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`- - - - - - - - - - - THIRD EDITION - - - - - - - - - - -
`
`Textbook of
`Gastroenterology
`
`VOLUME ONE
`
`EDITOR
`Tadataka Yamada, MD
`Adjunct Professor
`Department of Internal Medicine
`Division of Gastroenterology
`University of Michigan Health System
`Ann Arbor, Michigan
`
`David H. Alpers, MD
`William B. Kountz Professor of Medicine
`Department of Internal Medicine
`Division of Gastroenterology
`Washington University School of Medicine
`St. Louis, Missouri
`
`ASSOCIATE EDITORS
`Loren Laine, MD
`Professor
`Department of Medicine
`University of Southern California School of
`Medicine; and
`Chief, Gastroenterology Section
`Los Angeles County and University of Southern
`California Medical Center
`Los Angeles, California
`
`Chung Owyang, MD
`Professor of Internal Medicine
`H. Marvin Pollard Collegiate
`Professor of Gastroenterology; and
`Chief, Division of Gastroenterology
`University of Michigan Health System
`Ann Arbor, Michigan
`
`Don W. Powell, MD
`Edward Randall and Edward Randall, Jr.
`Distinguished Chairman; and
`Professor, Internal Medicine
`Professor, Physiology and Biophysics
`The University of Texas Medical Branch at
`Galveston
`Galveston, Texas
`
`J~ LIPPINCOTT W ILLIAMS & W ILKINS
`
`•
`
`PHILADE LP H IA • N EW YO R.K
`
`· BA LT IMOR.E
`
`
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`Acquisitions Editor: Beth Barry
`Developmental Editors: Rebecca Irwin Diehl; Glenda Insua
`Manufacturing Manager: Tim Reynolds
`Production Manager: Liane Carita
`Production Editor: Sally M. Scott
`Cover Designer: Christine Jenny
`Indexer: Gerry Lynn Messner
`Compositor: Maryland Composition Company, Inc.
`Printer: World Color
`
`© 1999, by Lippincott Williams & Wilkins Publishers. All rights reserved. This book is protected
`by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted, in any
`form or by any means-electronic, mechanical, photocopy, recording, or otherwise-without the
`prior written consent of the publisher, except for brief quotations embodied in critical articles and
`reviews. For information write Lippincott Williams & Wilkins, 530 Walnut Street, Philadelphia,
`PA 19106-3780.
`Materials appearing in this book prepared by individuals as part of their official duties as U.S.
`Government employees are not covered by the above-mentioned copyright.
`
`Printed in the United States of America
`
`9 8 7 6 5 4 3 2
`
`Library of Congress Cataloging-in-Publication Data
`
`Textbook ofgastroenterology / [edited by] Tadataka Yamada ... [et
`al.].-3rd ed.
`p. cm.
`Includes bibliographical references and index.
`ISBN 0-397-58735-X (set)
`1. Gastroenterology. 2. Gastrointestinal system-Diseases.
`I. Yamada, Tadataka.
`[DNLM: 1. Gastrointestinal Diseases. WI 140 T3551 1999]
`RC801.T48 1999
`616.3'3-dc21
`DNLM/DLC
`for Library of Congress
`
`98-40963
`CIP
`
`Care has been taken to confirm the accuracy of the information presented and to describe generally
`accepted practices. However, the authors, editors, and publisher are not responsible for errors or
`omissions or for any consequences from application of the information in this book and make no
`warranty, expressed or implied, with respect to the contents of the publication.
`The authors, editors, and publisher have exerted every effort to ensure that drug selection and
`dosage set forth in this text are in accordance with current recommendations and practice at the
`time of publication. However, in view of ongoing research, changes in government regulations, and
`the constant flow of information relating to drug therapy and drug reactions, the reader is urged
`to check the package insert for each drug for any change in indications and dosage and for added
`warnings and precautions. This is particularly important when the recommended agent is a new or
`infrequently employed drug.
`Some drngs and medical devices presented in this publication have Food and Drug Administration
`(FDA) clearance for limited use in restricted research settings. It is tl1e responsibility of the health
`care provider to ascertain the FDA status of each drug or device planned for use in their clinical
`practice.
