Documente Academic
Documente Profesional
Documente Cultură
09.01.2001
INTERNAL DIAGNOSTIC II
EXAMINATION PROCEDURES
Patient Evaluation
Exam procedures on Abdominal
Concentrate on chief complaint
A. History
1. Weight loss: 6-10% body weight in 6 month w/o diet
2. Vomiting blood
3. Blood in stool: frank blood, black tarry
4. Low back pain that is not relieved
5. Abdominal pain acute
Abdominal rigidity sign of Peritonitis, involuntary muscle spasm
Guarded Abd = belly pain = voluntary
6. Jaundice
B. Physical Examination
1. Inspection
2. Auscultation
3. Palpation
4. Percussion
C. Radiographic Examination
Standard examination: KUB – kidney, ureter, bladder (Plain film radiographic
evaluation of the abdomen). Upright or Supine. Look for air, fluid
A. HISTORY
A good history is of extreme importance in obtaining an accurate diagnosis
80% of the diagnosis is made from history alone
90% of the diagnosis is made from history and physical examination
Only 10% of the time are special diagnostic procedures required to establish the
diagnosis
16.01.2001
Nutrition: food intake, weight gain (thyroid dz, endocrine dz, diabetes, etc.) or loss
(malignancies) (5-10% of body weight w/in 6 months w/out trying to lose weight)
Medications (side effects, interfere w/ absorption of certain nutrients, can also be
associated w/ aggressive GI infection)
Alcohol intake (prominent effect on GI, and GU dz)
Pregnancy (Gravida = how many times been pregnant, Para = # of live births, Aborta =
# of elective or spontaneous abortions)
Stool characteristics (color, consistency, smell, frequency, blood, texture, bowel movement
(BM), pain w/ defecation, frequency, food digested or not, buoyancy = fat in stool
floats)
Urinary characteristics (color, appearance: clear, cloudy, etc., frequency: pain?, smell
sweet ketones, incontinence, dysuria = pain, oliguria = some)
Stressful like events
Recent infectious diseases
Trauma (seatbelt injuries, car accidents, etc.)
GI symptoms:
Abdominal pain (OPPQRST)
• Crampy abdominal pain assoc w/ obstruction or poor peristalsis in a
hollow tube, Distension causes the pain
Indigestion (aka Dyspepsia = Heartburn)
Nausea (Associated w/ every GI disorders
• Nausea center located in …….. FIND OUT !
• Reversed peristalsis
Diarrhea (frequent liquid stools)
• Viral gastroenteritis
Constipation (decrease in the volume of stools)
Fecal incontinence (cause: aging, stroke, spinal cord dz, cauda equina syndrome,
etc.)
Jaundice (yellow skin, ↑ of bilirubin in the blood, Itching)
4
GU symptoms:
Dysuria (painful urination)
Urinary frequency (increase – polyuria or decrease – oliguria)
Urinary incontinence (m/c cause = aging)
Hematuria (blood in the urine)
• 2 types: 1. frank blood = macroscopic, 2. microscopic
Chyluria (milky urine)
• Often sign of pus
B. PHYSICAL EXAMINATION
4 1 5
6 2 7
8 3 9
LLQ: m/c for abdominal pain because of constipation also ulcerative colitis,
diverticulosis, irritable bowel syndrome
RLQ: appendicitis m/c, Crohn’s dz, ulcerative, ovarian, genital
LUQ: gastritis, splenic infarcts, hiatal hernia, kidney
RUQ: liver, gallbladder, ulcerative colitis
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17.01.01
1. Inspection
Scars
Striae (stretch marks: purple, blue, silver, brown)
Lumps, bumps, moles
Contusions (symmetry)
Hernias
Distension
Visible Peristalsis
Visible Pulsation
Caput Medusa: radiating spicules of veins emanating from umbilical region
2. Auscultation
Bowel sounds (5-30 / min)
Borborygmus
Bruits (turbulence inside a hollow tube, over arteries = bruit, veins obstructed =
venous hum)
Peritoneal Friction rubs (sound like hair rubbed b/w fingers)
3. Percussion
Percussion notes: Tympany (over hollow viscus), Hyper tympanic (abnormal,
over distended area), Dull (over solid organs: liver, spleen, full bladder), Can also
measure the organs (liver, spleen)
4. Palpation
Masses (mobile, soft, hard, painful, pulsation)
Rigidity (= involuntary spasm of the abdominal mm., sign of peritonitis)
Guarding (= not a good sign, Pt doesn’t want you to touch the area)
Fluid, Fluid wave
Hepatomegaly, Splenomegaly
Tenderness (Rebound tenderness --> peritonitis = inflammation of peritoneum).
When report pain --> palpate diagonally! get rebound tenderness away from the
area of tenderness
Abdominal aorta (pulsation should come anterior – slight pulsation towards the
front, if feel lateral pulsation --> need to check further, AAA --> can palpate it
further lateral, 75% of aortic aneurysm are seen in lateral lumbar spine)
Murphy’s = gallbladder inflammation
Murphy’s kidney punch test
Burney’s point = b/w ASIS + pubis
Hernias
6
C. Radiographic Exam
Plain film (aka KUB film --> Kidneys, ureter, bladder)
Upright + Supine (air, fluid bubble, obstruction, distension, masses, abnormal
calcifications: m/c lymph nodes + abdominal aorta)
Phlebolith (= stone in the vein, calcification of renal valve)
Kidney stones, Gallstones (only 10-15% of the time, made of cholesterol)
Foreign bodies
Free air inside the peritoneum (sometimes seen after surgery)
Nuclear Scan (reserved for bleeding, radiographic contrast attaching to red cells, etc.)
