, a LANGE medical book
CURRENT
Diagnosis & Treatment
Gastroenterology,
Hepatology, & Endoscopy
Editor
Norton J. Greenberger, MD
Clinical Professor of Medicine, Harvard Medical School
Senior Physician, Division of Gastroenterology, Hepatology and Endoscopy
Brigham and Women’s Hospital
Boston, Massachusetts
Associate Editors
Richard S. Blumberg, MD
Professor of Medicine, Harvard Medical School
Chief, Division of Gastroenterology, Hepatology and Endoscopy
Brigham and Women’s Hospital
Boston, Massachusetts
Robert Burakoff, MD, MPH
Associate Professor of Medicine, Harvard Medical School
Clinical Chief of Gastroenterology, Division of Gastroenterology and Hepatology
Brigham and Women’s Hospital
Boston, Massachusetts
New York Chicago San Francisco Lisbon London Madrid Mexico City
Milan New Delhi San Juan Seoul Singapore Sydney Toronto
,Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved. Except as permitted under the United States Copyright Act of
1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system,
without the prior written permission of the publisher.
ISBN: 978-0-07-171473-0
MHID: 0-07-171473-1
The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-149007-8, MHID: 0-07-149007-8.
All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name,
we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where
such designations appear in this book, they have been printed with initial caps.
McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training pro-
grams. To contact a representative please e-mail us at .
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug thera-
py are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide infor-
mation that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of
human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the prepara-
tion or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all
responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are
encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the
product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work
is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommenda-
tion is of particular importance in connection with new or infrequently used drugs.
TERMS OF USE
This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”) and its licensors reserve all rights in and to the work. Use
of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the
work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute,
disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may use the work for your own
noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to
comply with these terms.
THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE
ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY
INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY
DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MER-
CHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that the
functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill nor
its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages
resulting therefrom. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances
shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from
the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall
apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.
, Contents
Authors ix 5. Acute Diarrheal Disorders 45
Preface xiii
Jerry S. Trier, MD
Acute Diarrhea 45
Section I. General Concerns Acute Diarrheal Disease Caused by
Specific Infections 50
1. Acute Abdominal Pain: Basic Principles
& Current Challenges 1 6. Mesenteric Ischemia 64
Frederick L. Makrauer, MD Elena M. Stoffel, MD, MPH
& Norton J. Greenberger, MD & Norton J. Greenberger, MD
Acute Abdominal Pain in the Elderly 3 Mesenteric Ischemia 64
Nonsurgical Disorders Simulating Acute Mesenteric Ischemia 65
the Acute Abdomen 4 Chronic Mesenteric Ischemia 71
Evaluation of the Acute Abdomen 4
Acute Appendicitis 6 7. Gastrointestinal & Biliary
Unique Presentations of Appendicitis 8 Complications of Pregnancy 75
2. Inflammatory Bowel Disease: Jaya R. Agrawal, MD
Immunologic Considerations 11 & Sonia Friedman, MD
Richard S. Blumberg, MD Gastroesophageal Reflux Disease 75
Nausea & Vomiting 78
General Principles of the Gut-Associated Hyperemesis Gravidarum 79
Lymphoid Tissues 12 Constipation 81
Pathogenesis of Inflammatory Bowel Disease 14 Diarrhea 82
Pathogenesis of Crohn Disease: Underlying Hemorrhoids 82
Mechanisms of Immune Dysregulation 15 Irritable Bowel Syndrome 83
Pathogenesis of Ulcerative Colitis: Fecal Incontinence 85
Immunologic Factors 17 Inflammatory Bowel Disease 85
Regulatory Pathways in the Maintenance Abdominal pain 88
of Intestinal Tolerance 18 Peptic Ulcer Disease 89
Therapeutic Implications of the Immunobiology Biliary Disease 89
of Inflammatory Bowel Disease 19 Pancreatitis 90
Appendicitis 91
3. Inflammatory Bowel Disease: Intestinal Obstruction, Pseudo-Obstruction,
Medical Considerations 22 & Gastrointestinal Cancer 92
Robert Burakoff, MD, MPH & Scott Hande, MD Endoscopy in Pregnancy 92
General Considerations 22 8. Hepatic Complications
Clinical Findings 23
of Pregnancy 98
Differential Diagnosis 26
Complications 27 Chinweike Ukomadu, MD, PhD
Treatment 28 Interpretation of Liver Biochemical
Prognosis 33 Tests During Pregnancy 98
Hepatic Conditions Unique to
4. Inflammatory Bowel Disease: Pregnancy 99
Surgical Considerations 34 Conditions not Unique to Pregnancy 101
Jennifer L. Irani, MD, Anthony Ramsanahie, MD
& Ronald Bleday, MD
Ulcerative Colitis 34
Crohn Disease 38
iii
CURRENT
Diagnosis & Treatment
Gastroenterology,
Hepatology, & Endoscopy
Editor
Norton J. Greenberger, MD
Clinical Professor of Medicine, Harvard Medical School
Senior Physician, Division of Gastroenterology, Hepatology and Endoscopy
Brigham and Women’s Hospital
Boston, Massachusetts
Associate Editors
Richard S. Blumberg, MD
Professor of Medicine, Harvard Medical School
Chief, Division of Gastroenterology, Hepatology and Endoscopy
Brigham and Women’s Hospital
Boston, Massachusetts
Robert Burakoff, MD, MPH
Associate Professor of Medicine, Harvard Medical School
Clinical Chief of Gastroenterology, Division of Gastroenterology and Hepatology
Brigham and Women’s Hospital
Boston, Massachusetts
New York Chicago San Francisco Lisbon London Madrid Mexico City
Milan New Delhi San Juan Seoul Singapore Sydney Toronto
,Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved. Except as permitted under the United States Copyright Act of
1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system,
without the prior written permission of the publisher.