`
`
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`Contents
`
`Enteric Pathways for Motility Control
`27
`Interstitial Cells of Cajal
`28
`Enteric Pathways for Secretomotor Control
`29
`Sympathetic Enteroenteric Inhibitory Reflexes
`Conclusions and Summary 30
`
`24
`
`Contributors
`Preface to the First Edition
`Preface
`
`xxiii
`xxxvii
`xxxix
`
`VOLUME ONE
`
`PART ONE
`Basic Mechanisms of Normal and
`Abnormal Gastrointestinal Function
`A. Components
`
`CHAPTER 1
`The Integrated Response of the
`Gastrointestinal Tract to a Meal
`Helen E. Raybould, Stephen J. Pandol
`3
`Cephalic and Oral Phases
`4
`Esophageal Phase
`5
`Gastric Phase
`7
`Duodenal Phase
`Small Intestinal Phase
`10
`Colonic Phase
`10
`Summary
`
`9
`
`1
`
`2
`
`2
`
`11
`
`CHAPTER 2
`The Enteric Nervous System and Its
`Extrinsic Connections
`John B. Furness, Joel C. Bornstein,
`Wolfgang A.A. Kunze, Nadine Clerc
`Structural Organization of the Enteric Nervous
`11
`System
`Microscopic Structure of the Enteric Nervous
`·
`15
`System
`Histochemical Profiles and Transmitter Multiplicity of
`16
`Enteric Neurons
`Physiologic Characteristics of Enteric Neurons
`20
`Functionally Defined Enteric Neurons
`23
`Extrinsic Connections
`
`17
`
`CHAPTER 3
`Gastrointestinal Hormones
`and Receptors
`Laurence J. Miller
`36
`Organization of the Gut Endocrine System
`History of Gastrointestinal Endocrinology 37
`39
`Hormone Secretory Cel ls
`Endocrine Cell Localization and Characterization
`Biosynthesis and Processing of Gastrointestinal
`41
`Hormones
`Hormone and Transmitter Molecules
`43
`Measurement of Hormones
`44
`Receptors
`Receptor Characterization and Quantification
`49
`Hormone-Specific Insights
`Hormones in Gastrointestinal Disease
`
`4 7
`
`59
`
`42
`
`CHAPTER 4
`The Brain-Gut Axis
`G.J. Dockray
`Developmental Biology of the Brain-Gut Axis
`68
`Methods for Studying the Brain-Gut Axis
`69
`Brain-Gut Connections
`72
`Signaling From Gut to Brain
`Efferent Functions of Peptidergic Visceral Afferent
`74
`Neurons
`
`67
`
`35
`
`40
`
`67
`
`V
`
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`vi
`
`Contents
`
`CNS Control of the Gut
`75
`Vagovagal Reflex Mechanisms
`Satiety Mechanisms
`77
`Overview
`78
`
`76
`
`82
`
`CHAPTER 5
`Smooth Muscle of the Gut
`Gabriel M. Makhlouf
`Structure of Smooth Muscle
`82
`Interaction of Contractile Proteins
`84
`Mobilization of Activator Calcium
`86
`Electrical Properties of Smooth Muscle
`91
`Rhythmic Electrical Activity of Smooth Muscle
`92
`Neural Regulation of Smooth Muscle by the Myenteric
`Plexus
`96
`Hormonal Regulation of Smooth Muscle Function
`Humoral Regulation of Smooth Muscle Function
`
`101
`102
`
`CHAPTER 6
`The Immune System
`Richard S. Blumberg
`Properties of the Immune System
`106
`Components of the Immune System
`107
`Cellular Interactions in the Immune System
`Gut-Associated Lymphoid Tissue 115
`Autoimmunity and Oral Unresponsiveness 119
`
`114
`
`106
`
`123
`
`CHAPTER 7
`Gastrointestinal Inflammation
`William F. Stenson
`Leukocyte Trafficking and Adhesion Molecules 125
`Leukocyte Chemotaxis and Activation
`128
`Cytokines
`130
`Lipid Mediators of Inflammation
`Nitric Oxide
`134
`Epithelial Cells
`135
`Inflammation and Epithelial Cell Gene
`Expression
`136
`Mast Cells 136
`Motility 137
`
`133
`
`CHAPTER 8
`Epithelia: Biologic Principles
`of Organization
`James L. Madara
`Organization of the Gut Wall
`141
`Organization of Epithelial Sheets 141
`Epithelial Barriers
`146
`Epithelial Responses to Disease and Injury 151
`
`141
`
`B. Motility
`CHAPTER 9
`Esophageal Motor Function
`Piero Biancani, Karen M. Harnett, Jose Behar
`Innervation
`158
`Pharynx and Oropharynx 162
`Upper Esophageal Sphincter 165
`Esophagus
`167
`Lower Esophageal Sphincter 173
`
`157
`
`157
`
`CHAPTER 10
`The Physiology of Gastric Motility
`and Gastric Emptying
`William L. Hasler
`Smooth Muscle Characteristics of the Stomach
`Innervation of the Stomach
`188
`Regional Motor Patterns in the Stomach and
`Duodenum 190
`Gastric Emptying 198
`
`188
`
`188
`
`215
`
`CHAPTER 11
`Motility of the Small Intestine and Colon