22.01.2001
1. Inspection, cont’d
Protuberant or Distended abdomen
Partial Bowel Obstruction: distended abdomen plus peristaltic movements heard
over the distension is practically diagnostic (sound tinny, Complete obstruction:
bowel is hyperactive, w/ time shuts down)
Increased air in bowel causing abdominal distension:
Mechanical factors, carcinoma or adhesions
Adynamic paralytic ileus (= not obstructive loss of bowel peristalsis, bowel is
paralyzed, shuts down. Causes = trauma, surgery, also due to endocrinologic dz)
7
Ascites: m/c cause is alcoholic cirrhosis leading to portal hypertension (IMP)
(cirrhosis = fibrosis, hardening of the liver), (↑ of blood pressure in the portal
system causes blood to back up fluid leaks to the abdomen ascites)
• Fluid Wave: press down abdomen and create a fluid wave is indicative
of ascites
• Puddle Sign: Have patient prone and then get on hands and knees, to get
all ascites to a dependent position, then flick and auscultate the
abdomen, listening for changes in intensity of sounds. Positive test
indicates ascites
• Ascites: can be assessed by shifting dullness when patient changes
position
• Chylous Ascites is milky (lipid) look to transudate, indicating lymphatic
blockage. Occurs with intraabdominal lymphomas and Hodgkin’s
disease. (milky lipid : transudate indicating lymphatic blockage gets
into 3rd space into abdomen)
Grey Turner’s Sign: Ecchymoses on the abdomen, an unusual place for ecchymoses, It
occurs in fulminant acute pancreatitis and carries a grave prognosis (Pt assumes in fetal
position and doesn’t want to get out of it = classic sign of pancreatitis)
Abdominal Hernias
Reducibility
4. Strangulated: an incarcerated hernia that has cut off its blood supply,
resulting in tissue necrosis and gangrene.
2. Auscultation
Peristaltic sounds:
Normal 3-30/minute
Absent bowel sounds adynamic ileus or late obstruction
Increased Bowel sounds: gastroenteritis or early obstruction
Borborygmi: High-pitched bowel sounds indicating small bowel obstruction. Can
be normal “hunger pangs”
Succussion Splash: Audible presence of increased amount of fluid in stomach
Normal after a large meal
It is occurs after fasting, then it is indicative or pyloric obstruction
Abdominal Bruits
Caused by calcification of AA
AAA (75% are seen on lateral lumbar)
Renal aneurysm (heard in left + right hypochondriac area, best heard in the back
over the costo…)
Splenic aneurysm (look like white circle over the spleen, splenic artery = most
tortuous of body)
Peritoneal Friction Rubs: hearing a peritoneal friction rub over the liver is indicative of
liver metastasis or primary hepatoma.(heard in people w/ surgery)
3.Percussion
Percuss for:
Ascites
Shifting dullness
Masses
Liver pan
10-12 cm in men, 8-11 cm in women
Splenic size (mononucleosis, leukemia, etc.)
Tympany
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4. Palpation
Tenderness
Palpate tender quadrant last
Rebound tenderness (not done over the area of complaint, done away from the
area w/ pain indicates peritonitis. Doesn’t indicate pain over an organ)
Guarding
Voluntary
Rigidity
Involuntary
Peritonitis
Organomegaly
Masses
Aortic pulsations
Hernia examination
Liver:
Hepatomegaly:
• Primary or metastatic Hepatoma (highly malignant, name seems to show
that it’s benign, better name = hepatocellular carcinoma)
• Alcoholic liver disease (fatty liver)
• Severe CHF (at least the right side is involved)
• Infiltrative diseases of liver like amyloidosis
• Myeloproliferative disorders: CML (Chronic Myelogenous Leukemia),
Myelofibrosis
Spleen
Splenomegaly
• Infections
• Leukemias
• Portal hypertension
Gallbladder
Courvoisier’s Law: Gallbladder is palpable in 25% of cases of pancreatic
carcinoma, due to painless distension
Murphy’s sign: RUQ pain aggravated by inspiration, indicative of acute
cholecystitis
Kidney
Enlarged kidneys: Polycystic kidney disease (check for thoraco-lumbar
anomalies, usually go together), hypernephroma (renal cell carcinoma), renal
cysts, hydronephrosis
11
Ptotic Kidney: Normal – sized kidney displaced inferiorly into abnormal
position; pelvic kidney
12
Aorta
Pulsatile mass in midline (to left) is suggestive of Aortic Aneurysm
Femoral Pulses and Distal Aorta: decreased of absence femoral pulses can be found in
several disorders
Dissecting Aortic aneurysm (hypotension)
Coarctation of Aorta (causing hypertension upper ext., hypotension in lower)
Severe atherosclerotic peripheral vascular disease
Leriche’s Syndrome: occlusion of the distal Aorta (can result from Saddle
thrombus: obstruct the flow from the Aorta)
Symptom Tetrad: Absent femoral pulses, intermittent claudication, gluteal
pain, impotence
Rectal Exam
25-50% of all malignant colonic polyps are w/in reach of your finger
23.01.2001
CONSTIPATION
Normal Defecation
3 to 7 stools per week
Gastro-colic reflex: “urge” to go after eating (in the morning f.ex.).
Gas = methane, sulfur
Constipation
decrease volume of bowel movements
functional (ex: lack of peristalsis) / mechanical (ex: blockage) disorder
Functional = can be treated w/ chiropractic
Very subjective
females>males
> 40 y.o. alternating constipation and diarrhea could suggest a tumor
Symptoms/Signs
Lack of consistent urgency
Smaller harder than normal stools (drink warm water)
Painful BMs
Abdominal “fullness”
Sense of incomplete emptying of bowels
13
Tenesmus (= persistent spasms of the rectum or bladder, accompanied by the desire to
empty the bowel or bladder, but doesn’t do anything. Common w/ inflammatory bowel dz,
Irritable bowel syndrome)
14
CONSTIPATION INVESTIGATION
Physical examination
Tenderness Left lower quadrant, decreased sounds, pain, fissures around the anus
Decreased bowel sounds
Masses
abdominal folds
tenderness (Left lower quadrant)
Sigmoidoscopy
Shows nothing
Treatment of Constipation
Manipulation
Increase fluid intake
Increase fiber in diet to >15 gm/day
Enemas as a last resort
Increase exercise
Medications
Psyllium (Metamucil, etc..)
Laxatives (Milk of Magnesia, MagCit)
Stool softeners (Peri-Colace)
Do not use these in obstructed/inflamed patients (ex: Crohn’s etc.)
