DIGESTIVE TRACT:

Stomach: Esophagus: Upper of esophagus skeletal (voluntary) muscle supplied by: somatic motor fibers (CN10) !o"er # smooth musclesupplied by: parasympathetic nerve fibers (CN10) e$tends as esophageal ple$us in the stomach

%ay be narro"ed by enlarged left atrium (detected by barium s"allo" $&ray) Jejunum: 'egins "here duodenum ends Upper ()* of small intestine is +e,unum

!o"er -)* is .leum Ileum: /nds at the large intestine Cecum

DIVERTICULITIS:
0ue to pseudodi e!ticula "utpouching of mucosa T!ap #eces "ith $acte!ia In#ection Di e!ticulitis% A$scess & infection spreads beyond diverticula 1resentation: Le#t Lo&e! 'uad!ant (ain Signs)s*mptoms: 2ever Constipation !o"er 3bdominal 4bstructive 5ymptoms (bloating 6 distention) Nausea 6 7omiting 8 patients "ith severe obstructive symptoms (E: & T!eatment: IV- 6 $o&el !est N14 or Clear !i:uid 0iet Locali+ed Tende!ness (!!9) Re$ound Tende!ness (!!9) (alpa$le ,ass 8 sigmoid colon (most common site of diverticulitis)

IV anti$iotics (broad spectrum covers ;(&) enteric bacteria 6 anaerobic bacteria) normally found in colon) CT Scan 8 outlines 6 identify abscess (preferable to barium enema for diagnosis "ith acute illness) Segmental Colonic Resection: reserved for recurrent bleeding

Unde! ./ *ea!s old "ith symptomatic diverticulitis ha e su!gical !esection because this subgroup is at g!eate! !is0 of complications & (ossi$le Complications: 3bdominal abscess) liver abscess Colonic obstruction 2istulas (Colovesical< Colovaginal< Colocutaneous)

'leeding: occurs in *= abrupt< painless< often massive maybe left or right colon ES"(1AGEAL DIVERTICULA: - Location: a /piphrenic b >ypopharyngeal (?enker@s) c. %id&esophageal true diverticula & Aesults from increase intraluminal pressure associated "ith distal obstruction & a%2 3en0e!s: & 4bstruction is stenotic c!icopha!*ngeus muscle 4Uppe! Esephageal Sphincte!2% & 1*popha!*ngeal he!niation commonly occurs in an area of natural "eaknes 45illian6s t!iangle2% & Small +en0e!6s: asymptomatic< but "hen enlarged causes symptom like dysphagia< halitosis< 6 aspiration d)t retained food 6 saliva & Breatment: & Su!gical di e!ticulectom* & C!ocopha!*ngeal m*otom* & ,a!supiali+ation: endoscopic stapling device use to divide cricopharyngeus 7 $%2 Epiph!enic: & 3ssociated "ith achalasia or distal esophageal stricture 7 c%2 ,id7esophageal: & Caused by traction from ad,acent inflammation involving all layers of esophagus & Usually asymptomatic until enlarges sufficiently to retain food & Breatment: & Su!gical !emo al of diverticula in con,unction "ith m*otom* if cause by achalasia AC1ALASIA: - !oss of Ganglion Cells in esophageal m*ente!ic ple8us - Common in ages 9:7;/ *!s old - 0efect in esophageal smooth muscle motility 6 rela$ation of LES% - 1atient can s"allo" but food is held up from passing to the stomach - Ultimate cause is an autoimmune process d)t latent human he!pes simple8 susceptibility - 5ymptoms: 0ysphagia Aegurgitation Chest pain: d)t esophageal spasm

i!us < combined "ith genetic

Ceight loss 0iagnois: =a!ium s&allo&: 0ilated esophagus "ith poor emptying 3ir fluid level Bapering at the !/5 >=ea07li0e? appearance Sigmoid con#igu!ation: in long standing achalasia

@it!ates A Calcium channel $loc0e!s administered before eating =otulinum to8in: in,ected to !/5 inhi$its acet*lcholine "hich improves dysphagia in DD= of cases