`William L. Hasler
`Anatomic Considerations
`216
`Smooth Muscle of the Small Intestine and Colon
`216
`Innervation of the Small Intestine and Colon
`218
`Physiologic and Pathophysiologic Motor Patterns During
`a Basal Fasting State
`220
`Physiologic and Pathophysiologic Modulators of Small
`Intestine and Colonic Motility 227
`Correlation of Motor Patterns With Transit in the Small
`Intestine and Colon
`234
`Sphincteric Function of the Lower Gastrointestinal
`Tract 235
`
`CHAPTER 12
`Motility of the Biliary Tree
`Norman W. Weisbrodt
`Anatomic Considerations and Species Variations
`Functional Considerations
`· 248
`Mechanisms for Physiologic Regulation and of
`Pathologic Changes
`259
`
`C. Secretion and Absorption
`CHAPTER 13
`Salivary Secretion
`Birgitte Nauntofte, Janicke Liaaen Jensen
`Salivary Glands and Salivary Functions
`Morphology 264
`Reflex Arch for Salivary Secretion
`Stimulus-Secretion Coupling 267
`
`265
`
`263
`
`246
`
`246
`
`263
`
`263
`
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`Secretion of Electrolytes and Water From Acini
`268
`Ductal Fluid Modification
`Regulation of Salivary Protein Secretion
`270
`Salivary Proteins
`273
`Buffer Systems of Saliva
`273
`Salivary Dysfunction
`
`270
`
`CHAPTER 14
`Gastric Secretion
`John Del Valle, Andrea Todisco
`279
`Anatomy of Gastric Mucosa
`283
`Regulation of Acid Secretion
`288
`Cellular Basis of Acid Secretion
`302
`Other Gastric Secretory Products
`Clinical Implications of Gastric Secretion
`
`307
`
`278
`
`CHAPTER 15
`Electrolyte Secretion and Absorption:
`320
`Small Intestine and Colon
`Marshall H. Montrose, Stephen J. Keely, Kim E. Barrett
`321
`The Intestinal Epithelium
`325
`Principles of Epithelial Transport
`327
`Electrolyte Transport Proteins
`333
`Transepithelial Electrolyte Transport
`Regulation of Electrolyte Transport 338
`345
`Conclusions
`
`CHAPTER 16
`Pancreatic Secretion
`Chung Owyang, John A. Williams
`Formation and Composition of Pancreatic Juice
`359
`Stimulation of Pancreatic Secretion
`Intracellular Control of Pancreatic Secretion
`368
`Inhibition of Pancreatic Secretion
`371
`Patterns of Secretion
`
`355
`
`356
`
`363
`
`380
`
`384
`386
`
`CHAPTER 17
`Bile Secretion
`Richard H. Moseley
`380
`Bile Composition
`382
`Morphologic Considerations
`384
`Physiologic Considerations
`Bile Acid-Dependent Bile Formation
`Bile Acid-Independent Bile Formation
`387
`Paracellular Pathway
`Regulation of Bile Secretion
`388
`Bilirubin Transport
`388
`Biliary Excretion of Drugs
`388
`Biliary Lipid Secretion
`389
`Biliary Protein Secretion
`390
`Acinar Heterogeneity
`391
`Ductular Events
`Gallbladder Structure and Function
`392
`Enterohepatic Circulation
`394
`Clinical Correlates
`
`388
`
`391
`
`267
`
`D. Nutrition
`
`Contents
`
`vii
`
`404
`
`404
`
`404
`
`CHAPTER 18
`Carbohydrate Assimilation
`Peter G. Traber
`Chemistry and Structure of Carbohydrates
`405
`Dietary Carbohydrates
`405
`Dietary Fiber
`409
`Carbohydrate Assimilation
`Lumenal Phase of Digestion: Starch Hydrolysis
`410
`Brush Border Carbohydrases
`416
`Absorption of Monosaccharides
`Spatial Localization of Hydrolysis and Transport Along
`421
`the Crypt-Villus Axis
`Efficiency and Rate-Limiting Steps of Carbohydrate
`422
`Assimilation
`
`409
`
`CHAPTER 19
`Intestinal Lipid Absorption
`Nicholas 0. Davidson
`429
`Intestinal Lipid Balance
`429
`lntralumenal Lipid Digestion
`435
`Intracellular Events in Lipid Reassembly
`Intestinal Lipoprotein Assembly and Secretion
`449
`Lipid Absorption in Malabsorptive States
`
`428
`
`440
`
`CHAPTER 20
`Protein Digestion and Assimilation
`Vadivel Ganapathy, Frederick H. Leibach
`457
`Aspects of Dietary Proteins
`457
`Digestion of Proteins
`460
`Absorption of Protein Digestion Products
`462
`Fate of Absorbed Protein Digestion Products
`462
`Physiologic and Clinical Significance
`Regulation of Amino Acid and Peptide Absorption
`463
`Protein-Energy Malnutrition
`Defects in Digestion and Absorption of Proteins
`
`456
`
`463
`
`463
`
`CHAPTER 21
`Vitamin and Mineral Absorption
`Stephen W. Lacey, Richard H. Seidel, Jr.