15
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24.01.2001
ACUTE DIARRHEA
More than 3 BMs per day with liquidity of feces
DDx
UC (ulcerative colitis) – superficial inflammatory bowel of the large intestine
Crohn's (distal)
Pseudomembranous colitis (C. difficile) – (occurs after use of antibiotics, but
doesn’t kill C. Difficile)
Malabsorption
Diverticulitis (occurs in Left Colon)
Medications (cholinergic agents)
Laboratory
Elevated WBC (mild 75,000-100,000 Leukemia)
Altered electrolytes
Occult blood
Physical examination
Tender abdominal area
Stool examination
Inflammatory cells (IBD, bacterial infection)
ova/parasites
Blood (IBD, bacterial infection)
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Stool culture
Treat for specific bacteria if positive
18
Flexible Sigmoidoscopy
Abnormal mucosa (pseudomembranes, ulcerations)
Rehydration
H2O, Pedialyte
Clear liquids
Avoid coffee, alcohol, dairy, fruits (because of fibers), seasoned foods
Medications
Loperamide, etc .....(Lomotil)
Anti-biotics, anti-protozoals
CHRONIC DIARRHEA
Passage of frequent loose stools for > 3 weeks
Signs/Symptoms
Blood in stool
Weight loss
Abdominal pain
19
Low grade fever
Might have some nausea and vomiting (Reflex center in Area of Postrema)
20
Treatment
Fluid replenishment
Electrolyte supplementation
Abstain form lactose-containing products
Add hydrophilic products (psyllium)
Medications - decrease peristalsis
Lomotil
Imodium
29.01.2001
DYSPEPSIA
(Commonly called Heartburn)
HICCUP (Singultus)
(rapid spasms of the diaphragm)
Recurrent or persistent hiccups have been associated with over 100 causes in the
following categories:
Central nervous system disorders
Metabolic disorders
Irritation of the vagus or phrenic nerves
Surgical intervention
Psychogenic
Idiopathic
GASTROINTESTINAL GAS
Belching (eruptation)
Usually caused by swallowing air (aerophagia) – ex: eat too fast, chewing gums,
carbonated drinks, smokers
With each swallow, 2 to 5 ml of air is ingested
Causes
Rapid eating
gum chewing
smoking
drinking carbonated beverages
mouth breathing
23
GASTROINTESTINAL BLEEDING
Upper GI
Bleeding from an area proximal to the stomach is usually regurgitated
(hematemesis) as bright red blood – ligament of Treitz
If the area of bleeding is distal to the esophagus, the regurgitated blood is usually
“coffee ground” type.
Gastric acid acts on blood coagulates into granules which are
regurgitated. No distinct cut off b/w esophageal or stomach bleeding
Esophageal varices bleed chronically regurgitation
Blood from upper GI hemorrhage that is not regurgitated, is digested and results
in black tarry stools (melena).
Bleeding from upper GI does not come out bright red blood
If upper GI bleeding yields large amounts of defecated blood (hematochezia),
then the blood loss was massive
Lower GI
Bleeding is from the small intestine or colon
95% of the cases from the colon
Hematochezia is usually present (Def. = BRBPR: bright red blood per rectum)
Stool streaked w/ blood: picking up blood off from some mass
THE PERITONEUM
ASCITES
Healthy men have little or no intraperitoneal fluid. Healthy women, depending on the
phase of their menstrual cycle, may have up to 20 ml of intraperitoneal fluid
Ascites may be of peritoneal origin (diseased peritoneum) or non-peritoneal origin
(normal peritoneum)
The most common cause of ascites (about 80%) is portal hypertension secondary to
chronic liver disease (non-peritoneal origin)
Peritoneal ascites is usually caused by infections, malignancy, and inflammation of the
peritoneum. (Appendicitis could inflame the region of the peritoneum also)
MISCELLANEOUS ASCITES
Chylous ascites: a milky lipid-rich lymph with a high triglyceride level (> 1000 mg/dl)
usually caused by lymphatic obstruction from malignancy
Bile ascites: most commonly caused from biliary tract surgery, liver biopsy, or abdominal
trauma
PERITONEAL CARCINOMATOSIS
Peritoneal carcinoma from metastasis is relatively common
The originating tumors are usually adenocarcinoma arising from the: ovary, uterus,
pancreas, stomach, colon, lung, or breast
With the exception of ovarian origin, the prognosis is poor. Only 12% survival at 6
months
MESOTHELIOMA
Primary malignancies of the peritoneum are rare (Mesothelioma occurs in the lung,
people exposed to asbestos)
When they occur, they are usually mesotheliomas
Over 70% of the cases have a history of asbestos exposure
The ascitic fluid is characteristically hemorrhagic
The prognosis is extremely poor
ESOPHAGUS
X-ray: Indentations produced by the transverse aortic arch (above) and the left atrium
(below)
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NORMAL DEGLUTITION
The bolus of food is propelled into the esophagus by a powerful contraction of the
pharyngeal muscles. (Parts of upper pharyngeal: nasopharynx, ….,check anatomy)
Contraction waves behind the advancing bolus are referred to as peristalsis
Contraction waves initiated by swallowing are termed primary peristaltic waves
Contraction waves not initiated by swallowing are called secondary peristaltic waves
Both 1st and 2nd waves are the effective waves of peristalsis
Peristalsis gets slower as you age
PRESBYESOPHAGUS
It is an abnormality of esophageal motility usually associated with aging
It involves the lower one-third to one-half of the esophagus
The primary peristaltic contraction is impaired and there is an increase in non-propulsive
random contraction (there is also an increase of tertiary waves: ineffective non-
propulsive ineffective = “curling”, results in dysphasia)
The non-propulsive random contractions are called tertiary contraction or curling
Radiographically these tertiary contractions are referred to as the “Curling Phenomenon”
and look like multiple ring-like contractions that rapidly appear and disappear until the
peristaltic wave moves the bolus into the stomach
Curling phenomenon is also known as “corkscrew esophagus” or “beaded esophagus”
05.02.2001
Test: Monday 12, 10 am
ACHALASIA
Achalasia is also known as cardiospasm (narrowing of distal esophagus near
gastroesophageal junction)
It is a motor disorder caused from decrease or absence of the ganglion cells in the
myenteric plexus (muscle in the gut) (aka Auerbach’s plexus)
There is loss of primary peristalsis, a failure of relaxation in the lower esophageal
sphincter (prevents reflux), and lack or normal peristalsis in the rest of the esophagus
Pre-stenotic dilation
On x-ray there is a smooth tapering of the distal esophagus called a “bird’s beak”
Achalasia usually cause dysphagia with both solids and liquids (liquid dysphasia is
worse)
In addition to dysphagia, substernal discomfort or fullness may be noted after eating
Regurgitation is common and may lead aspiration followed by recurrent bouts of
pneumonia or chronic pulmonary inflammation (aspiration pneumonia)
Untreated, the esophagus may become markedly dilated (sigmoid esophagus)
28
CHALASIA
This is the reverse of achalasia of the lower esophageal sphincter (sphincter doesn’t
close)
It is usually discovered soon after delivery, as a cause of vomiting in infants
The esophagus is dilated and peristalsis is diminished resulting in free reflux of gastric
contents.