DI--USE ES"(1AGEAL S(AS,: - %anifested by episodes of dysphagia 6 chest pain - 3bnormal esophageal contraction - Normal deglutitive !/5 rela$ation - Aadiographically: >Co!0sc!e& Esophagus?% - 0iagnosed by manomet!*% %gt: An8ioliticsB Su!gical 4long m*otom*) esophagectom*2 for severe "eight loss 6 unbearable pain GASTR"ES"(1AGEAL RE-LUC DIS"RDER: - Commonly characteriEed by esophagitis% - Esophagitis: results "hen gastric acid 6 pepsin reflu$ed causing e!osions A ulce!s% - 5ymptoms: 1ea!t$u!n 6 !egu!gitation 0ysphagia 6 chest pain less common Complications: Aelated to chronic esophagitis (bleeding 6 stricture) =a!!ett6s metaplasia: Breatment: Li#est*le modi#ication Catego!ies: a ) 3voidance of foods that reduce !/5 pressure (fatty foods< alcohol< spearmint< peppermint< tomato&based foods< coffee 6 tea) b ) 3voidance of acidic foods c ) 'ehaviors to minimiEe reflu$) heartburn ;astric acid secretion inhibitors: ameliorates reflu$ symptoms allo"ing esophagitis to heal 11.@s more efficacious than >( receptor antagonist (>(A35) Lapa!oscopic @issen -undoplication pro$imal stomach is "rapped around the distal esophagus to create antireflu$ barrier %anagement for chronic ;/A0 /ndoscopically: recogniEed by tongues o# !eddish mucosa e$tending pro$imally from gastroesophageal ,unction >istopathologically: specialiEed columna! metaplasia% Can progress to adenoca!cinoma%

(ha!macologic:

Su!gical:

C"L"@IC "=STRUCTI"@: Acute Colonic "$st!uction& surgical emergency causes colonic perforation >ighest risk for perforation those "ith intact ileocecal al e (does not allo" air to reflu$ back into small bo"el) Closed7loop: most feared complication of acute intestinal obstruction .t results "hen lumen is occluded in 9 points by a single mechanism (e$: fascial hernia) Cecum: most fre:uent site of perforation ("all tension is highest in bo"el "ith largest diameter: >Laplace6s La&?) Small Intestine: most common site of intestinal obstruction (because of narro"er caliber)< especially the Le#t Colon (because stool in this area is more formed 6 unable to pass through a narro"ed lumen La$o!ato!* A C7!a* #inding: Leu0oc*tosis "ith shift to the leftoccurs in strangulation /levated serum amylase Stepladde! &ith ai! #luid le el >(athognomonic? for small bo"el obstruction Gene!al ha+e: d)t peritoneal fluid Co##ee $ean shaped mass: seen in strangulating closed loop obstruction Thin =a!ium UGIS: differentiates partial vs complete obstruction

Thic0 =a!ium by mouth: avoided "hen obstruction is high grade) complete inspissated 6 make incomplete obstruction into complete aspirated into tracheobronchial tree CT scan: most commonly used modality but difficult to differentiate adynamic ileus< partial 6 complete obstruction >=i!d6s =ic0 sign?: is an abdominal series finding "hen sigmoid volvulus occurred or enlarged cecum "hen cecal torsion)bascule is present Gast!og!a#in enema: helps demonstrate complete obstruction

BARIUM should never be given by mouth to a patient with possible colonic obstruction until that possibility has been excluded. Signs A s*mptoms: a%2 ,echanical Intestinal "$st!uction: Cramping mid7a$dominal pain 'orborygmi "ith paro$ysms of pain 1ain becomes less severe as obstruction progresses because of decrease motility in edematous intestine Locali+ed pain &)o colic0* component "hen strangulation is present Vomiting: occurs earlier profuse the higher the obstruction Contains bile 6 mucus if occurs high in the intestine 'ecomes #eculent (orange&bro"n "ith foul odor) in lo& ileal o$st!uction 1iccups 4singultus2% "$stipation A #ailu!e to pass #latus: complete obstruction

Dia!!hea: partial obstruction $%2 Ad*namic Ileus A (seudo7o$st!uction: Colicky pain is absent 0iscomfort from distention Vomiting fre:uent but rarely profuse Complete obstipation may or may not occur Singultus: hiccups is common