`468
`Absorption of Water-Soluble Vitamins
`4 7 4
`Absorption of Fat-Soluble Vitamins
`476
`Absorption of Minerals
`Localization of Vitamin and Mineral Absorption
`
`CHAPTER 22
`General Nutritional Principles
`David H. Alpers, Samuel Klein
`Basic Nutritional Principles
`Altered Nutritional States
`
`485
`502
`
`468
`
`480
`
`485
`
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`viii
`
`Contents
`
`E. Miscellaneous
`
`CHAPTER 23
`Gastrointestinal Blood Flow
`Karen D. Crissinger, D. Neil Granger
`519
`Anatomy of the Gastrointestinal Circulation
`521
`Techniques for Measurement of Blood Flow
`Basal Hemodynamics and Oxygenation
`524
`Blood Flow Regulation
`524
`Physiology and Biochemistry of lschemia
`
`535
`
`CHAPTER 24
`Growth and Development
`of the Gastrointestinal Tract
`Mark W. Babyatsky, Daniel K. Podolsky
`Embryology and Histogenesis
`547
`Functional Maturation
`552
`Transcriptional Regulation of Development 564
`Growth and Differentiation in the Mature
`566
`Gastrointestinal Tract
`
`CHAPTER 25
`Neoplasia of the Gastrointestinal Tract
`John M. Carethers, C. Richard Boland
`Normal Cellular Control Mechanisms
`Molecular Carcinogenesis
`589
`Tumor Formation and Behavior 602
`Clinical Markers of Neoplasia
`605
`
`586
`
`CHAPTER 26
`The Barrier Function of the Gut
`Paul B. Watkins
`The Functional Anatomy of the Gastrointestinal
`Barrier 612
`The Metabolic Barrier of the Gastrointestinal
`Tract 614
`Metabolites Generated Within the Enterocytes
`Pharmacology of the Gut
`619
`
`CHAPTER 27
`The Gastrointestinal Biota
`Kenneth H. Wilson
`Composition of the Biota
`Metabolism
`628
`630
`Host Defense Function
`Antibiotic Effects on Gastrointestinal Biota
`Interactions of Biota and the Host 632
`
`624
`
`631
`
`519
`
`519
`
`547
`
`585
`
`611
`
`618
`
`624
`
`PART TWO
`Approaches to Common
`Gastrointestinal Problems
`
`637
`
`638
`
`CHAPTER 28
`Psychosocial Factors in the Care of Patients
`with Gastrointestinal Disorders
`Douglas A. Drossman
`638
`Biopsychosocial Model of Illness and Disease
`Interactions of Biological and Psychosocial Factors in
`Gastrointestinal Illness
`639
`Establishing a Therapeutic Physician-Patient
`642
`Relationship
`Obtaining Psychosocial Data: The Interview 644
`Understanding the Data
`646
`Treatment
`652
`Concluding Comment: Physician Considerations
`
`655
`
`660
`
`CHAPTER 29
`Approach to the Patient With Dyspepsia
`and Related Functional Gastrointestinal
`Complaints
`Nicholas J. Talley, Gerald Holtmann
`Clinical Presentation of Dyspepsia and Related
`660
`Functional Gastrointestinal Complaints
`Dyspepsia in the General Population and Clinical
`662
`Practice
`665
`Structural Causes of Dyspepsia
`666
`Pathogenesis of Nonulcer Dyspepsia
`Diagnostic Approach to the Patient With Uninvestigated
`671
`Dyspepsia
`Management Strategies
`Prognosis
`677
`
`672
`
`CHAPTER 30
`Approach to the Patient With Dysphagia
`and Odynophagia
`Donald 0. Castell, Philip 0. Katz
`Globus
`683
`683
`Classification
`Pathophysiologic Considerations
`Patient Evaluation and Diagnosis
`Therapeutic Considerations
`691
`Odynophagia
`691 -
`
`684
`685
`
`683
`
`CHAPTER 31
`Approach to the Patient With Noncardiac
`Chest Pain
`Joel E. Richter
`Prevalence and Health Care Impact 694
`Characteristics of Esophageal Chest Pain
`Causes of Esophageal Chest Pain
`695
`
`695
`
`694
`
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`696
`
`Chest Pain and Esophageal Motility Disorders
`702
`Chest Pain and Gastroesophageal Reflux
`Brain-Gut Interaction in Noncardiac Chest Pain
`Differential Diagnosis of Substernal Chest Pain
`Algorithm for Evaluating Noncardiac Chest Pain
`708
`Treatment of Esophageal Chest Pain
`The Author's Approach to Treating Noncardiac Chest
`710
`Pain
`
`703
`706
`708
`
`714
`
`743
`
`CHAPTER 32
`Approach to the Patient With Gross
`Gastrointestinal Bleeding
`Grace H. Elta
`715
`Clinical Presentation
`716
`Acute Upper Gastrointestinal Bleeding
`729
`Acute Lower Gastrointestinal Bleeding
`734
`Bleeding From an Unknown Source
`
`CHAPTER 33
`Approach to the Patient With Occult
`Gastrointestinal Bleeding