The usual cause is an incomplete development of neuromuscular control in the lower
esophagus
Diffuse esophageal spasm (DES)– causes intermittent dysphagia and chest pain, repetitive
contractions of the esophagus, and thickening of the esophageal wall. Dx is made w/
manometry.
Vogt’s classification:
Type I – complete absence of the esophagus (least common type)
Type II – incomplete esophagus with both upper and lower segments ending in a
blind pouch (no fistula w/ the trachea). Fistula = abnormal tubular connection
Type III – incomplete esophagus with a tracheoesophageal fistula
a. Fistula between the upper segment and the trachea
b. Fistula between the lower segment and the trachea, the upper ending blindly
(most common type)
c. Fistula between the trachea and both esophageal
The most common is type III-b and the least common is type I
Aspiration pneumonia would occur w/III a, III b (no direct connection) + III c
LARYNGOTRACHEOESOPHAGEAL CLEFTS
Clefts are formed as a result of a failure of normal separation of the fetal foregut into
trachea and esophagus
Generally these clefts are limited to the larynx, cricoid area, and the upper trachea
Problems associated: breathing, …
ESOPHAGEAL WEBS
Webs are thin, diaphragm like membranes of squamous mucosa (located inside the lumen
of the esophagus)
They may be singular or multiple and usually occur in the mid or upper esophagus
Webs can cause obstruction with proximal esophageal dilation
When symptomatic they usually cause solid food dysphagia
They are usually diagnosed from a barium swallow (or EGD: Esopho Gastro
Duodenoscopy= Flexible endoscope)
When symptomatic, they are usually treated with bougienage (passage of a dilating
instrument called a bougie)
A closed duplication results in a cystic mass lined with esophageal epithelium and filled
with fluid)
They are usually found in the central of posterior mediastinum (the esophagus is there)
The cysts may enlarge rapidly during infancy
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07.02.2001
ESOPHAGITIS
Esophagitis is the most common disease affecting the esophagus
Types of esophagitis:
Chemical esophagitis
Acute ulcerative esophagitis
Reflux esophagitis
Peptic ulcer of the esophagus
Infectious esophagitis
Crohn’s disease
Mechanical esophagitis
CHEMICAL ESOPHAGITIS
Swallowing of caustic materials may cause necrosis and ulceration of the mucosa of the
esophagus
The surface of the mucosa becomes irregular due to the edema, ulceration, and necrosis
As the inflammation subsides, fibrosis and scar-tissue develop, which may result in the
formation of strictures (= Shrinking. Can be long or short)
The strictures are most frequent a the following levels
The thoracic inlet
The level of the aortic arch
At or above the level of the diaphragmatic hiatus
(there are the most narrowing) – Clinically ends up in dysphasia
REFLUX ESOPHAGITIS
Associated with Gastroesophageal Reflux Disease
This condition features reflux of gastric contents into the lower esophagus
Only when the gastric contents damage the esophageal mucosa is it “reflux esophagitis”
(different from GERD)
32
The reflux may or may not have an associated hiatus hernia (approx 30-40%)
33
The major symptom is heartburn which occurs 30-60 minutes after meals and upon
reclining
Patients with severe involvement generally have an incompetent lower esophageal
sphincter
The amount of damage depends on the potency of the reflux and the amount of time that
it is in contact with the mucosa
INFECTIOUS ESOPHAGITIS
Infection of the esophagus occurs most commonly in immunosuppressed patients
AIDS patients
Organ transplant patients (Cyclosporine, because of chemo)
Cancer patients
Diabetes mellitus (type I)
Patients on maintenance steroid or antibiotic therapy (Pt w/ Crohn’s, arthritis
patients, etc.)
The most common pathogens are: candida albicans, herpes simplex, and cytomegalovirus
The most common symptoms are: dysphagia, odynophagia (painful swallowing), and
substernal chest pain
The most frequent radiographic findings are: a shaggy mucosal outline, multiple
ulcerations, segmental narrowing, and diminished peristalsis
CROHN’S DISEASE
Crohn’s disease is also called Regional Enteritis
The esophagus is an uncommon location for Crohn’s disease, it is usually associated with
the small bowel and colon
(“tongue to bongue”), typically found in distal ileum and proximal colon
When Crohn’s disease occurs in the esophagus, it usually presents as flat thickened
mucosal folds which progress to a typical cobblestone pattern (affects transmural layer
can get stenosis)
Stenosis may occur giving the radiographic appearance of a cone-like tapering and pre
stenotic dilation. Stenosis may lead to complete obstruction requiring resection
Unlike in the small bowel and colon, esophageal fistulas are unusual
MECHANICAL ESOPHAGITIS
Mechanical esophagitis can be caused by anything that is swallowed and becomes lodged
in the esophagus
Some common examples are metal objects like coins, bones, pills, etc.
The favorite site for a swallowed bone to become impacted is the cervical part of the
esophagus at or just above the level of the thoracic inlet.
