Gastrointestinal
Anatomy
The gastrointestinal tract (GI tract) is essentially a long muscular tube connecting the mouth to the anus. Each section has a special function, which also precludes it to certain diseases.
The esophagus is the muscular tube connecting the mouth to the stomach and it traverses through the chest. This does not have a specific lining to protect it from acid and thus it is very prone to effects from reflux from stomach acid. Other diseases include cancer, polyps and diverticulum.
The next organ, which is the stomach, aides in the digestion and grinding of foods. It produces acid to help with this and can cause reflux disease into the esophagus. Other diseases include ulcer disease as well as occasional cancers.
The food then travels into the small intestine, which measures approximately 12 feet. This helps to finish digestion of the food as well as the majority of absorption of the food and nutrients from the intestines. Common diseases of the small intestine include inflammatory bowel diseases such as Crohn's disease and occasional tumors of the small intestine. There are less than 3,000 cases of malignant tumors per year diagnosed within the small intestine.
From there the contents empty into the colon which measures roughly 3-4 feet in length and the major function of the colon is to absorb water from the stool to conserve moisture. Part of the colon is a small residual organ called the appendix which serves essentially no function in humans except to occasionally get infected, causing acute appendicitis or to harbor tumors. Other main pathology included within the colon is diverticula, polyps and cancers. The rectum is the final area of the GI tract, which acts as a storage depot for stool until elimination can occur. Hemorrhoids, polyps and occasional tumors can also affect the rectum.
The gallbladder plays an important role in digestion and this is a muscular bag located underneath the right rib cage that stores bile. When the proper signal is sent to this it empties the bile into the first portion of the small intestine aiding in the digestion of greasy and fatty foods. The majority of mythology from this includes stones, dysfunction of the gallbladder and possible infection. Cancer is a very rare entity.
Abdominal Pain
Neurovast consolation of disease processes that can cause abdominal pain, which are not entirely limited to the GI tract. Other potential organs and systems that can contribute to the pain include the liver, spleen, pancreas, aortic, kidneys and female organs.
From a GI standpoint, common causes of upper abdominal pain can result from diseases of the gallbladder, stomach or pancreas. Mid-abdominal pain can be associated with diseases of the small bowel or even early appendicitis. Lower abdominal pain is often associated with colon diseases, hernias or urinary or female organ diseases. In general, abdominal pain is abnormal and should be evaluated by your physician to ascertain the exact etiology.
Reflux Disease
Gastroesophageal reflux disease (or GERD) affects an estimated 40,000,000 Americans per year. This is caused by acid produced in the stomach, refluxing up into the esophagus. The esophagus does not have the proper lining to protect it from the acidic burns from this. A wide variety of symptoms can be caused by this and these range from excruciating chest pain, to a hoarse voice and dental carries to vague abdominal discomfort. In addition, this can also play a role in causing asthma and increasing the risk of esophageal cancer. The diagnosis is usually made by the history as well as endoscopy, 24-hour PH monitoring of acid levels in the esophagus and x-ray studies. Initial treatments include lifestyle modifications such as stopping smoking, drinking alcohol and not eating late at night. This is followed by medications and if all else fails there are surgical options, which include minimally invasive surgeries, which often produce excellent results.
Ulcer Disease
Ulcers most commonly occur in the stomach and first portion of the small intestine (duodenum). This is often multi factorial, including diet, alcohol use, anti-inflammatory medications, and nicotine to name a few. The majority of ulcers are now associated with infections of the lining of the stomach and duodenum by bacteria called Helicobacter pylori. This is very treatable with medications. The diagnosis gold standard is endoscopy to identify these and to rule out any other cause such as cancer. Ulcers rarely require surgery now except for life threatening complications such as severe bleeding, perforation, obstruction, or large, non-healing ulcers.
Hernias
Hernias are a weakness or a tear in the wall of the abdomen. These can occur in a variety of manners and these can occur in children as well as adults. In adults these typically tend to be acquired and the most common types of hernias include incisional hernias, inguinal (or groin) hernias, and umbilical hernias. In essence, unless surgery presents a significant risk to the patient's health most hernias should be repaired to prevent some of the more serious complications, which include incarceration of the hernia, strangulation of the hernia and increasing size of the hernia. In general, hernia operations are usually performed as an outpatient and some can be performed with minimally invasive techniques as well and these provide excellent results. Decision for surgery should be decided between the patient and their surgeon.
