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Library of Congress Cataloging-in-Publication Data
Gastrointestinal emergencies (Tham)
Gastrointestinal emergencies / edited by Tony C.K. Tham, John S.A. Collins, Roy Soetikno. – Third edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-118-63842-2 (pbk.)
I. Tham, Tony C. K., editor. II. Collins, John S. A., editor. III. Soetikno, Roy, editor. IV. Title.
[DNLM: 1. Gastrointestinal Diseases–therapy. 2. Emergency Treatment. 3. Endoscopy, Gastrointestinal. WI 140]
RC801
616.3′3–dc
232015024791
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover image: © Paul Bradbury/GettyImages
Seiichiro Abe
National Cancer Center Hospital, Tokyo, Japan
Aijaz Ahmed MD
Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
Patrick B. Allen MB, FRCP, BSc
Consultant Gastroenterologist, Ulster Hospital, Belfast, Northern Ireland, UK
Constantinos P. Anastassiades MBBS (Lond), FACP
Consultant, Division of Gastroenterology & Hepatology, Khoo Teck Puat Hospital, Singapore
Adj. Assistant Professor of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
Stephen Attwood MCh, FRCS, FRCSI
Consultant Upper GI and Laparoscopic Surgeon, Honorary Professor, Durham University, Durham, UK
Andrés Cárdenas MD, MMSc, PhD, AGAF
Faculty Member/Senior Specialist, GI Unit, Institute of Digestive Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
David L. Carr-Locke MB, Bchir, FRCP, FASGE
Chief, Division of Digestive Diseases, Associate Chair of Medicine, Mount Sinai Beth Israel Medical Center, New York, USA
Professor, Icahn School of Medicine, New York, USA
W. Johnny Cash MD, FRCP
Consultant Hepatologist, Royal Victoria Hospital, Belfast, Northern Ireland, UK
John S. A. Collins MD
Associate Postgraduate Dean, Northern Ireland Medical and Dental Training Agency
Formerly Consultant Gastroenterologist, Royal Victoria Hospital, Belfast, Northern Ireland, UK
Wallace Dinsmore MD, FRCP, FRCPI, FRCPEd
Professor of Medicine, Department of GU Medicine, Royal Victoria Hospital, Belfast, UK
Shai Friedland MD
Assistant Professor, Stanford University School of Medicine and VA Palo Alto, Stanford, CA, USA
Subrata Ghosh MD, FRCP, FRCPE, FRCPC, FCAHS
Professor of Medicine, Microbiology & Immunology, University of Calgary, Alberta, Canada
Pere Ginès MD, PhD
Chief of Hepatology, Liver Unit, Institute of Digestive Diseases Hospital Clinic, IDIBAPS, Professor of Medicine, University of Barcelona, Spain
Isabel Graupera
Institut de Malalties Digestives i Metabolisme, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
Philip S. J. Hall MRCP, MB, BCh
Specialty registrar in Gastroenterology, Gastroenterology training program, Altnagelvin Hospital, Londonderry, Northern Ireland, UK
Paul Kevin Hamilton BSc (Hons), MD, FRCPE
Specialty Registrar, Department of Clinical Biochemistry; Formerly Consultant Physician and Clinical Pharmacologist; Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
Brian J. Hogan
Specialty Registrar, Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
Marietta Iacucci MD, PhD
Clinical Associate Professor of Medicine Division of Gastroenterology, University of Calgary, Alberta, Canada
Tonya Kaltenbach MD, MS
Veterans Affairs Palo Alto Health Care System, Clinical Assistant Professor of Medicine (Affiliated), Stanford University, Palo Alto, CA, USA
Joseph K. N. Kim
Icahn School of Medicine, New York, USA
Jennifer M. Kolb MD
Icahn School of Medicine at Mount Sinai, Internal Medicine, New York, NY, USA
Bee Chan Lee MB, MRCP
Consultant Gastroenterologist, Warwick Hospital, Warwicks, England, UK
David R. Lichtenstein MD
Director of Endsocopy & Associate Professor of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
Ian McAllister MD
Consultant Surgeon, Ulster Hospital, Dundonald, Belfast, Northern Ireland, UK
Daniel F. McAuley
Professor and Consultant in Intensive Care Medicine, Royal Victoria Hospital and Queen’s University of Belfast, Belfast, Northern Ireland, UK
Kevin McCallion
Consultant Surgeon, Ulster Hospital, Dundonald, Belfast, Northern Ireland, UK
Emma McCarty
Consultant in Genitourinary Medicine, Royal Victoria Hospital, Belfast, Northern Ireland, UK
James J. McNamee FCARCSI, FRCA, FCICM, FFICM
Consultant in Intensive Care Medicine, Royal Victoria Hospital, Belfast, Northern Ireland, UK
Graham Morrison MB, MRCP
Consultant Gastroenterologist, Altnagelvin Hospital, Londonderry, Northern Ireland, UK
Ichiro Oda MDNational Cancer Center Hospital, Tokyo, Japan