`Graeme P. Young
`The Problem and its Prevalence
`Pathophysiologic Considerations
`7 45
`Etiology
`7 4 7
`Clinical Manifestations
`7 48
`Tests for Occult Bleeding
`751
`Approach to the Patient
`Fecal Occult Blood Screening for Colorectal
`752
`Neoplasia
`Therapeutic Considerations
`
`7 43
`7 44
`
`756
`
`CHAPTER 34
`Approach to the Patient With U nexplained
`76 1
`Weight Loss
`Dean L. Antonson, James K. Madison, Renee L. Young
`761
`Unintentional Weight Loss
`765
`Intentional Weight Loss
`Psychotherapy and Psychotropic Medications for
`771
`Anorexia Nervosa and Bulimia Nervosa
`
`CHAPTER 35
`Approach to the Patient With Nausea
`and Vomiting
`William L. Hasler
`Socioeconomic Impacts of Nausea and Vomiting
`776
`Pathophysiology of Nausea and Vomiting
`Differential Diagnosis of Nausea and Vom iting
`784
`History and Physical Examination
`Laboratory Studies and Diagnostic Testing
`787
`Principles of Management
`Complications of Nausea and Vomiting
`
`790
`
`785
`
`775
`
`775
`
`780
`
`Contents
`
`ix
`
`CHAPTER 36
`Approach to the Patient With Abdominal
`795
`Pain
`Pankaj J. Pasricha, Michael D. Crowell, Gervais Tougas
`795
`Neuroanatomy of the Visceral Pain Pathway
`796
`Neurophysiology of Pain
`797
`Neurochemistry of the Pain Pathways
`Sensitization and Visceral Hyperalgesia: Current
`803
`Concepts
`Clinical Syndromes
`Future Directions
`
`804
`810
`
`CHAPTER 37
`Approach to the Patient With Gas and
`Bloating
`Jay A. Perman, Debra N. Boatwright
`Composition and Sources of Intestinal Gas
`817
`Clinical Gas Syndromes
`Clinical Assessment 819
`820
`Therapy
`Breath Tests
`
`821
`
`8 15
`
`815
`
`CHAPTER 38
`Approach to the Patient With Acute
`Abdomen
`Michael W. Mulholland
`827
`Neuroanatomy of Abdominal Pain
`Associated Gastrointestinal Symptoms
`History 829
`830
`Physical Examination
`830
`Confounding Factors
`Causes of Acute Abdomen in Adults
`Operative Therapy for Acute Abdomen
`
`831
`837
`
`828
`
`CHAPTER 39
`Approach to the Patient With Ileus and
`Obstruction
`Robert W. Summers
`Pathophysiologic Considerations
`History 846
`84 7
`Physical Examination
`Differential Diagnosis and Diagnostic Strategies
`Assessment 851
`Therapeutic Considerations
`
`842
`
`854
`
`CHAPTER 40
`Approach to the Patient With Diarrhea
`Don W. Powell
`859
`Definition
`Pathophysiology of Diarrhea
`867
`Acute Diarrheas
`
`860
`
`826
`
`842
`
`848
`
`858
`
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`X
`
`Contents
`
`875
`
`Acute Infectious Diarrheas
`867
`Prolonged Infectious Diarrheas
`873
`Nosocomial Diarrheas
`87 4
`Runner's Diarrhea
`875
`Chronic Diarrheas
`875
`Steatorrhea (Ma labsorptive Diseases)
`Watery Diarrheas
`878
`True Secretory Diarrheas
`879
`Inflammatory Diarrheas
`882
`Clinical Evaluation of Chronic Diarrhea
`883
`Specific Laboratory Tests for Steatorrhea (Malabsortion
`Syndromes) 890
`Laboratory Tests for Watery Diarrhea
`892
`Laboratory Tests for Inflammatory Diarrhea
`894
`Evaluation of Severe or Elusive Diarrhea
`894
`Antidiarrheal Therapy 896
`
`CHAPTER 41
`Approach to the Patient
`With Constipation
`Arnold Wald
`Definitions
`910
`Socioeconomic and Medical Consequences
`Pathophysiologic Considerations
`911
`Evaluation of Constipation
`915
`Diagnostic Strategies
`918
`Treatment Considerations
`919
`
`910
`
`910
`
`CHAPTER 42
`Approach to the Patient With Jaundice
`Cary A. Caldwell, Marion G. Peters
`Bil irubin Metabolism
`927
`Hyperbilirubinemia
`930
`lntrahepatic Cholestasis
`935
`Extrahepatic Cholestasis
`939
`Evaluation of the Patient With Jaundice
`
`939
`
`926
`
`CHAPTER 43
`Approach to the Patient With Abnormal
`Liver Chemistries
`Richard H. Moseley
`Clinical Evaluation
`946
`Hepatic Function Tests
`949
`Serum Markers of Hepatobiliary Dysfunction
`Disease-Specific Markers
`953
`General Approach
`956
`
`951
`
`946
`
`CHAPTER 44
`Approach to the Patient With Ascites
`Bruce A. Runyon
`Causes of Ascites and Mechanisms of Ascites
`Formation
`966
`Evaluation of the Patient With Ascites
`
`969
`
`966
`
`Complications of Ascites
`978
`Treatment of the Patient With Ascites
`Summary and Conclusions
`987
`
`983