Gallbladder Disease
1,000,000 Americans per year are diagnosed with gallstones and approximately 80% of these patients will be asymptomatic. Stones occur due to an abnormality in the concentration of the bile within the gallbladder causing particles to precipitate out eventually leading to the formation of stones. Asymptomatic patients have a 15% chance to develop symptoms and typical symptoms include nausea, vomiting, abdominal pain over the right rib cage, chest pain, or pain which radiates through the back. Often times the chest pain can be confused initially with heart attack or other heart diseases. The only approved way for treatment of the gallbladder stones or gallbladder dysfunction includes surgical removal of the gallbladder through minimally invasive techniques. This is often an outpatient surgery or an overnight stay in the hospital and approximately 95% can be removed through the minimally invasive techniques.
Diverticulosis
Diverticula are pockets or projections that occur at weak points in the bowel wall. This is most common in the sigmoid colon, which is located in the left lower quadrant of the abdomen. As these little pockets grow the wall becomes thinner and if infection occurs then patients are termed to have diverticulitis. There are very significant complications from diverticulitis, which can include bleeding, and change in the bowel habits. The most serious is perforation of the diverticulitis, which allows the bacteria to escape into the intra-abdominal cavity. This necessitates an emergency surgery and patients often require a temporary colostomy to allow the infection to resolve before reconnecting the colon and removing the colostomy. Typical symptoms of diverticulosis/diverticulitis can include bowel dysfunction such as discomfort, diarrhea or constipation. It can also cause obstruction if there is a low-grade inflammation that causes a gradual narrowing of the colon. Typically a patient will notice pain in the left lower area of the abdomen and this is initially treated with oral antibiotics. However, if the infection progresses then often it is necessary to hospitalize the patient for IV antibiotics and further work-up to confirm the diagnosis.
Once the diagnosis of diverticulitis has been made depending on the age of the patient and the number of episodes they had elective surgery is considered to avoid the serious complications of perforation and the need for colostomy. With an elective surgery colostomies are usually not necessary and this can also be performed through minimally invasive techniques
Appendicitis
Appendicitis is the most common condition leading to emergency operations in children. The average risk of developing appendicitis during a lifetime has been estimated between 6-20%. This typically presents with nausea, lack of appetite, fever and abdominal pain. Generally the abdominal pain starts around the belly button and migrates to the right lower quadrant of the abdomen. The only treatment for acute appendicitis is surgical removal of this. If the appendix has not burst prior to surgery, the patient will just have an overnight stay in the hospital. However, if there is a more complex process such as a perforated appendicitis with an abscess or general peritonitis this changes the hospital course dramatically and can require many days or up to weeks of IV antibiotics and oral antibiotics. There is also an increased risk of recurring infections within the abdomen. Approximately 30-40% of children will have perforated their appendix prior to the time of operation.
Colon Cancer
75% of all colorectal cancers occur in patients, which have no previously noted risk factors for colorectal cancer. Risk factors include cancer in a first-degree relative, inherited syndromes, personal history of prior cancer or polyps and other diseases such as inflammatory bowel disease. Screening for colon cancer is generally recommended as 1 of 3 options: Flexible sigmoidoscopy every 5 years combined with an annual fecal occult blood testing, air contrast barium enema every 10 years, or colonoscopy every 10 years are the 3 major options. It is slowly appearing that colonoscopy may be the most sensitive screening test of the 3. In the normal risk patient, screening should begin at age 50. However, if someone is at a high risk then the screening should begin earlier, no later than 40 years of age and this depends somewhat on their family history for colon cancer.
The presentation of colon cancer depends on the location. Cancers that are located in the right side of the large intestine, are noticed much later due to their lack of symptoms. One of the more common findings in this location of tumor is fecal occult blood noticed by your physician on yearly exams. The left side of the colon in the area of the rectal sigmoid is a common area for presentation of colon cancer and this can present with pain, perforation, or obstruction of the colon. Treatment for colon cancer is surgical treatment followed by possible chemotherapy depending on the staging.