Impacted pills may lead to chemical ulceration due to prolonged mucosal contact.
NSAID’s, iron, vitamin C, and some antibiotics are some of the more common
medications involved
Complications of impacted esophageal foreign bodies may include: ulceration, infection,
abscess formation (chronic), perforation, mediastinitis (need to have perforation first),
and pleural effusion (build up of fluid in the pleural space. Get pleural effusion because
of inflammation: mediastinum covered by …
LEIOMYOMA
Benign tumors of the esophagus are rare
Aka fibroid tumor
Leiomyoma is the most common benign tumor of the esophagus (smooth muscle)
It is usually a single intramural tumor that produces a sharp angular junction between the
mass and the esophageal wall which results in a filling defect
Since the extramural portion of the tumor usually projects into the mediastinum, it rarely
causes dysphagia and may be asymptomatic and remain undetected unless it is picked up
incidentally on an endoscopic or radiographic examination.
Their clinical significance is that they must be differentiated from malignant lesions
35
ESOPHAGEAL CARCINOMA
Carcinoma may develop in any part of the esophagus
They are either squamous cell carcinomas or adenocarcinomas (because esophagus is
lined w/ epithelium)
Half of the cases of squamous cell occur in the distal third of the esophagus and the other
half occur in the proximal two thirds
Increased risk of squamous cell carcinoma is associated with chronic use of alcohol and
tobacco
Adenocarcinoma usually occur in the distal third of the esophagus
The vast majority of adenocarcinomas develop as a complication of metaplasia due to
chronic gastroesophageal reflux
They typically occur in the 50 to 70 age group and are 3 times more common in men
The major symptoms are progressive solid food dysphagia and weight loss. Other
symptoms may present depending upon which tissues the tumor extends into. As an
example: tracheoesophageal fistula may result in coughing on swallowing or pneumonia;
laryngeal involvement may produce hoarseness (Coughing also caused by recurrent
laryngeal nerve)
There is a wide variety of radiographic presentations from a simple filling defect to total
esophageal obstruction
The diagnosis is confirmed by endoscopy with biopsy
The prognosis is poor in that most patients do not present in the physician’s office until
the condition is advanced and incurable (poor because can be asymptomatic for a long
time and lot of lymph nodes in the area)
The presence of supraclavicular (aka Virchow’s node) or cervical lymphadenopathy or of
hepatomegaly implies metastatic disease
27.02.2001
STOMACH
6 parts: (Drawing)
1. Top = fundus (where “magenblase” is)
2. Body
3. Antrum
A. Anatomic Cardia
B. Incisura Angularis
C. Pyloric canal (peptic ulcers)
D. Duodenal Bulb
The typical gastritis symptoms are postprandial (= after eating) indigestion, fullness,
bloating, nausea, early satiety, epigastric pain, and intolerance of fatty foods
There are two main types of non-erosive gastritis: Helicobacter pylori infection and
mucosal changes associated with pernicious anemia
H. Pylori: a spiral gram-negative rod that resides under the mucus layer next to
the epithelial cells. Acute superficial infections may cause a transient clinical
illness characterized by nausea and abdominal pain lasting for several days . If the
inflammation extends deeper, into the gastric glands, gland atrophy and
metaplasia of the epithelium may result. H. pylori infection is strongly associated
with peptic ulcer disease, however, only 15% of patients with chronic H. pylori
infection develop peptic ulcer. Several endoscopic and serologic test procedures
can be used to detect H. pylori. Bu a positive serologic test does not necessarily
mean that there is an active infection. Even after H. pylori has been eradicated,
antibodies can remain for 6-12 months.
Specific Gastritis
There are a number of different conditions that fall under the classification of specific
gastritis: phlegmonous, granulomatous, eosinophilic, lymphocytic, and Ménétrièr’s
disease
Phlegmonous type is an abscess that can be the caused by bacterial, viral, fungal, or
parasitic infections. It is considered to be a life-threatening medical emergency which
requires gastric resection and antibiotic therapy
Granulomatous type consists of granulation tissue resulting from chronic inflammation
caused such conditions as tuberculosis, syphilis, fungal infections, sarcoidosis, or Crohn’s
disease
Increase of tuberculosis in metropolitans (loves the spine)
Eosinophilic type is characterized by infiltration of the mucosa, muscularis, or serosa
layers with eosinophils. Corticosteroids help stop the eosinophilic infiltration
Lymphocytic type demonstrates a diffuse infiltration of lymphocytes on biopsy. On
endoscopy, there are mucosal erosions and a varioliform (pox-like) appearance.
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Ménétrièr’s disease is characterized by giant, thickened gastric folds. There is
significant protein loss which may lead to severe hypoproteinemia anasarca (generalized
massive edema). Idiopathic
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05.03.2001
There are three major causes for peptic ulcer disease: Helicobacter pylori, NSAID’s, and
hypersecretory states such as Zollinger-Ellison syndrome
H. Pylori: some studies have indicated that 70-75% of gastric and duodenal ulcer
patients have H. Pylori infections. H. Pylori is thought to increase gastric acid
secretion. Studies have shown that after standard therapy, 70-85% of patients will
have ulcer recurrence within 1 year. If H. pylori is successfully eradicated, the
recurrence rate drops to about 20%
NSAID’s: Aspirin is the most ulcerogenic of the NSAID’s. NSAID’s cause
decreased mucus and bicarbonate secretion, diminished mucosal blood flow, and
possibly reduced cell renewal. Chronic NSAID users increase their risk for gastric
ulcers 40-fold
Zollinger-Ellison syndrome: this condition is caused by gastrin-secreting
neuroendocrine tumors called gastrinomas. This is the least common cause of
peptic ulcer disease. In addition to the stomach, gastrinomas may occur in the
pancreas, duodenum, and regional lymph nodes. Over two-thirds are malignant.
