, and the use of diabetes and general medications. Section two discusses specific problems and their treatment, focusing on allergies, appendicitis, asthma; back pain; bites and stings; bronchitis; bruises, cuts, and scrapes; burns and sunburns; chest pain; colds, flu, and cough; constipation; diarrhea; dizziness and fainting; fever; foot and leg problems; headaches; heartburn; mouth problems; nausea and vomiting; sexual concerns; sexually transmitted diseases; skin problems; sprains and strains; urinary tract infections; and vaginitis. Section three focuses on conditions of special concern for people who have diabetes, including heart disease and stroke and eye, kidney, and nerve diseases. Section four explains how to deal with hypoglycemia and hyperglycemia and provides space for writing down emergency numbers and other emergency information.
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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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When Is Abdominal Pain a Danger Sign? How to Tell, What to Do. Journal of Critical Illness. 15(4): 226-233. April 2000.
When abdominal pain is a patient's chief complaint, the diagnosis is often challenging. This article offers three case studies that can help physicians determine when abdominal pain is a danger sign. The history and physical examination are of the greatest use in identifying patients whose pain may be due to a serious or life threatening condition. Vascular emergencies (abdominal aortic aneurysm, mesenteric ischemia, and myocardial infarction) can cause abdominal pain. In the elderly, appendicitis is both more dangerous and more difficult to diagnose than in younger patients. The diagnostic tests that are most helpful in confirming or ruling out serious causes of abdominal pain include helical CT and focused bedside ultrasonography. The author cautions that reliance on laboratory tests and plain radiographs can be misleading. For women of childbearing age with abdominal pain, do not overlook the urine pregnancy test. A few serious abdominal abnormalities can be excluded only by invasive means: for example, ovarian torsion (by laparoscopy) and mesenteric ischemia (by angiography). 3 figures. 1 table. 29 references.
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