(ain 8 prominent symptom "ith constipation precedes complete obstruction Dia!!hea: initial as bo"el distal to obstruction empties %ay be persistent "ith partial obstruction because of increase intestinal secretion pro$imal to obstruction 5udden obstruction e8t!eme pain abdominal distention (in intact ileocecal valve) A$dominal distention: Fhallma!0? of all intestinal obstruction %ost marked in colonic than small bo"el involvement ,ass: palpated at the site of obstruction mandatory identification of site of obstruction 5upine 6 erect abdominal $&rays Usually manifested in closed&loop obstruction 3ppearance of Shoc0B Tende!nessB Rigidit*B -e e! indicates peritoneal contamination 3uscultation: !oud high&pitched borborygmi "ith colicky pain (absent late in strangulation)

T!eatment: a%2 Small intestinal o$st!uction & Aestore #luid A elect!ol*te balance & Decomp!ession "ith N;B & (otassium !eplacement because of vomiting 6 poor intake & !ong intestinal tube is not indicated & Lapa!oscopic techniDues for operative intervention (less "ound complications) & Non&operative therapy& for incomplete obstruction ")o increasing abdominal pain 6 leukocytosis $%2 Colonic o$st!uction & Colonoscopic decomp!ession: for incomplete obstruction & 0ecompression by cecostom* or t!ans e!se colostom*% & 1rimary resection of obstructing left sided lesions "ith on& table "ashout of colon & 1rimary resection 6 anastomosis: for right 6 transverse colon safe because of less stool 6 bacterial content in this area

& ,etallic stent: G is placed if malignant lesion is present (left sided is more successful than right sided) G temporary solution (Fbridge to surgeryH) G allo"s colonic preparation before surgery G cecal perforation is more likely if diameter in palin abdominal film is G10 cm & 1a!tmann6s (!ocedu!e: G for left sided obstruction G resection "ith end colostomy c%2 Ad*namic Ileus: & Aesponds to non&operative decompression & 1rognosis: ;ood & Correction of electrolyte (potassium 6 magnesium) & Repetiti e colonoscop*: accomplished successful decompression of colonic ileus & @eostigmine: effective than other conservative treatment for colonic ileus ,EC5EL DIVERTICULU,: - Aemnant of embryonic sac (3I3: "mphalomesente!ic Duct or Vitelline Duct) "mphalomesente!ic Ductconnects yolk sac to gut provides nutrition until placenta is established *th 8 Jth "eek 34; duct attenuate 6 separates from intestine - 8 D cm outpouching o# ileum along antimesenteric border *0&J* cm from ileocecal valve Clinical ,ani#estations: 5ymptoms arise in <st o! 9nd *ea! of life (average ( * yr) 5ymptomatic %eckel 0iverticulum lined by ectopic mucosa (including acid sec!eting mucosa) ulce!ation of ad,acent ileal mucosa inte!mittent painless !ectal $leeding% 5tool brick colored or cu!!ant jell*% Anemia: because of bleeding (self&limited because of contraction of splanchnic vessels)

'leeding is less dramatic "ith melanotic stools Diagnosis: ,ec0el Radionuclide Scan: most sensitive performed after .7 infusion of Bechnetium&KKm pertechnetate %ucus secreting cells take up pertechnetate Cimetidine)Aanitidine);lucagon)1entagastrin enhance uptake of pertechnetate -alse7negati e scan may be seen in anemic patients

Radio7la$eled tagged !ed $lood cell scan for actively bleeding T!eatment:

Su!gical E8cision (for symptomatic) EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE I@TUSSUCE(TI"@: - 1otion of alimentary tract is telescoped into ad,acent segment %ost common cause of intestinal obstruction F mos% A ;*!s %ost common abdominal emergency G9*!s Ra!e in neonates %ale to female ratio F:< 2e" reduced spontaneously (if notintestinal infarction< perforation< peritonitis< 6 death) 5easonal peak: Sp!ing A Autumn Correlation to Respi!ato!* Adeno i!us noted Can complicate otitis media< gastroenteritis< >enoch&5cholein 1urpura< UAB. (AT1"L"GH: Upper bo"el portion 4intussusceptum2 invaginates into lo"er portion 4intussuscipiens2 pulling mesentery into enveloping loop Constriction of mesentery 4bstruction of venous return /ngorgement of intussusception /dema 6 bleeding 'loody stool (sometimes containing mucus) 3pe$ of intussusception can e$tend into transverse< descending< sigmoid< 6 rectum if neglected Rectal p!olapse%

