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Imaging of the Small Intestine

Although the small bowel is long and convoluted, imaging modalities allow its visualization ( Figs. 53.1 and 53.2 ). Barium contrast studies, computed tomography (CT) with enterography, and several forms of endoscopy (direct, wireless capsule, double balloon) are used to visualize select areas. Open full size image Fig. 53.1 Imaging Studies of the Small Intestine. CT, Computed tomography. Open full size image Fig. 53.2 Wireless Capsule…

Gastrointestinal Hormones and Neurotransmitters

Secretin became the first gastrointestinal (GI) hormone identified in humans in 1902. Since then, a myriad of GI peptides have been identified as hormones. Most have been verified, others have not; regardless, their functions are extremely important. GI hormones act in one of the following four ways: 1. Endocrine function. Epithelial cells secrete a substance into the circulation that acts at a distance. 2. Autocrine function.…

Anatomy of the Small Intestine

Topography and Structure of the Small Intestine and Terminal Ileum The small intestine consists of a retroperitoneal portion, the duodenum, and a mesenteric portion comprising the coils of the jejunum and the ileum ( Fig. 50.1 ). Given that the mesenteric portion of the small intestine is subject to considerable individual and functional variations, its total length varies considerably. The average length for adults is approximately…

Abdominal Access

Robotic Access Based on Dr. Halsted's legacy, a surgeon should always protect tissues with exquisite care based on three principles: asepsis, hemostasis, and gentleness. None of the preoperative preparation is as essential as the manner in which details are executed. Gentleness is essential in the performance of any surgical procedure. However, in recent decades a shift toward the search for less invasive procedures has seen the…

Abdominal Wall and Abdominal Cavity Hernias

The word “hernia” derives from the Greek hernios, which means “bud.” It indicates a protrusion of organs through an abnormal defect (opening) in a natural cavity, being the opening, the key part of the definition. In fact, the protrusion may not be recognized in some patients early in the process. The neck of the hernia sac corresponds to the hernial orifice. The dimension of the neck…

Alimentary Tract Obstruction and Intestinal Injuries

Alimentary Tract Obstruction Any organic or functional condition that primarily or indirectly impedes the normal propulsion of luminal contents from the esophageal inlet to the anus should be considered an obstruction of the alimentary tract ( Fig. 47.1 ). The spectrum of diseases affecting the alimentary tract and its clinical manifestation is significantly related to the constituent organ(s) involved. Thus, esophageal disorders manifest mainly through their…

Mesenteric Ischemia and Other Vascular Lesions

Mesenteric Ischemia The mesenteric circulation receives approximately 25% of cardiac output under resting conditions. Mesenteric ischemia results from inadequate blood flow to the intestine and it is commonly classified as an acute episode or as a chronic disease. It can be segmental, with localized areas of bowel ischemia, or extensive, where most of the bowel is affected ( Fig. 46.1 ): 1. Acute mesenteric ischemia is…

Peritoneum and Related Diseases

Peritoneum Peritoneum is derived from Greek origins, peri meaning “around” and tonos meaning “stretching.” The peritoneum is the extensive serous membrane that lines the innermost surface of the abdominal wall and abdominal organs. The serous layer consists of dense mesothelial cells and encompasses a surface area of 1.8 m 2 . The peritoneum is divided into parietal and visceral peritoneum. The parietal peritoneum is attached to the…

Abdominal Wall Anatomy

Anterolateral Abdominal Wall Before describing the abdominal parietes (wall), it is important to define the anatomic limits of the abdomen. For the purpose of a specific description, the abdomen is the area of the body that limits with the diaphragm superiorly and the pelvic cavity inferiorly. The parietes of the abdomen can be divided into four general parts: anterolateral abdominal wall; posterior abdominal wall; diaphragm (roof…

Effects of Total Gastrectomy

Total gastrectomy almost always results in nutritional problems ( Fig. 43.1 ). Usually performed to attempt a curative procedure for carcinoma, total gastrectomy also may be done to treat trauma. Open full size image Fig. 43.1 Effects of Total Gastrectomy. Clinical Picture After total gastrectomy, patients have great difficulty gaining weight, and most never regain their preoperative weight. Others may develop selected deficiencies. The clinical picture…

Postgastrectomy Complications: Partial Gastrectomy

Complications in the postgastrectomy period occur with both open and laparoscopic surgical techniques and may occur after complete healing. These include recurrent ulceration, gastroparesis (delayed gastric emptying), afferent loop syndrome, dumping syndrome and postvagotomy diarrhea, bile reflux gastritis, and gastric adenocarcinoma. Symptoms vary depending on the complication and are briefly described here. Recurrent Ulceration Marginal ulcers, or jejunal ulcers, are rare and may occur in less…

Principles of Gastric Surgery

With the advent of H 2 inhibitors and proton pump inhibitors (PPIs) and treatment of Helicobacter pylori, gastric surgery has declined significantly. Previously, the primary indication for gastric surgery was control of peptic ulcer disease, but the success of medical therapy greatly decreased the need for gastric surgery. Indications for gastric surgery have not changed: uncontrollable gastrointestinal (GI) bleeding, perforation, or obstruction. A recent indication for…

Tumors of the Duodenum

Tumors of the duodenum are rare. The benign neoplasms that may be encountered are Brunner gland hyperplasia, polypoid adenomas, lipomas, leiomyomas, neurofibromas, hemangiomas, and aberrant pancreatic tissue. All benign tumors are rare and often only slightly elevated. A polyp may be on a pedicle and then appear mobile, shifting back and forth by peristaltic motion, and occasionally prolapsing into the pylorus ( Fig. 40.1 ). Open…

Cancers of the Stomach

Cancer involving the stomach is the second most common cancer in the world. Although it is decreasing in North America, stomach cancer continues to increase throughout the rest of the world. The incidence of adenocarcinoma has increased only in lesions at the cardioesophageal junction ( Fig. 39.1 ). Open full size image Fig. 39.1 Cancers of the Stomach. The etiology of stomach cancer remains complex, and…

Gastrointestinal Lymphoma and Mucosa-Associated Lymphoid Tissue

Lymphomas of the stomach are of two types, both of B-lymphocyte origin: marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) type and diffuse, large B-cell lymphoma ( Fig. 38.1 ). Open full size image Fig. 38.1 Gastric Lymphoma and Mucosa-Associated Lymphoid Tissue (MALT) Tumor. GI, Gastrointestinal; IL-8, interleukin-8. Mucosa-Associated Lymphoid Tissue Tumor The stomach is the most common site of lymphoma in Western societies.…

Benign Tumors of the Stomach and Gastrointestinal Stromal Tumors

Benign tumors of the stomach are relatively rare. Numerous autopsy studies reveal that gastric polyps are present in approximately 0.1% of gastric specimens. However, with the advent of endoscopy, small tumors have been more readily identified ( Fig. 37.1 ). These tumors can be classified as epithelial, submucosal, and ectopic. Open full size image Fig. 37.1 Benign Gastric Tumors. GIST, Gastrointestinal stromal tumor. Benign tumors of…

Upper Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding may indicate acute or chronic loss of blood from the GI tract. It may originate in the upper or the lower part of the tract. Acute bleeding may be life threatening; chronic bleeding is slow or even occult ( Fig. 35.1 ). The GI tract can lose as much as 50 mL of blood per day, which is replaced, without anemia, but it is…