ISBN: 978-0-07-171473-0
MHID: 0-07-171473-1
The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-149007-8, MHID: 0-07-149007-8.
All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name,
we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where
such designations appear in this book, they have been printed with initial caps.
McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training pro-
grams. To contact a representative please e-mail us at .
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug thera-
py are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide infor-
mation that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of
human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the prepara-
tion or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all
responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are
encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the
product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work
is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommenda-
tion is of particular importance in connection with new or infrequently used drugs.
TERMS OF USE
This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”) and its licensors reserve all rights in and to the work. Use
of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the
work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute,
disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may use the work for your own
noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to
comply with these terms.
THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE
ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY
INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY
DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MER-
CHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that the
functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill nor
its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages
resulting therefrom. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances
shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from
the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall
apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.
, Contents
Authors ix 5. Acute Diarrheal Disorders 45
Preface xiii
Jerry S. Trier, MD
Acute Diarrhea 45
Section I. General Concerns Acute Diarrheal Disease Caused by
Specific Infections 50
1. Acute Abdominal Pain: Basic Principles
& Current Challenges 1 6. Mesenteric Ischemia 64
Frederick L. Makrauer, MD Elena M. Stoffel, MD, MPH
& Norton J. Greenberger, MD & Norton J. Greenberger, MD
Acute Abdominal Pain in the Elderly 3 Mesenteric Ischemia 64
Nonsurgical Disorders Simulating Acute Mesenteric Ischemia 65
the Acute Abdomen 4 Chronic Mesenteric Ischemia 71
Evaluation of the Acute Abdomen 4
Acute Appendicitis 6 7. Gastrointestinal & Biliary
Unique Presentations of Appendicitis 8 Complications of Pregnancy 75
2. Inflammatory Bowel Disease: Jaya R. Agrawal, MD
Immunologic Considerations 11 & Sonia Friedman, MD
Richard S. Blumberg, MD Gastroesophageal Reflux Disease 75
Nausea & Vomiting 78
General Principles of the Gut-Associated Hyperemesis Gravidarum 79
Lymphoid Tissues 12 Constipation 81
Pathogenesis of Inflammatory Bowel Disease 14 Diarrhea 82
Pathogenesis of Crohn Disease: Underlying Hemorrhoids 82
Mechanisms of Immune Dysregulation 15 Irritable Bowel Syndrome 83
Pathogenesis of Ulcerative Colitis: Fecal Incontinence 85
Immunologic Factors 17 Inflammatory Bowel Disease 85
Regulatory Pathways in the Maintenance Abdominal pain 88
of Intestinal Tolerance 18 Peptic Ulcer Disease 89
Therapeutic Implications of the Immunobiology Biliary Disease 89
of Inflammatory Bowel Disease 19 Pancreatitis 90
Appendicitis 91
3. Inflammatory Bowel Disease: Intestinal Obstruction, Pseudo-Obstruction,
Medical Considerations 22 & Gastrointestinal Cancer 92
Robert Burakoff, MD, MPH & Scott Hande, MD Endoscopy in Pregnancy 92
General Considerations 22 8. Hepatic Complications
Clinical Findings 23
of Pregnancy 98
Differential Diagnosis 26
Complications 27 Chinweike Ukomadu, MD, PhD
Treatment 28 Interpretation of Liver Biochemical
Prognosis 33 Tests During Pregnancy 98
Hepatic Conditions Unique to
4. Inflammatory Bowel Disease: Pregnancy 99
Surgical Considerations 34 Conditions not Unique to Pregnancy 101
Jennifer L. Irani, MD, Anthony Ramsanahie, MD
& Ronald Bleday, MD
Ulcerative Colitis 34
Crohn Disease 38
iii