%ost cases do not strangulate the bo"el "ithin 1st (Lhr but may lead to intestinal gangrene 6 shock Clinical mani#estations: 5udden severe paro$ysmal colic0* pain (recurs at fre:uent intervals) 5training "ith legs A 0nees #le8ed 6 loud cries Comfortable 6 play bet"een paro$ysms of pain Ceak 6 lethargic if intussusception is not reduced Shoc0 li0e state 6 fever can developed 1ulse: "eak 6 thready Aespiration: shallo" 6 grunting (ain: manifested by moaning sounds Vomiting: fre:uent in ea!l* phase =ile stained vomitus: late phase% Normal stool evacuated in 1st fe" hours of symptoms 5mall or no flatus)fecal e$cretion after initial presentation =lood* stool: passed in <st <9h!s (not for 1&( days at times) Cu!!ant Jell* Stool: D0= of infants Classic triad: (ainB Sausage7shaped a$dominal mass (palpable)< Cu!!ant jell* stool M1*= of patients (alpation: SAUSAGE7Shaped mass (ill defined< increase siEe 6 firmness during paro$ysms of pain) !ocation: Right Uppe! A$domen (long a$is is cephalocaudal)

A((E@DICITIS: - 4ccurs as a result of appendiceal luminal o$st!uction - -ecalith: most common cause (accumulation) inspissation of fecal matter around vegetable fibers - 4ther causes: /nlarged lymphoid follicles (associated "ith viral infections: measles) .nspissated barium Corms (pin"orms< ascaris< tinea)

Bumors (carcinoid carcinoma) Appendiceal ulce!ation: other pathologic finding He!sinia: -0= of proven cases of appendicitis !uminal bacteria multiply invade appendiceal "all venous engorgement increase intraluminal pressure arterial compromise gangrene perforation Clinical mani#estation: 3bdominal discomfort 6 anore$ia (e!ium$ilical pain: initial slo" conducting C fibers Right Lo&e! 'uad!ant (ain 4,c=u!ne*6s point2 fast conducting 0elta fibers ,c=u!ne*6s (oint: located on a line $et&een ante!io! iliac spine A um$ilicus% Ano!e8ia: very common @ausea A omiting: *0&D0= of cases (vomiting is usually self limited) Change in bo"el habits little diagnostic value U!ina!* #!eDuenc* 6 D*su!ia: if appendi$ lies ad,acent to bladder Right Uppe! 'uad!ant (ain: manifested among pregnant Diagnosis cannot be established unless tenderness can be elicited Ret!ocecal or (el ic Appendi8: #lan0 tende!ness (rectal) pelvic e$amination) Re#e!!ed !e$ound tende!ness: absent early in the illness -le8ion # the !ight hip A gua!ded mo ement: parietal peritoneal involvement 1*pe!esthesia4skin of A!9)B (soas signB "$tu!ato! sign: late findings 6 rarely of diagnostic value Bemp: Normal or slightly elevated (-J (NC & -ONC) I FJ%FKC suggest pe!#o!ation%

Tach*ca!dia: commensurate "ith temperature elevation Rigidit* 6 Tende!ness: suggest diffuse peritonitis Distention: rare unless severe diffuse peritonitis ha developed ,ass: localiEed perforation (not detected before - days after the onset) Ca!cinoma o# cecum o! C!ohn6s: early presence of mass (e!#o!ation: rare before (Lh after onset (O0= after LOh) ,ode!ate leu0oc*tosis ("ith concomitant left shift): 10<000 8 1O<000 cells)! Leu0oc*tosis I9/B/// cells)! probable perforation Anemia A $lood in the stool: suggest carcinoma of cecum (especially in elderly) U!ine: contains C'C 6 A'C if appendi$ lies close to right ureter or bladder U!inal*sis: useful in e$cluding genitourinary conditions A$dominal #ilms: not routinely obtain unless other conditions such as intestinal obstruction or ureteral calculus present Ult!asonic Demonst!ation: enlarged 6 thick "alled appendi$ Ult!asound: useful to e$clude ovarian cyst< ectopic pregnancy< or tuboovarian abscess -!ee pe!itoneal ai!: uncommon even in perforated appendicitis -e e!: common among M(yrs A$dominal Distention: often the only physical finding /lderly (older than J0yrs) pain 6 tenderness is blunted thus diagnosis delayed (!egnant: %ost common e$trauterine condition re:uiring abdominal operation 3ppendi$ is shi#t to RU' ((nd 6 -rd trim) 3ppendicitis: most common in second t!imeste! UT3: best diagnosis for pregnant (O0= accurate)< perforated (-0= accurate)