Treatment:
Avoid those things that stimulate acid secretion such as smoking, alcohol,
analgesics, and milk
Gastric Neoplasm
Most tumors of stomach are malignant. Reverse in colon (benign)
The most common primary malignancy of stomach is gastric adenocarcinoma. With its
exception of skin cancer, it is the m/c cancer worldwide
Gastric Adenocarcinoma
Gastric ulcer dose not usually transform into cancer. Things that are thought to predispose
one to gastric cancer:
Blood group A
Adenomatous polyps larger than 2 cm
Immunologic deficiencies
Poor diet (no direct proof
It is rare for gastric carcinoma to occur under age 30, with the majority occurring
between the ages of 50 and 70
Men are affected twice as often as women and there is a higher incidence in Hispanics,
American blacks, and American Asians.
Gastric carcinoma appears most often as a bulky mass with deep central ulceration. Less
commonly, it may extend through out the entire stomach which is referred to as “linitis
plastica” (a poor prognosis). It is difficult to distinguish polypoid carcinomas from the
benign polyps that they may develop from
Three fourths of all gastric carcinomas occur in the distal third of the stomach
Gastric carcinoma may invade the lymph nodes, invade adjacent tissues by local
extension, or under go hematogenous spread
o Virchow’s nodes = Left supraclavicular fossa
o 2 ways: hematogenous spread (vascular system) and lymphangitic spread
(lymph vessels)
Common areas for metastasis are: lung, pleura, liver, brain, and bone
Early on, physical examination is often unremarkable. Later, weight loss, anemia,
hepatomegaly, splenomegaly, jaundice and ascites may be present
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Signs of metastases:
Enlarged left supraclavicular lymph node (Virchow’s Node)
An umbilical nodule (Sister Mary Joseph Nodule)
A rigid rectal shelf (Blumer’s Shelf)
Ovarian metastases (Krukenberg Tumor)
If detected early enough, surgical resection is the only therapy with curative potential
The long term survival of gastric carcinoma is less than 15%. In those cases in which
surgical resection is successful, long term survival is greater than 50%
Leiomyosarcoma
Represents 1% of gastric cancers
Metastases to the liver and lymph nodes is common
Metastatic Carcinoma
Malignant melanoma, breast carcinoma, and lung carcinoma are the most frequent
metastatic diseases to the stomach
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Hiatal Hernia
A hiatal hernia is protrusion of the stomach above the diaphragm
The etiology is usually unknown, it is thought to be either a congenital abnormality or
occur secondary to trauma:
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A subjective diagnosis based on the presence of a compatible profile and the exclusion of
other organic disorders
The disorder is extremely common with up to 20% of the adult population having
symptoms compatible with the diagnosis.
It is a life-long conditions that usually begins in the late teens to twenties, predominately
in females
Symptoms should be present for at least 3 months before the diagnosis can be considered
Drug therapy should be reserved for patients with severe symptoms that do not respond to
conservative measures
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Stool examination usually reveals no fecal leukocytes and stool cultures reveal no
pathogens.
The antibiotics disrupt the normal bowel flora and allow the bacterium to flourish.
C. difficile is the major cause of diarrhea in patients hospitalized for more than 3 days.
Most patients report mild to moderate greenish, foul-smelling watery diarrhea with lower
abdominal cramps. (can go to pseudomembranous enterocolitis)
Complications
Dehydration
Electrolyte imbalance
Toxic megacolon
Perforation
Weight loss
Protein-losing enteropathy
In severe cases, death
Crohn’s Disease
One-third of the cases involve only the distal small bowel (ileitis)
Half the cases involve the distal small bowel and proximal colon (ileocolitis)
In 20% of the cases only the colon is involved
Crohn’s disease is a transmural process that can result in:
Inflammation
Ulceration
Stricturing (narrowing)
Fistula formation
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Abscess formation
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Crohn’s disease presents with a wide variety of signs and symptoms because its
involvement is variable in both location and severity of inflammation
Intestinal obstruction
o Narrowing of the small bowel may occur as a result of inflammation of
fibrotic stenosis
o Patients report postprandial bloating, cramping pains, and loud
borborygmi
Perianal disease (other presentation of Crohn’s): which usually includes anal fissures,
perianal abscesses, and fistulas
Extraintestinal manifestations
Oral aphthous ulcers
Increased prevalence of gallstones due to malabsorption of bile salts
Nephrolithiasis with urate or calcium oxalate stones
Complications
Abscess
Obstruction
Fistulas
Perianal disease
Carcinoma – Patient’s with colonic disease are a t a greater risk of developing
colonic carcinoma
Hemorrhage – unusual in Crohn’s disease (except for Crohn’s colitis)
Malabsorption – from bacterial over-growth in patients with fistulas
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No specific treatment exists for Crohn’s disease, treatment is directed toward
symptomatic improvement and controlling the disease process
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Ulcerative Colitis
Like Crohn’s disease, ulcerative colitis has an idiopathic etiology
The inflammation involves the mucosal surface of the colon, resulting in diffuse friability
and erosions with bleeding.
In 50% of the patients the disease is confined to the rectosigmoid region; 30% extend to
the splenic flexure (left-sided colitis); less than 20% extend more proximally (extensive
colitis)
Bloody diarrhea is the hallmark sign. (Ulcerative colitis tends to be pure diarrhea.
Cancer = alternate b/w diarrhea and constipation)
Patients should be asked about stool frequency, the presence and amount of rectal
bleeding, cramps, abdominal pain, fecal urgency, and tenesmus.