Anal and rectal cancers often times can be treated with chemotherapy and radiation therapy prior to surgery to try and srink the tumer. Occasionally this can just be a local excision of the tumor not necessitating a large intra-abdominal surgery.
Follow up for colon cancers are extremely important. Up to 50% of patient's can develop a recurrence. 80% of these recurrences will occur within the first 2 years of the primary surgery, so post-operative follow-up during this period is essential. This includes frequent history and physical exams, measurement of serum tumor markers and liver tests as well as chest x-rays and possible CT scans and colonoscopies. The exact follow up should be determined by you and your physician.
Rectal Bleeding/Pain
Bleeding after bowel movements can be attributed to a number of causes. More common cause include internal hemorrhoids, anal fissures or even cancers. Thus, any bleeding after bowel movements should be evaluated by your physician. Internal hemorrhoids tend to cause painless bleeding and often times can be treated medically as well as with changes in your diet by increasing your fiber intake, avoiding constipation or straining is imperative in the treatment of hemorrhoids and other rectal pathology. External hemorrhoids often present as a very painful bulge at the anal orifice and these can be treated either conservatively with sitz baths and creams or with a very minor surgical procedure done in the office removing the blood clot, which is causing the pain. This usually provides fairly significant relief of the symptomatology.
Anal fissures are a common cause of painful rectal bleeding. These can occur after a bout of constipation and are best thought of as a crack in the lining of the anus. This then causes pain as bowel movements pass through the anus and will have a small amount of bleeding. These are preferably treated conservatively with sitz baths and other medications and suppositories and surgery is saved for chronic anal fissures or non-healing fissures. Rectal cancers can also present as occasional pain and rectal bleeding and this can often be diagnosed in the office with exam by your physician.
Hemorrhoids
Also known as piles, hemorrhoids can be very irritable but are usually not serious. However, in some cases hemorrhoids are a sign of very serious conditions such as cancer of the colon or rectum.
What are hemorrhoids?
Hemorrhoids are enlarged veins located around the anus and rectum. There are 2 kinds of hemorrhoids, internal and external. External hemorrhoids are located outside the anus and can be felt as lumps. Internal hemorrhoids are inside the rectum and cannot be felt or seen.
What causes hemorrhoids?
Hemorrhoids are caused when blood above the rectum puts pressure on the rectal area. Some of the conditions that are known to cause this pressure are: pregnancy, obesity, constipation, diarrhea, and straining during a bowel movement.
Non -serious complications
- Thrombosis: A blood clot in the hemorrhoid causing sever pain and immediate medical attention.
- Bleeding: Both internal and external hemorrhoids can cause bleeding which will be noticeable in the toilet, underwear, and stool.
- Itching: External hemorrhoids can be extremely irritating and uncomfortable, particularly if the area is moist.
Treating Hemorrhoids
Treatment varies depending on the location and seriousness of the problems they cause.
The Conservative Treatment:
This involves keeping the area as clean as possible using mild soap and using talcum powder to keep the hemorrhoids as dry as possible. Eating a high fiber (bran) diet and plenty of roughage helps to retain water in the stool making it softer and easier to pass. A hot bath when pain occurs can help relieve the pain and promote healing.
Ligation:
Many times a small rubber band can be tied around the base of an internal hemorrhoid causing the blood to stop flowing, eventually causing the hemorrhoid to fall off. Sometimes this treatment needs to be repeated.
Infrared Photocoagulation
An infrared light is used to coagulate internal hemorrhoids. This treatment also may require several treatments.
Lasers
Lasers direct a high-intensity beam at the tissue producing heat, which coagulates or cauterizes the hemorrhoid. Laser treatment is a very new technique and is still being researched but will likely be beneficial in the future.
Surgery
In serious cases such as continuous bleeding, extreme pain, and large hemorrhoids, surgery is sometimes recommended.
Prevention
Eating plenty of fiber and roughage, not delaying or preventing a bowel movement, aerobic exercise, and drinking plenty of water will help to prevent hemorrhoids from occurring or reoccurring.