T!eatment:

"$se! ation: L&Dh if diagnosis is in :uestion al"ays more beneficial than harmful Anti$iotics: not administered if diagnosis is uncertain "ill mask the perforation Appendectom*: 2re:uently accomplished laparoscopically associated "ith less post&op narcotic use 6 earlier discharge 1* 8 (0= incidence of normal appendi$ at the time of appendectomy to avoid perforation

0ifferent approach is indicated if mass is #ound F7: da*s a#te! the onset of symptoms represents phlegmon or a$scess% 1atients "ith phlegmon or abscess is treated "ith $!oad spect!um anti$iotics 6 d!ainage o# a$scess IFcmB pa!ente!al #luidsB 6 $o&el !est% Inte! al appendectom*: performed safely D 8 1( "eeks later

(E(TIC ULCER DISEASE: & Ulce!s: defined as mucosal breaks of I:mm "ith depth to su$mucosa - (h*siolog*: 1CL A (epsinogen capable of inducing mucosal in,ury Somatostatin: from D cells of gastric mucosa response to >Cl .nhibit acid production direct (parietal cell) 6 indirect mechanism (decrease histamine release from /C! cells 6 gastrin from ; cells)

Gh!elin appetite regulating hormone (stomach) stimulates acid secretion through vagal stimulation Acid p!oduction: a%2 =asal circadian pattern highest night lo"est morning

Choline!gic (via vagus) 6 1istamine!gic input (via local gastric sources) principal contributors to basal acid secretion $%2 Stimulated 1hases: a ) Cephalic< b ) Gast!ic< c ) Intestinal a%2 Cephalic o components: sight< smell< taste of food o gastric secretion via agus nerve $%2 Gast!ic o components: food in the stomach o o driven by nutrients (amino acids 6 amines) stimulates G cells Gast!in secretion (a!ietal cell activation Distention of stomach 6 intestine by food ;astrin 6 acid secretion c%2 Intestinal o luminal distention o nutrient assimilation

(athoph*siologic $asis: A%2 Gast!ic Ulce!: - 1eak incidence at Dth decade of life - G P occur in males Can represent malignancy should be biopsied upon discovery 4ften found distal to the junction $et&een ant!um A acid sec!eto!* mucosa 'enign ;U@s rare in gastric fundus histologically similar to 0U@s 3ttributed to N53.0 6 > pylori ;astric acid output is normal or decrease Signs A s*mptoms: /pigastric pain: burning or gna"ing< ill& defined< hunger pain 1ain is p!ecipitated $* #ood

@ausea A &eight loss is common T*pes: Bype . Gast!ic $od* lo" acid production Bype .. Ant!um lo" to normal acid production Bype ... Cithin -cm of (*lo!us accompanied by duodenal ulcer normal to high acid production

Bype .7 Ca!dia lo" acid production 1%p*lo!i: 3ccounts for ma,ority of 1U0 3ssociated "ith ,ALT (%ucosa 3ssociated !ymphoid Bissue) lymphoma 6 ;astric 3denocarcinoma 3l"ays associated "ith Ch!onic Acti e Gast!itis% -acto!s: o U!ease: 1roduces ammonia protects from gastric acids o ,otilit* A ,ucinase: allo"s to pass through mucous layer o Adhe!ence #acto!s: anchors to intracellular ,unction of enteric cells @SAIDS: .nterrupts (!ostaglandin synthesis impair mucosal defense 6 repair 1rostaglandin depletion: Increase 1Cl secretion 0ecrease ,ucin secretion 0ecrease 1C"F secretion 0ecrease Su!#ace Acti e (hospholipid secretion 0ecrease Epithelial cell proliferation

=%2 Duodenal Ulce!: & 4ften occurs in <st po!tion o# duodenum% & Usually G<cm diameter & ;iant ulcer: F7;cm