Moderate disease
o Most severe diarrhea with frequent bleeding
o Abdominal pain and tenderness may be present but are not severe
o Mild fever, anemia, and hypoalbuminemia
Severe disease
o More than six to ten bloody bowel movements per day
o Severe anemia, hypovolemia, and hypoalbuminemia (get edema)
o Impaired nutrition
o Significant abdominal pain and tenderness
Endoscopic findings
The mucosal appearance is characterized by edema, friability, mucopus, and
erosions
Colonoscopy should not be performed in “severe disease” patients because of the
risk of colon perforation
(Any male > 40 y.o. w/anemia has a GI malignancy until proven otherwise)
Vascular Ectasias
Vascular ectasias are also called angiodysplasia and arteriovenous malformation
They most commonly occur in elderly individuals in the cecum and ascending colon
They may be a cause of acute or chronic blood loss
They may be congenital or related to autoimmune disorders such as scleroderma
Most are thought to arise from chronic muscular contraction that obstructs the venous
mucosal drainage
Over time, the mucosal capillaries dilate and become incompetent, and arteriovenous
communication forms (incompetent = backflows)
Uncomplicated diverticulosis
More than two-thirds of patients with diverticulosis have no specific symptoms
The majority of these will never be aware of the diverticula
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Complications:
perforation, fistula formation, colon stricturing, partial or complete bowel
obstruction. check
Treatment
Most cases of diverticulitis will need to be hospitalized during the acute stage
Patients should be given nothing by mouth and should receive intravenous fluids
Antibiotics should be given for 7 to 10 days
Unless the diverticula is removed, diverticulitis will recur in one-third of the
patients
Diverticular bleeding
Essential of diagnosis
o Bleeding begins without warning in otherwise asymptomatic patients
o Acute onset of abdominal cramping followed by a large amount of bright
red or maroon blood mixed with clots (hematochezia)
o If large amounts of blood are lost, signs of hypovolemia, orthostatic
changes in vital signs, or shock may develop
o (Exsanguinate: bleed to death) – (orthostatic change ↓ BP)
o Bleeding usually stops spontaneously, requiring no further treatment, in up
to 90% of the cases
o 80% of patients have only one episode of bleeding
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Adenomatous Polyps
1. Non-familial adenomatous polyps
Peutz-Jeghers syndrome
o An autosomal dominant condition with hamartomatous polyps throughout
the gastrointestinal tract and mucocutaneous pigmented macules on the
lips, buccal mucosa and skin
o The hamartomas may become quite large, leading to bleeding,
intussusception (telescopes, folds on itself), or obstruction
o Volvulus or intussusception
o Although hamartomas are not premalignant, up to 50% of these patients
develop malignancies of the gastrointestinal tract
Colorectal Cancer
Colorectal cancer is the second leading cause of death due to malignancy in the United
States (1st cause = lung cancer for men and women – breast = 2nd)
Colorectal cancers are almost all adenocarcinomas
Approximately half of these cancers are located within the rectosigmoid region
Risk factors:
90% of cases occur in patients over 50
A history of adenomatous polyps increases the risk of subsequent adenomas and
carcinoma and requires periodic colonoscopic examination
A person with one family member with colon caner has a twofold to threefold
increased risk; if the family member was under 55, the risk is much greater
Familial polyposis syndrome increases the risk of colorectal cancer
In hereditary nonpolyposis colorectal cancer syndrome, not only is there an
increase in the risk of colorectal cancer, there is an increase in the risk of
developing cancers in other areas such as: endometrial, ovarian, renal, gastric
carcinoma
Pancreatic, and small intestinal
The risk of adenocarcinoma of the colon begins to rise about 7-10 years after the
onset of ulcerative colitis
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Clinical findings
Signs and symptoms
o Adenocarcinomas grow slowly and may be present for several years
before symptoms appear
o Asymptomatic tumors may be detected by the presence of fecal occult
blood
o Chronic blood loss from right-sided colonic cancers may cause iron
deficiency anemia with fatigue and weakness
o The right colon has a large diameter and more liquid fecal mater, making
obstruction uncommon in cancers in this area
o Obstruction with colicky pain and a change in bowel habits may
accompany cancers in the left colon because the diameter is smaller and
the fecal matter is more solid
o Constipation and diarrhea may alternate
o The stool may be streaked with blood, although, marked bleeding is
unusual
o Patients may note tenesmus, urgency, and recurrent hematochezia
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video
bypass of stomach = what is it called?
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Colorectal Cancer
Inspection
Cancers may be detected with a high degree of reliability with either barium
enema or colonoscopy
Stage IV
o Presence of distant metastasis
o Long-term survival rate 5%
o Systemic chemotherapy for palliation only, it does not prolong survival
Anorectal Disease
Hemorrhoids
Internal hemorrhoids are a plexus of superior hemorrhoidal veins located above
the dentate line (circumferential line that divides the rectum in half) which are
covered by mucosa
o The principal problems attributable to internal hemorrhoids are bleeding
and mucoid discharge
o They are confined to the anal canal (stage I), prolapse during straining and
reduce spontaneously (stage II), prolapse and require manual reduction
after bowel movement (stage III), may remain chronically protruding
(stage IV)
External hemorrhoids arise from the inferior hemorrhoidal veins located below
the dentate line and are covered with squamous epithelium of the anal canal or
perianal region
Hemorrhoids may become symptomatic as a result of activities that increase
venous pressure, resulting in distention and engorgement. Straining at stool,
constipation, prolonged sitting, pregnancy, obesity, and low-fiber diets all may
contribute
They are usually treated with a high fiber diet and increased fluid intake. Stage III
and IV hemorrhoids with chronic severe bleeding may require surgical excision
Anorectal Infections
Proctitis is defined as inflammation of the distal 1.5 cm of rectum and is
characterized by anorectal discomfort, tenesmus, constipation, and discharge (+
lots of itching)
Most cases of proctitis are sexually transmitted, especially by anal-receptive
intercourse
Infectious proctitis can be caused by:
o Neisseria gonorrhea
o Treponema pallidum
o Chlamydia trachomatis (m/c sexually transmitted disease)
o Herpes simplex (type 2)
o Condyloacuminata (venereal warts)
Rectal prolapse
Rectal prolapse is protrusion through the anus of some or all layers of the rectum
It is most commonly seen in the elderly
If the prolapse is chronic, its results in mucous discharge, bleeding, incontinence,
and sphincter damage
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Patients with complete prolapse require surgical correction
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Fecal Incontinence