Khalid Osman FRCS
North Tyneside General Hospital, Tyne & Wear, UK
Kelvin Palmer FRCP(Edin)
Formerly Consultant Gastroenterologist, Western General Hospital, Edinburgh, UK
Ioannis S. Papanikolaou
Department of Internal Medicine and Research Unit, “Attikon” University General Hospital, University of Athens, Greece
David W.M. Patch MBBS, FRCP
Consultant Hepatologist, Department of Hepatology, Royal Free Hospital, London, UK
Ryan B. Perumpail MD
Stanford Hospital and Clinics, Stanford, CA, USA
Aarti K. Rao MD
Resident Physician, Department of Internal Medicine, Stanford University; Department of Gastroenterology, Veterans Affairs Palo Alto Health Care System, CA, USA
Michele B. Ryan
Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Andres Sanchez-Yague MD, PhD
Chief, Gastroenterology Unit, Vithas Xanit International Hospital, Benalmadena, Spain
Consultant, Gastroenterology Unit, Hospital Costa del Sol, Marbella, Spain
Allison R. Schulman
Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Reza Shaker MD, FACP
Professor and Chief, Division of Gastroenterology and Hepatology; Director, Digestive Disease Center, Medical College of Wisconsin, Milwaukee, WI, USA
Peter D. Siersema MD, PhD
Professor of Gastroenterology and Chief, Department of Gastroenterology and Hepatology, University Medical Center, Utrecht, The Netherlands
Maria Cecilia M. Sison-Oh
Medical Center Manila, Manila, Philippines
Roy Soetikno MD, MS (Health Service Research)
Chief, GI Section, Veterans Affairs Palo Alto Health Care System, Palo Alto
Associate Professor, Stanford University, Stanford, CA, USA
Daniel J. Stein MD
Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
Matthias Steverlynck
Centre Hospitalier de Mouscron, Belgium
Haruhisa Suzuki
National Cancer Center Hospital, Tokyo, Japan
Tony C. K. Tham MD, FRCP, FRCPI
Consultant Gastroenterologist, Dundonald, Ulster Hospital, Belfast, Northern Ireland, UK
Christopher C. Thompson
Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Philip Toner MRCP
Specialty Registrar, Department of General Medicine, Belfast Health and Social Care Trust, Belfast City Hospital, Belfast, UK
George Triadafilopoulos MD, DSc
Clinical Professor of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
Jo Vandervoort MD
Department of Gastroenterology, Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium
Barbara Willandt
KU Leuven, Netherlands
Richard C. K. Wong BSc, MBBS(Lond), FASGE, FACG, AGAF, FACP
Professor of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
Medical Director, DHI Endoscopy Unit, University Hospitals Case Medical Center, Cleveland, OH, USA
Robert J. Wong MD, MS
Stanford University School of Medicine, Stanford, CA, USA
John S. A. Collins
Northern Ireland Medical and Dental Training Agency, Royal Victoria Hospital, Belfast, UK
Dysphagia refers to a subjective sensation of the obstruction of swallowed solids or liquids from mouth to stomach. Patients most frequently complain that food “sticks” in the retrosternal area or simply will “not go down.” Patients may complain of a feeling of choking and chest discomfort. In some cases food material is rapidly regurgitated to relieve symptoms.
Dysphagia can be divided into two types:
Odynophagia is the sensation of pain on swallowing which is usually felt in the chest or throat. Globus is the sensation of a lump, fullness or tightness in the throat.
The causes of the above types of dysphagia are shown in Tables 1.1 and 1.2.
Table 1.1 Etiology of oropharyngeal dysphagia.
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Table 1.2 Etiology of esophageal dyphagia.
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Acute dysphagia is a relatively uncommon, but dramatic, presenting symptom and constitutes a gastrointestinal emergency. The patient will complain of difficulty initiating swallowing or state that food is readily swallowed but results in the rapid onset of chest discomfort or pain, which is only relieved by passage or regurgitation of the swallowed food bolus. The latter sensation can result after swallowing a mouthful of liquid. In the acute case it is important to ask the patient about the presence of other neurological symptoms.
If oropharyngeal dysphagia is suspected, the following points are important:
A diagnostic algorithm for the symptomatic assessment of the patient with dysphagia is shown in Fig. 1.1.
The etiology of esophageal dysphagia is summarized in Table 1.2.