& 5harply demarcated & %ay reach muscularis propria & 'ase of ulcer consist of Eone of eosinophilic nec!osis ") surrounding fibrosis & %alignant 0U@s are rare & 1%p*lo!i 6 @SAID induced & 3ssociated "ith acid sec!eto!* a$no!malities & =asal A noctu!nal acid inc!ease & 3ssociated "ith accelerated gastric emptying of li:uids & =ica!$onate is dec!ease in duodenal bulb & Complications: I a%2 GI $leeding & %ost common complication & Common among GD0 years old & (0= of patients "ithout "arning s)s$ & >igh incidence in elderly d)t N53.0s I $%2 (e!#o!ation & (nd most common complication & >igh incidence in elderly d)t N53.0s & enetration! form of perforation in "hich ulcer bed tunnels to ad,acent organ & DU6s tend to perforate poste!io!l* into the panc!eas pancreatitis & GU6s tend to penetrate into the le#t hepatic lo$e & Gast!ocolic #istulas associated "ith ;U@s I c%2 Gast!ic "utlet "$st!uction & !east common & Aelative o$st!uction secondary to in#lammation A edema in pe!ip*lo!ic region & 4bstruction d)t scar re:uires balloon dilation or surgery & 5)s$ of obstruction develop insidiously & /arly satiety< nausea< vomiting< increase postprandial abdominal pain< 6 "eight loss 7 Diagnostic E aluation: =iops* U!ease Test: GK0 8 K*= (specificity 6 sensitivity) Se!ologic testing:
<F

C)

<.

C L u!ea $!eath test) -ecal 1%p*lo!i antigen test

Gast!ic Acid Anal*sis) Sham #eeding for complicated or refractory 1U0 =a!ium stud*: pro$imal ;. tract first test for documenting ulcer 5ingle contrast: O0= detection rate in 0U 0ouble contrast: K0= DU: appears as &ell7dema!cated c!ate! most often in $ul$ GU: may present as $enign or malignant =enign GU: appears as disc!ete c!ate! "ith !adiating mucosal #olds from ulcer margin ,alignant Ulce!s: IFcm 6 associated "ith mass

Endoscop*: /$amine uppe! GI t!act ,ost sensiti e A speci#ic to e$amine upper ;. tract 2acilitates photog!aphic documentation 3llo"s $iops* to rule out malignancy (;U) or > pylori .dentify too small lesions 0etermine source of $lood loss in ulcer

T!eatment: I% Acid @eut!ali+ing Test: a% Antacids $% 19 Recepto! Antagonist c% (!oton (ump Inhi$ito!s a%2 Antacids: G Commonly use for symptomatic relief for d*spepsia% G Aluminum h*d!o8ide 6 magnesium h*d!o8ide: mot commonly used G Aluminum h*d!o8ide constipation 6 phosphate depletion G ,agnesium h*d!o8ide loose stools G ,agnesium7containing preparation contraindicated for !enal #ailu!e hypermagnesemia G Aluminum cause ch!onic neu!oto8icit*

G Calcium ca!$onate converted to calcium chlo!ide in stomach milk alkali syndrome hypercalcemia< hyperphospatemia< renal calcinosis< renal insufficiency) G Sodium =ica!$onate systemic alkalosis $%2 19 Recepto! Antagonist: G Cimetidine< Aanitidine< 2amotidine< NiEatidine G .nhibits basal 6 stimulated acid secretion G Breatment of active ulcers (L&D "eeks) in combination "ith antibiotics G Cimetidine: & -i!st 19 !ecepto! antagonist used for treatment of acid peptic disorders & .nitial recommended dose -00mg :id & O00mg >5 for active ulcer: healing at O0= in L "eeks & Ceak antiand!ogenic effect reversible gynecomastia 6 impotence & .nhibits c*toch!ome (.:/ monitor "arfarin< phenytoin< 6 theophilline & Aeversible adverse effects: & Confusion & /levated serum aminotransferase< creatinine< serumprolactin

I@-LA,,AT"RH ="MEL DISEASE:

ULCERATIVE C"LITIS: - %ucosal disease that involves rectum and e$tends pro$imally to involve all parts of colon L0&*0= limited to the rectum 6 rectosigmoid -0&L0= e$tends beyond the sigmoid but not involving the "hole colon (0= total colitis 10&(0= e$tends (&-cm to the terminal ileum =ac0&ash ileitis: endoscopic changes (little significance) 2ine granular surface (sand pape! appea!ance) mild inflammation 5evere hemorrhagic< edematous< 6 ulcerated (seudopol*ps: present in long standing disease resulting from epithelial regeneration !ong standind disease colon is na!!o&ed A sho!tened%