`
`992
`
`CHAPTER 45
`Skin Lesions Associated With
`Gastrointestinal Diseases
`Joseph L. Jorizzo, Elizabeth F. Sherertz,
`Michelle L. Bennett
`Inflammatory Bowel Disease
`992
`Rheumatologic Diseases
`996
`Skin Disease and Gastrointestinal Bleeding 998
`Syndromes Associated With Gastrointestinal
`Polyps
`1000
`Cutaneous Signs of Gastrointestinal
`Malignancy
`1001
`Bullous Diseases of the Skin That Can Directly Affect
`the Gastrointestinal Tract
`1002
`Skin Conditions Associated With Abdominal
`Pain
`1002
`Pancreatic Disease
`1003
`Dermatologic Disorders Associated With
`Malabsorption
`1004
`Nutritional Disorders 1004
`Perinea! Skin Lesions
`1005
`
`1008
`
`1015
`
`CHAPTER 46
`Oral Manifestations of Gastrointestinal
`Disesases
`Sherin S. Koshy, Timothy T. Nostrant
`Gastroesophageal Reflux Disease
`1008
`Polyposis Syndromes
`1008
`Bleeding Disorders
`1009
`Immunodeficiency States 1010
`Collagen Vascular Disease
`1012
`Vitamin Deficiencies and Malabsorption
`Inflammatory Bowel Disease
`1013
`Lead Poisoning 1013
`Plummer-Vinson Syndrome
`
`1013
`
`1012
`
`CHAPTER 47
`Approach to Gastrointestinal Problems
`in the Elderly
`Daniel M. Quirk, Lawrence S. Friedman
`Physiology 1015
`Nutrition
`1016
`Esophageal Disorders
`Peptic Ulcer 1019
`Malabsorption
`1020
`Diarrhea
`1022
`Colonic Disease
`1022
`Constipation and Fecal Incontinence 1024
`Biliary and Pancreatic Disease
`1025
`Liver
`1025
`Gastrointestinal Cancer
`
`1016
`
`1026
`
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`CHAPTER 48
`Approach to Gastrointestinal Problems
`in the lmmunocompromised Patient
`Phillip D. Smith, Edward N . Janoff
`1035
`Clues to Underlying Immune Dysfunction
`Evaluation of Patients With Gastrointestinal Illness
`Suspected of Having an Underlying Immune
`Defect 1043
`
`1034
`
`CHAPTER 49
`Approach to the Patient With a
`Gastrointestinal Neoplasm
`Bernard Levin
`Epidemiology 1050
`Prevention
`1050
`1052
`Approach to Patient Care
`Management of the Patient With Terminal
`1057
`Gastrointestinal Cancer
`
`1050
`
`CHAPTER 50
`Approach to Gastrointestinal Disease
`in the Female Patient
`Ellen M. Zimmermann, Gregory M. Christman
`Gastrointestinal Diseases and Pregnancy 1059
`Gynecologic Disease as an Etiology of Lower Abdominal
`Pain
`1070
`
`1059
`
`CHAPTER 51
`Approach to the Patient Requiring
`Nutritional Supplementation
`David H. Alpers, Samuel Klein
`Nutritional Assessment 1081
`Choosing the Route for Nutrition Support 1085
`Enteral Nutrition
`1085
`Parenteral Nutrition
`1088
`Micronutrient Deficiency and Treatment 1090
`Nutritional Support in the Hospitalized Patient With
`1102
`Gastrointestinal Disease
`
`1081
`
`1108
`
`CHAPTER 52
`Genetic Counseling for Gastrointestinal
`Patients
`Leon B. Henderson, Jerome I. Rotter
`Contribution of Genetics to Gastrointestinal
`1108
`Disorders
`Organization of Genetic Material and Molecular
`1110
`Genetics
`Types of Genetic Diseases and Modes of
`Inheritance 1111
`Gene Map, Linkage, Association, and Positional
`1119
`Cloning,
`
`Contents
`
`xi
`
`1123
`Teratogens
`Clinical Genetics
`1125
`
`CHAPTER 53
`Approach to the Patient With Drug
`or Alcohol Dependency
`David W. Crabb
`Drugs of Abuse and Brain Reward Systems
`Principles of Treatment 1134
`Individual Drugs of Abuse
`1134
`Diagnosis of Patients With Suspected Substance
`1140
`Abuse
`Management of Acute Drug Overdose or
`1142
`Toxicity
`
`1132
`
`1133
`
`CHAPTER 54
`Advice to Travelers
`Samuel L. Stanley, Jr.
`Pretravel History 1145
`General Precautions
`1146
`Vaccinations
`1148
`1154
`Protection Against Malaria
`Other Infectious Diseases That Pose a Risk
`Travelers' Diarrhea
`1156
`
`1145
`
`1156
`
`CHAPTER 55
`N osocomial Infections and Risks to Health
`Care Providers
`Paul B. L'Ecuyer, Victoria J. Fraser
`Overview of Hospital Epidemiology
`Tuberculosis
`1166
`1167
`Blood-Borne Pathogens
`Nosocomial Transmission of Gastrointestinal
`1171
`Pathogens
`
`1161
`
`1160
`
`1179
`
`1180
`
`1180
`
`PART THREE
`Gastrointestinal Diseases
`A. Esophagus
`CHAPTER 56
`Esophagus: Anatomy and Structural
`Anomalies
`Gregory A. Boyce, H. Worth Boyce, Jr.
