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Chapter 19 - Postoperative gastrointestinal complications
- from Section 5 - Gastroenterology
- Edited by Michael F. Lubin, Emory University, Atlanta, Thomas F. Dodson, Emory University, Atlanta, Neil H. Winawer, Emory University, Atlanta
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- Medical Management of the Surgical Patient
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Summary
Introduction
Gut function is often impacted by surgical interventions, and postoperative gastrointestinal complications are common. Fortunately, most are minor and self-limited, but a number may be severe, and rarely, life threatening. Many of the complications can either be prevented or treated with proper prophylaxis and early recognition. Given the escalating use of bariatric surgery in the treatment of obese patients, this population is faced with unique postoperative issues.
Postoperative gastrointestinal bleeding
Postoperatively, gastrointestinal bleeding is an uncommon but potentially serious complication. Clinically significant bleeding occurs in 0.5–1% of patients in the acute postoperative setting [1,2]. The major causes of acute postoperative bleeding include stress ulceration, bleeding from an intestinal anastamosis, ischemic colitis, and bleeding from preexisting lesions such as gastroduodenal ulcers and diverticular disease. Gastrointestinal hemorrhage temporally remote from surgery occurs less commonly, but may be due to aortoenteric fistulae and recurrent or marginal ulcer disease.
Stress-related mucosal disease
Stress-related mucosal disease (SRMD), or stress-ulceration is the most common cause of postoperative GI bleeding, although its incidence has decreased with increased use of prophylaxis since 1999 [3,4]. Stress ulcers are primarily believed to be due to disturbances in the mucosal microcirculation, with relative local hypoperfusion causing a loss of mucosal integrity, an imbalance between aggressive and protective factors and subsequently development of multiple gastric erosions and ulcerations [5–7]. Suppressing gastric acid secretion is currently the best way to protect against these mucosal events; antisecretory agents have been employed successfully for prophylaxis of SRMD in high-risk patients [8].
Chapter 17 - Liver disease
- from Section 5 - Gastroenterology
- Edited by Michael F. Lubin, Emory University, Atlanta, Thomas F. Dodson, Emory University, Atlanta, Neil H. Winawer, Emory University, Atlanta
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Summary
Introduction
Due to the critical synthetic and metabolic functions of the liver, patients with underlying liver disease are at increased risk of morbidity and mortality during the perioperative period. Previously undiagnosed liver disease is estimated to be present in 1 in 700 otherwise healthy surgical candidates [1,2]. Failure to recognize the presence of underlying liver disease during preoperative evaluation can lead to postoperative morbidity and significantly increased mortality [3]. Identification of these patients prior to surgery will aid in proper risk stratification and management.
Classification of patients with liver disease involves determination of the degree of hepatic damage and the type of abnormality. It is equally important to consider the type of surgery that the patient will undergo. Hepatic complications in the perioperative period may also occur, which are frequently related to use of hepatotoxic medications, development of ischemia, or infection.
Preoperative evaluation
The preoperative evaluation should assess the patient for evidence of acute or chronic liver disease. Special attention should be paid to family history of liver disease as well as risk factors for liver disease such as alcohol abuse, distant receipt of blood transfusions, or illicit drug use. The physical exam should include evaluation for signs of chronic liver disease including spider nevi, temporal and/or muscle wasting, ascites, palmar erythema, and hepatosplenomegaly. Jaundice is rare in the absence of liver pathology (< 1% of patients) and raises concern for more significant liver disease [4]. A careful review of the patient’s blood work may reveal abnormalities suggestive of an underlying liver condition. While many blood tests may reflect liver diseases, the most clinically relevant are the liver enzymes aspartate aminotransferase (AST), alanine aminotransferase (ALT), as well as bilirubin, albumin, and coagulation tests (prothrombin time, INR). Elevation of gammaglutamyltranspeptidase (GGT) or alkaline phosphatase may reflect underlying cholestatic liver disease; however, the significance of their abnormalities during the preoperative evaluation is directly proportional to the finding of other evidence of chronic hepatic dysfunction.