There are five general requirements for bowel continence (control)
o Solid or semisolid stool
o A distensible rectal reservoir
o A sensation of rectal fullness
o Intact pelvic nerves and muscles
o The ability to reach a toilet in a timely fashion
Minor incontinence
o This consists of slight soilage of undergarments that tends to occur with
straining or coughing
o This may be due to local anal problems such as hemorrhoids and skin tags
that make it difficult to form a tight anal seal, especially if the stools are
somewhat loose
Major incontinence
o Any complete uncontrolled loss of stool reflects a significant problem with
sphincter or neurologic damage
o Causes of sphincter damage include traumatic childbirth, episiotomy,
prolapse, prior anal surgery, and physical trauma
o Neurologic disruption may be cause by obstetric trauma, aging, diabetes
mellitus, multiple sclerosis, spinal cord injury, and cauda equina syndrome
Anal fissures
These are linear ulcers that are usually less than 5 mm in length
They are believed to arise from trauma to the anal canal during defecation due to
straining, constipation or high internal sphincter tone
Patients complain of severe , tearing pain during defecation followed by throbbing
discomfort
Pruritus ani
This condition is characterized by perianal itching and discomfort
It may be caused by poor anal hygiene associated with fistulas, fissures, prolapsed
hemorrhoids, skin tags (hamartoma where a little tag of skin comes off), and
minor incontinence
Overzealous cleaning with soaps may cause a contact dermatitis
Other causes of pruritus ani include pinworms, candidal infection, scabies, and
venereal warts
Malabsorption
Malabsorption generally denotes disorders in which there is a disruption of digestion and
nutrient absorption
Normal digestion and absorption may be divided into three phases:
2. Mucosal phase – this phase requires a sufficient surface area of intact small
intestinal epithelium. Brush border enzymes help in the hydrolysis of
disaccharides and di-an tripeptide
3. Absorptive phase – Obstruction of the lymphatic system results in impaired
absorption of chylomicrons and lipoproteins
Celiac Sprue
Sprue is also known as gluten enteropathy or celiac disease
This condition is thought to be a genetically predisposed sensitivity to gluten
The gluten incites a humoral or cell-mediated inflammatory response that results in
mucosal inflammation and destruction leading to a malabsorption of most nutrients
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In addition the patient may be anemic, bruise easily due to Vitamin K deficiency, have
hyperkeratosis (thick skin) due to Vitamin A deficiency, and bone pain due to
osteomalacia
10% of patient with celiac sprue have a skin condition called dermatitis herpetiformis.
Products containing wheat, rye, and barley must be eliminated from the patients diet.
Products and flours made from rice, soybean, potato and corn are safe.
Whipple’s Disease
Whipple’s disease is a rare multisystemic illness caused by infection with Tropheryma
whippelii. The source of the infection is unknown, but no cases of human-to-human
spread have been documented
Most cases have gastrointestinal symptoms that include abdominal pain, diarrhea, and the
signs of malabsorption (distension, flatulence, and steatorrhea)
The type and degree of malabsorption depend upon the length and site of the resection
and the degree of adaptation of the remaining bowel
Lactase Deficiency
Lactase is a brush border enzyme that hydrolyzes the disaccharide lactose into glucose
and galactose
Lactase levels are high at birth but decline steadily in non-Europeans during childhood,
adolescence, and into adulthood.
Most obstruction will cause simple occlusion of the intestinal lumen that results in
distension and large losses of fluid into the gut
If the obstruction is proximal, the patient will develop cramping abdominal pain and
vomiting within minutes of the obstruction and there will be minimal abdominal
distention
If the obstruction is distal, it may take hours for the cramping abdominal pain and
vomiting to appear and the abdominal distention is usually pronounced
Strangulation with necrosis of the bowel wall, which may lead to perforation, peritonitis,
and sepsis are the major complications of obstruction
After the patient is stabilized, surgery is performed to remove the cause of obstruction
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Early satiety or postprandial vomiting occurs in patients with conditions causing delayed
transit through the stomach and upper small bowel.
Bowel sounds:
Obstruction causes high-pitched rushes (tiny)
In Pseudo-obstruction the bowel sounds are quiet but usually present (ileus)
Bowel habits:
Diarrhea or constipation are the cardinal symptoms of motor disorders
Diarrhea is more than three bowel movements a day
Constipation is less than three bowel movements a week
Symptoms include:
Early satiety
Nausea
Vomiting
Phytobezoars (a concretion composed of the skin, seeds, and fibers of fruits and
vegetables)
There is severe abdominal distention with massive dilation of the cecum or right colon
which may be precipitated by:
Electrolyte imbalances
Medications
The symptoms are usually mild abdominal pain and tenderness. However, the patients
may be unable to …missed the end
Patients become symptomatic only after there has been extensive replacement of the
smooth muscle with collagen
Diabetes mellitus
The primary symptom is diarrhea
Intestinal infections
Brain stem lesions
Hyperthyroidism
Benign Tumors
Adenomatous polyps are the most common benign mucosal tumor
Although they are usually asymptomatic, because of the remote possibility of
malignant transformation, surgical excision is usually recommended
Malignant Tumors
Adenocarcinoma
They are very aggressive
They usually occur in the duodenum or proximal jejunum
Eighty percent have already metastasized at the time of diagnosis
Lymphoma
They most commonly occur in the distal small intestine
The majority are non-Hodgkin’s B cell lymphomas
Carcinonoids
They are the most common neuroendocrine tumors (particularly epinephrine)
The overall 5 year survival rate is 50%
Over 95% of all gastrointestinal Carcinoids occur in either the rectum, the
appendix of the small intestine
Small intestinal carcinoids most commonly occur in the ileum
Appendicitis
KNOW
Intestinal Tuberculosis
Previously rare in the USA, its incidence has been rising in immigrant groups and
patients with AIDS
Increased 15-20% in last 10 years
Happens in upper lobes
Intestinal tuberculosis may cause mucosal ulcerations or scarring and fibrosis with
narrowing of the lumen
Patients may complain of chronic abdominal pain, obstructive symptoms, weight loss,
and diarrhea. An abdominal mass may be palpable. Get febrile, night sweats
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Complications include intestinal obstruction, hemorrhage, fistula formation, and
bacterial overgrowth with malabsorption
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Protein-Losing Enteropathy
Protein-losing enteropathy comprises a number of conditions that result in excessive loss
of serum protein into the gastrointestinal tract
The essential diagnostic features are hypoalbuminemia and an elevated fecal alpha one
antitrypsin level (found also in emphysema)