`Embryology
`1180
`Adult Anatomy
`1181
`Histology 1182
`1185
`Developmental Anomalies
`Pharyngoesophageal Diverticula
`1192
`Esophageal Diverticula
`1193
`Esophageal Hiatal Hernias
`1194
`
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`xii
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`Contents
`
`CHAPTER 57
`Motility Disorders of the Esophagus
`Peter J. Kahrilas
`Oropharyngeal Swallowing Disorders
`Esophageal Motility Disorders 1209
`
`1199
`
`Corrosive Esophagitis
`Radiation Esophagitis
`
`1316
`1318
`
`1199
`
`B. Stomach
`
`1235
`
`CHAPTER 58
`Reflux Esophagitis
`Roy C. Orlando
`Epidemiology 1235
`Etiology 1236
`Potency of the Refluxate
`1236
`Esophageal Defenses
`1237
`Conditions Associated With Reflux
`Clinical Manifestations 1244
`Diagnostic Studies and Differential Diagnosis 1245
`Clinical Course and Complications 1249
`Therapy 1252
`Gastroesophageal Reflux in Infants and
`Children
`1258
`Alkaline Reflux Esophagitis 1258
`
`1244
`
`CHAPTER 59
`Esophageal Infections, Including Disorders
`Associated With AIDS
`C. Mel Wilcox
`Epidemiology and Predisposing Factors
`Fungal Infections 1264
`Viral Infections 1268
`Mycobacterial Infections 1272
`Bacterial Infections
`1272
`Protozoa! Infections
`1273
`Specific HIV-Related Esophageal Disorders
`
`1264
`
`1273
`
`1263
`
`CHAPTER 60
`Esophageal Neoplasms
`Anil K. Rustgi
`Squamous Cell Carcinoma
`1278
`Esophageal Adenocarcinoma
`1286
`Other Epithelial Tumors
`1292
`Nonepithelial Tumors
`1294
`Overall Summary and Future Directions 1295
`
`CHAPTER 61
`Miscellaneous Diseases of the Esophagus
`Douglas 0 . Faigel, M. Brian Fennerty
`Foreign Bodies in the Esophagus
`1304
`Systemic Diseases Affecting the Esophagus
`Dermatologic Diseases Affecting the
`Esophagus
`1308
`Esophageal Trauma
`1311
`Pill Esophagitis 1314
`
`1306
`
`1278
`
`1304
`
`CHAPTER 62
`Stomach: Anatomy and Structural
`Anomalies
`Jean-Pierre Raufman
`Anatomy of the Stomach and Duodenum
`Gross Anatomy
`1326
`Microscopic Anatomy 1329
`Embryology of the Stomach and Duodenum
`Congenital Abnormalities of the Stomach
`Hypertrophic Pyloric Stenosis
`1336
`Congential Abnormalities of the Duodenum
`
`1326
`
`1326
`
`1326
`
`1335
`1335
`
`1337
`
`CHAPTER 63
`Disorders of Gastric Emptying
`William L. Hasler
`Disorders With Delayed Gastric Emptying 1341
`Disturbances of the Gastric Electrical
`Pacemaker 1352
`Disorders With Rapid Gastric Emptying
`Functional Dyspepsia
`1358
`
`1355
`
`1341
`
`1370
`
`CHAPTER 64
`Acid Peptic Disorders
`John Del Valle, Hartley Cohen, Loren Laine,
`James M. Scheiman
`Impact of Peptic Ulcer Disease
`1370
`Epidemiology and Natural History 1370
`Pathophysiology of Peptic Ulcer Disease
`Clinical Manifestations and Differential
`Diagnosis 1394
`Diagnostic Studies in Peptic Ulcer Disease
`Therapy for Ulcer Disease
`1402
`
`1373
`
`1396
`
`1445
`
`CHAPTER 65
`Zollinger-Ellison Syndrome
`John Del Valle, James M. Scheiman
`Epidemiology 1445
`Pathophysiology 1445
`Tumor Distribution
`1446
`Clinical Manifestations 1446
`Differential Diagnosis and Diagnostic Studies 1448
`Tumor Localization
`1450
`Therapy
`1453
`Prognosis
`1456
`
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`Contents
`
`xiii
`
`1463
`
`CHAPTER 66
`Gastritis, Gastropathy, Duodenitis,
`and Associated Ulcerative Lesions
`John H. Yardley, Thomas R. Hendrix
`Classification of Gastritis and Gastropathy 1464
`Approaches to Diagnosis of Gastritis and
`Gastropathy 1465
`Common Forms of Gastritis and Gastropathy 1466
`Pathology of Gastric Ulceration in Relation to Chronic
`Gastritis 14 78
`1479
`Uncommon Forms of Chronic Gastritis
`Chronic Duodenitis and Duodenal Ulcer 1489
`
`1517
`Treatment
`Other Gastric Tumors
`
`1520
`
`CHAPTER 68
`Surgery for Peptic Ulcer Disease
`and Postgastrectomy Syndromes
`Neal E. Seymour, Dana K. Andersen
`Elective Surgery for Peptic Ulcer Disease 1530
`Surgery for Duodenal Ulcer 1531
`Surgery for Gastric Ulcer 1537
`Surgical Treatment for Peptic Ulcer
`1538
`Complications
`Complications of Surgery for Peptic Ulcer 1542