Chapter 16 - Peptic ulcer disease
- from Section 5 - Gastroenterology
- Edited by Michael F. Lubin, Emory University, Atlanta, Thomas F. Dodson, Emory University, Atlanta, Neil H. Winawer, Emory University, Atlanta
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Summary
Introduction
Peptic ulcer disease (PUD) refers to a defect in the gastrointestinal mucosa of the stomach or duodenum that penetrates through the muscularis mucosa. Most studies of PUD have defined an ulcer as requiring a minimum diameter of 5 mm, although this size criterion is arbitrary. Ulcers form when there is a mismatch in protective and damaging gastrointestinal factors, with the most common destructive factors being infection with the bacteria Helicobacter pylori and use of non-steroidal anti-inflammatory drugs (NSAIDs). Without treatment of the primary cause, PUD is typically a relapsing-remitting chronic condition. Symptoms are variable, are often non-specific, and may even be absent. The mainstay of diagnosis of PUD is upper endoscopy. Since PUD is an acid-related condition, treatment includes acid suppression as well as specific treatment aimed at any causative factors identified.
Epidemiology
The worldwide incidence of PUD is approximately 0.1–0.2% and appears to be decreasing [1]. Furthermore, hospitalization rates, need for surgery, and PUD-related mortality are also all decreasing [2,3]. These improvements are likely due to the decreased prevalence of H. pylori, use of increasingly potent acid suppression, and the increased therapeutic role of upper endoscopy. The prevalence of PUD in patients with H. pylori infection is 1–6% [4], and is 11% in patients taking low-dose aspirin [5]; in the absence of H. pylori infection or NSAID use PUD is uncommon [6].
Contributors
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- By Rose Teteki Abbey, K. C. Abraham, David Tuesday Adamo, LeRoy H. Aden, Efrain Agosto, Victor Aguilan, Gillian T. W. Ahlgren, Charanjit Kaur AjitSingh, Dorothy B E A Akoto, Giuseppe Alberigo, Daniel E. Albrecht, Ruth Albrecht, Daniel O. Aleshire, Urs Altermatt, Anand Amaladass, Michael Amaladoss, James N. Amanze, Lesley G. Anderson, Thomas C. Anderson, Victor Anderson, Hope S. Antone, María Pilar Aquino, Paula Arai, Victorio Araya Guillén, S. Wesley Ariarajah, Ellen T. Armour, Brett Gregory Armstrong, Atsuhiro Asano, Naim Stifan Ateek, Mahmoud Ayoub, John Alembillah Azumah, Mercedes L. García Bachmann, Irena Backus, J. Wayne Baker, Mieke Bal, Lewis V. Baldwin, William Barbieri, António Barbosa da Silva, David Basinger, Bolaji Olukemi Bateye, Oswald Bayer, Daniel H. Bays, Rosalie Beck, Nancy Elizabeth Bedford, Guy-Thomas Bedouelle, Chorbishop Seely Beggiani, Wolfgang Behringer, Christopher M. Bellitto, Byard Bennett, Harold V. Bennett, Teresa Berger, Miguel A. 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Yee, Viktor Yelensky, Yeo Khiok-Khng, Gustav K. K. Yeung, Angela Yiu, Amos Yong, Yong Ting Jin, You Bin, Youhanna Nessim Youssef, Eliana Yunes, Robert Michael Zaller, Valarie H. Ziegler, Barbara Brown Zikmund, Joyce Ann Zimmerman, Aurora Zlotnik, Zhuo Xinping
- Edited by Daniel Patte, Vanderbilt University, Tennessee
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- The Cambridge Dictionary of Christianity
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Rates and causes of mortality in Endangered African wild dogs Lycaon pictus: lessons for management and monitoring
- Rosie Woodroffe, Harriet Davies-Mostert, Joshua Ginsberg, Jan Graf, Kellie Leigh, Kim McCreery, Robert Robbins, Gus Mills, Alistair Pole, Gregory Rasmussen, Michael Somers, Micaela Szykman
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Effective species conservation depends upon correctly identifying the threats that cause decline or hinder recovery. Because estimates of the relative viability of different populations of Endangered African wild dogs Lycaon pictus are most strongly influenced by adult and pup mortality, we analysed rates and causes of mortality in eight wild dog populations under study in southern and eastern Africa. The probabilities of detecting wild dog deaths were influenced by the monitoring methods used. The least biased estimates of mortality causes were obtained through intensive monitoring of radio-collared individuals; this is impossible for pups, however. Mortality patterns varied substantially between populations. Rates of human-caused mortality were higher for wild dogs radio-collared outside protected areas than for those collared inside, but rates of natural mortality were comparable, suggesting that anthropogenic mortality is additive to natural mortality. The relative importance of factors such as snaring and infectious disease also varied regionally. Hence, although our analyses identified no new threats beyond those highlighted in a 1997 range-wide Action Plan, they suggest that local plans will be valuable to target conservation activities more precisely.