2ulminant disease to$ic colitis or megacolon develop bo"el "all thins perforation 1istologic #eatu!es: G 0istorted colonic crypt: gap bet"een crypt bases 6 muscularis mucosae G 'asal plasma cells 6 multiple basal lymphoid aggregates QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ Q CR"1@6S DISEASE: - 3ffects ;. tract from mouth to anus -0&L0= has small bo"el disease alone L0&**= both small 6 large intestine 1*&(*= colitis alone .n the J*= of patients "ith small intestinal disease< the terminal ileum is involved in K0= Aectum is often spared 5egmental "ith skip areas in the midst of disease intestine Aarely may involve liver 6 pancreas Bransmural prosess unlike UC %ild aphthous or small supe!#icial ulce!ations 3ctive stellate ulce!ations fuse longitudinally and transversely to demarcate islands of mucosa that fre:uently are histologically normal Co$$lestone appearance characteristics of C0 3ctive C0 is characteriEed by focal inflammation and formation of fistula tracts 'o"el "all thickens narro"ed and fibrotic chronic< recurrent bo"el obstructions C!eeping #at: 1ro,ections of thickened mesentery encase the bo"el

Loose agg!egations o# mac!ophages microscopically

1E(AT"=ILIARH SHSTE,: Li e!: La!gest gland in the body Ceight: <://g !ocation: Aight Upper 3bdominal Cavity Color: Aeddish bro"n 5urrounded by fibrous sheath: Glisson6s Capsule >eld up in place by several ligaments: a) Round ligament: remnant of obliterated umbilical vein enters left liver hilum b) -alci#o!m ligament: - separates left lateral 6 left medial segments - anchors liver to anterior abdominal "all c) Ligamentum enosum: bet"een caudate lobe 6 left lateral segment: obliterated ductus venosusR covered by plate of arantius d) Le#t A Right T!iangula! Ligament: secure ( sides of liver to the diaphragm e) Co!ona!* ligaments: e$tending from triangular ligament anteriorly #2 1epatoduodenal ligaments: - 3I3: (o!ta 1epatis - Contains the >(o!tal T!iad? ((o!tal vein< 1epatic artery< =ile duct) - -o!amen o# Minslo& or Epiploic -o!amen: entrance route for (!ingle ,anue e! - (!ingle maneu e!: clamping the portal triad Cantlie6s line: separate Aight 6 !eft lobes (plane from gallbladder fossa to .7C)
Lo$es: Aight lobe !eft lobe Caudate lobe 9uadrate lobe 'uad!ate 6 Caudate: 3natomically (belongs to Aight lobe) 2unctionally (belongs to !eft lobe) blood supply from left hepatic artery 6 left portal vein drain into left hepatic duct 3ccessory lobe: not true lobes

Right lo$e: D0&J0=of liver mass Caudate lo$e: lies to the left contains - segments (5piegel lobe< 1aracaval portion< Caudate process) Couinaud: divide liver into O segments (!eft lobe& 5egments .< ..< ...< .7R Aight lobe& 5egments 7< 7.< 7..< 7...) I L Caudate lobe II A III L !eft lateral segment IV L !eft medial segment (.7a & CephaladR .7b 8 Caudad) 3I3: 9uadrate lobe V A VIII7 Aight anterior lobe VI A VII7 Aight posterior lobe =lood Suppl*: A.) 1epatic A!te!* (*= of blood supply B.) (o!tal Vein J*= of blood supply

=lood D!ainage: 1epatic Vein a. c. Right 7< 7.< 7..< 7... Le#t ..< ... b. ,iddle .7 7< 7...