`
`CHAPTER 67
`Tumors of the Stomach
`C. Richard Boland, Thomas J. Savides
`Epidemiology
`1500
`Etiology
`1502
`Cl inical Manifestations 1506
`Diagnosis
`1512
`Clinical Course
`1515
`
`1500
`
`CHAPTER 69
`Miscellaneous Diseases of the Stomach
`Robert S. Sandler, Andrea Todisco
`Gastric Bezoars
`1549
`Foreign Bodies
`1553
`Gastric Rupture
`1554
`Gastric Volvulus
`1555
`
`1530
`
`1549
`
`VOLUME TWO
`
`C. Small Intestine
`
`CHAPTER 70
`Small Intestine: Anatomy and Structural
`Anomalies
`Deborah C. Rubin
`1561
`Gross Anatomy
`Microscopic Anatomy
`1563
`Embryology 1571
`Congenital Anomalies
`Structural Anomalies
`
`1571
`1576
`
`CHAPTER 71
`Dysmotility of the Small Intestine
`Michael Camilleri, Sinn Anuras
`Epidemiology
`1584
`Etiology
`1584
`Clin ical Manifestations
`Complications
`1600
`Diagnostic Studies
`1601
`Differential Diagnosis Between Chronic Intestinal
`Pseudoobstruction and Mechanical
`1603
`Obstruction
`Treatment 1604
`
`1600
`
`1561
`
`1561
`
`1584
`
`CHAPTER 72
`Small Intestine: Infections With Common
`Bacterial and Viral Pathogens
`Harry B. Greenberg, Suzanne M. Matsui,
`Jeffery S. Loutit
`Food Poisoning and Common Source
`1612
`Outbreaks
`1613
`Travelers' Diarrhea
`1615
`Bacterial Infection
`1628
`Viral Pathogens
`Therapeutic Considerations
`
`1633
`
`1611
`
`CHAPTER 73
`Chronic Infections of the Small Intestine
`1641
`George T. Fantry, Lori E. Fantry, Stephen P. James
`Whipple Disease
`1641
`Tropical Sprue
`164 7
`Tuberculosis
`1650
`Mycotic Infections 1653
`
`CHAPTER 74
`Celiac Disease
`Paul J. Ciclitira
`Definition
`1660
`History 1660
`
`1660
`
`
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`xiv
`
`Contents
`
`Epidemiology 1660
`Pathology 1661
`1662
`Cereal Chemistry
`1663
`Toxicity Studies
`Hypothesis for Pathogenesis
`Genetics 1665
`1666
`Clinical Features
`1668
`Laboratory Tests
`1670
`Diagnostic Tests
`Disease Associations
`1671
`Treatment 1673
`
`1664
`
`CHAPTER 75
`Disorders of Epithelial Transport
`in the Small Intestine
`Adrienne M. Scheich, Richard J. Grand
`Defects in Intestinal Carbohydrate Transport
`Disorders of Amino Acid Absorption
`1678
`Disorders of Electrolyte and Mineral Transport 1680
`Primary Bile Acid Malabsorption
`1683
`Disorders of Lipid Malabsorption
`1684
`Defects in Intestinal Cobalamin Absorption
`Disorders of Lactose and Sucrose Absorption
`
`1677
`
`1677
`
`1686
`1688
`
`CHAPTER 76
`Bacterial Overgrowth
`Ellen Li
`Conditions Favoring Bacterial Overgrowth
`Pathogenesis
`1698
`Pathology 1700
`Clinical Manifestations 1700
`Diagnosis 1701
`Treatment 1702
`
`1697
`
`1697
`
`CHAPTER 77
`Short Bowel Syndrome
`Richard N. Fedorak
`Etiology 1705
`Factors Influencing Short Bowel Syndrome
`Clinical Manifestations 1709
`Management 1711
`
`1704
`
`1705
`
`CHAPTER 78
`Tumors and Other Neoplastic Diseases
`of the Small Intestine
`Peter Lance
`Epidemiology 1722
`Etiology: Possible Pathophysiologic
`1723
`Mechanisms
`Clinical Manifestations of Small Bowel Tumors
`Differential Diagnosis
`1725
`Diagnostic Modalities 1726
`Varieties of Small Bowel Tumor 1728
`
`1 722
`
`1723
`
`CHAPTER 79
`Miscellaneous Diseases of the Small
`Intestine
`Marc S. Levin
`Ulcers of the Small Intestine 1739
`Drug-Induced Small Bowel Disease
`Necrotizing Enterocolitis
`1751
`Protein-Losing Gastroenteropathy 1752
`
`17 46
`
`D. Colon
`
`CHAPTER 80
`Colon: Anatomy and Structural
`Anomalies
`Steven M. Cohn, Elisa H. Birnbaum
`Colonic Development
`1761
`Histology 1762
`Anatomy
`1765
`Structural and Congenital Abnormalities
`
`1768
`
`1739
`
`1761
`
`1761
`
`1775
`
`CHAPTER 81
`Inflammatory Bowel Disease
`William F. Stenson
`Epidemiology 1776
`1776
`Etiology and Pathogenesis
`Ulcerative Colitis : Clinical Findings and Natural
`History 1782
`Crohn's Disease: Clinical Findings and Natural
`History 1785
`Extraintestinal Manifestations
`Pathology
`1790
`Radiography
`1793
`Endoscopy
`1797
`1800
`Differential Diagnosis
`Nutritional Management 1802
`Drugs Used in Inflammatory Bowel Disease
`Medical