While acute dysphagia may be painful, especially in relation to foreign body or food bolus impaction above an existing stricture, a history of odynophagia usually suggests an inflammatory condition or disruption of the esophageal mucosa leading to the irritation of pain receptors. The causes of odynophagia are:
Clinical signs in patients who present with dysphagia are uncommon. On examination, the following signs should be noted:
Dysphagia is considered to be an “alarm symptom” and should be investigated as a matter of urgency in all cases. Upper gastrointestinal endoscopy is a safe investigation in experienced hands provided the intubation is carried out under direct visualization of the oropharynx and upper esophageal sphincter. The endoscopist should be alert to the possibility of a high obstruction and the likelihood of retained food debris or saliva if dysphagia has been present for some time. If there is a history of choking, the patient should have a liquid-only diet for 24 hours followed by a 12-hour fast prior to the procedure. In some cases, the careful passage of a nasoesophageal tube to aspirate retained luminal contents may be necessary. At endoscopy, obstructing lesions can be biopsied and peptic strictures can be dilated with a balloon or bougie.
The presence of a dilated food and saliva-filled esophagus in the absence of a stricture raises the possibility of achalasia.
Barium studies are not a prerequisite for endoscopy but should be considered complementary in dysphagia. Barium swallow may give additional information in the following situations:
In some cases, a barium swallow may be a useful investigation in certain circumstances:
Esophageal manometry is indicated if both endoscopy and barium studies are inconclusive in the presence of persistent symptoms. Manometry requires intubation of the esophagus with a multilumen recording catheter attached to a polygraph. Pressure changes are recorded during water bolus swallows along the esophageal body and at the upper and lower esophageal sphincters.
The management of dysphagia depends on the underlying cause. In a patient presenting with total dysphagia who is unable to swallow even small amounts of liquid or saliva, urgent treatment is indicated (Fig. 1.2).
The management of oropharyngeal dysphagia can be treated by control of the underlying neurological or metabolic disorder. Dietary modification under the supervision of a speech and language therapist may maintain oral swallowing and avoid gastrostomy tube placement in patients with stroke and pseudobulbar or bulbar palsy. Gastrostomy tube placement may be the only management option in patients with inoperable mouth or throat tumors, or in cases where recurrent pulmonary aspiration is life threatening.
When the endoscopic appearances are characteristic of a benign peptic stricture, dilatation can usually be carried out at the time of the procedure using either wire-guided bougies or a balloon. If the stricture is complex, very tight or associated with esophageal scarring, it may be safer to carry out wire-guided dilatation using graded bougies. The majority of patients will gain symptomatic relief and the risk of complications is low (see Chapter 21, Esophageal Perforation).
It is essential that all patients are treated with an adequate dose of a proton pump inhibitor to prevent recurrence. Repeat dilatations are necessary in some cases and repeat inspection and biopsy is advised if there is any concern about mucosal dysplasia or malignancy.
Suspected carcinoma, which is detected at endoscopy, requires biopsy confirmation and subsequent staging so that a management plan can be formulated. The most accurate modality for staging is endoscopic ultrasound which can assess depth of local invasion and regional lymph node status. Chest and abdominal computerized tomography (CT) is a less accurate technique but CT/positron emission tomography (PET) scanning enhances staging accuracy, especially in adenocarcinomas.
Surgery offers the only chance of cure but only 30% of tumors are resectable and 5-year survival is 10% in European studies. Contraindications to surgery include invasion of vascular structures, metastatic disease and patients with comorbidity and high operative risk.
Palliative management will be indicated in 70% of patients following staging. Esophageal dilatation, followed by the endoscopic placement of a metal stent, gives adequate swallowing relief in the majority of cases. In situations where there is complete obstruction of the esophageal lumen by tumor, endoscopic laser therapy can provide adequate palliation of dysphagia. The prognosis is poor with a mean survival of 10 months after diagnosis with a 5-year survival of 5%. Where surgical resection is completed after staging and selection, 5-year survival can be up to 25%.
Following radiotherapy to the thorax or head and neck, some patients develop esophagitis, which may progress to stricturing and fibrosis. The diagnosis is confirmed by endoscopy and biopsy. Treatment consists of balloon or bougie dilatation and may have to be repeated in severe cases.
Both of these esophageal lesions can result in dysphagia or lead to food bolus impaction. Webs are typically composed of thin mucosal tissue covered with squamous epithelium. They tend to occur proximally in the upper cervical esophagus and may be missed or ruptured at endoscopy, which is both diagnostic and therapeutic in these cases. They have been associated with chronic iron deficiency anemia. Rings are mucosal circular structures associated with dysmotility and seen at the esophagogastric junction. A Schatzki ring is a solitary thin rim of mucosa usually seen in the distended lower oesophagus. They are usually treated by dilatation and may be recurrent.
See Chapter 20, Foreign Body Impaction in the Esophagus.
This is an increasingly recognized cause of dysphagia and is diagnosed by characteristic endoscopic appearances and the finding of a dense eosinophilic infiltrate in esophageal mucosal biopsies (>15 per high power field). Dilatation is rarely required and the condition responds to low-dose swallowed topical steroids, administered by a metered inhaler.