Caudate drains directly into IVC

7 =ili!u$in: & break do"n product of normal heme & bound to albumin in circulation sent to liver con,ugated to glucu!onic acid (by glucuronyl transferase) soluble in "ater & 1 bilirubin reacts to ( Uridine diphosphoglucuronic acid (U01;3) form bilirubun diglucuronide e$treted to bile canaliculi (small amounts escapes to blood: e$creted in urine) & Conjugated $ili!u$in e$creted to intestine as "aste (intestinal mucosa is impermeable to con,ugated bilirubin) & Unconjugated $ili!u$in A U!o$ilinogen permeable to intestinal mucosa some is reabsorbed to portal circulation e$creted by liver enters circulation e$creted in urine 7 =ile: & & & & 1roduced by hepatoc*tes% <Lite!) da* produce by the liver Components: "ater< electrolytes< bile pigments< bile salts< phopholipids (lecithin)< cholesterol Aoles: & digestion 6 absorption of lipids< lipid soluble vitamins & eliminate "aste products

Gall Stones: - 2ormed because of abnormal bile composition - Bypes: a%2 choleste!ol stone (O0=)< $%2 pigment stone (black or bro"n types) - S*mptoms: =ilia!* Colic: - %ost specific 6 characteristic symptom (costant 6 long lasting) - SuddenB pe!sistentB stead*B se e!e intensity - 0uration: <:mins%to : hou!s% - 5ubsiding gradually or rapidly - 2re:uently nocturnal "ithin fe" hours of retiring - 1recipitated by fatty meal< consumption of large meal follo"ing a prolonged fasting< normal meal - =e*ond : hou!s 4acute cholec*stitis2% (ain: - 5teady RU' or Epigast!ic pain - Aadiation: .nterscapular< Aight scapula< 5houlder @ausea A omiting:

fre:uently accompany episodes of biliary pain

Ele ated se!um $ili!u$in or Al0aline phosphatase: suggest common duct stone

-e e!) chills: implies complication (cholecystitis< pancreatitis< cholangitis) T!eatment: Su!ge!*: (!oph*lactic Cholec*stectom* for large gall stones 4IFcm2% Routine cholec*stectom* preferred for all young patients "ith silent stones

U!sodeo8*cholic acid (U0C3): - 0ecreases cholesterol saturation of bile - 1roduce lamellar li:uid crystalline phase (dispersation of chemicals) - Aetard cholesterol crystal nucleation - 3chieve good results in M*mm stones - G1*mm rarely dissolves

Acute Cholec*stitis: - 3cute inflammation of gall bladder "all - Usually follo"s obstruction of cystic duct by stone - - factors of inflammation: a ) %echanical increase intraluminal pressure 6 distention "ith resulting ischemia of gall bladder "all b ) Chemical !ysolecithin (action of phospholipase on lecithin in bile) 6 other tissue factors

c ) 'acterial *0&O0= (/ coli< Ilebsiella< 5trep< Clostridium) 5ymptoms: 'egins as an attack of biliary pain 4n progression pain becomes generaliEed to AU9 radiates to interscapular area< roght scapula< shoulder 1eritoneal signs: increase pain "ith ,arring or deep respirations 4ften anorectic 6 nauseated 7omiting: "ith signs of /C2 depletion +aundice: unusual in early phase !o" grade fever /nlarged< tensed gallbladder: palpable in (*&*0= of cases ,u!ph*6s sign: 1ain in palpation at the right costal margin during deep inspiration and cough causing inspiratory arrest !ocaliEed Aebound Benderness: AU9 is common ,i!i++i6s S*nd!ome: rare complication< impaction in the cystic duct or gallbladder neck

causing C'0 compression C'0 obstruction +aundice (UB?& stones lying outside the hepatic duct) Diagnosis: Briad: - AU9 tenderness - 2ever - !eukocytosis (10<000&1*<000 cells)!) 5erum bilirubin: - %ildly elevated & MO*mol)! (*mg)d!) - G*0= of patient UB?:

Calculi (K0&K*=) Bhickening of "all 1ericholecystic fluid 0ilation of bile duct

- 5tones lying outside the hepatic duct %iriEEi@s 5yndrome & ,anagement: ,epe!idine: for analgesia because it cause less spasm to the sphincte! o# oddi% IV anti$iotics: for severe acute cholecystitis - 1ipeperacillin or mecloEillin - 3mpicillin sulbactam - Ciproflo$acin - %o$iflo$acin - -rd generation cephalosphorins - %etronidaEole: if gangrenous or emphysematous - .mipenem)meropenem: for more severe 6 life threatening infections Cholec*stectom*: & Breatment of choice for acute cholecystitis & .deally "ith in J( hours after diagnosis

Ch!onic cholec*stitis: & 3I3: >=ilia!* Colic? & Ascho##7 Ritans0* Sinuses: atrophied gallbladder mucosa "ith epithelium protruding to the muscle coat QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ Q