7.1 Digestive System

colon cancer

Colorectal cancer, almost always adenocarcinoma, is the collective designation for a variety of malignant neoplasms that may arise in either the colon or rectum (Fig. 14.11). Colorectal cancer afflicts men and women equally. S/S:Symptoms are vague in the early stages. Rectal bleeding and blood in the stool may occur. The disease may metastasize to adjacent organs, such as the bladder, prostate, ureters, vagina, and sacrum. Later symptoms may include pallor, ascites, cachexia (a marked weakness of the body), lymphadenopathy, and hepatomegaly (enlargement of the liver). Any significant change in bowel habits should be regarded as suspicious; this may include alternating states of diarrhea and constipation and the presence of blood in the stool. Procedure:Only tumor biopsy can verify colorectal cancer, but other tests can help in detection. Digital examination of the rectum may be sufficient to detect rectal tumors. Testing the blood for liver enzymes and the tumor markers CEA and CA-19 is often done. Testing for occult blood in the stool, sigmoidoscopy, and colonoscopy to obtain a biopsy are helpful in detection. Ultrasound, MRI, and CT scanning help to show metastasis. Barium x-rays can locate lesions that are manually or otherwise visually undetectable. Treatment:Surgery to remove the tumor, adjacent tissues, and any affected lymph nodes is the treatment of choice. Chemotherapy and radiation therapy also may be used if the cancer has deeply perforated the bowel wall or metastasized. Carcinoembryonic antigen testing (see Chapter 5) is helpful in monitoring clients before and after treatments to detect metastasis or recurrence.

Crohn's Disease

Crohn disease, sometimes called regional enteritis or granulomatous colitis, is a serious, chronic inflammation, usually of the ileum, although it may affect any portion of the GI tract. Crohn disease is distinguished from closely related bowel disorders by its inflammatory pattern. The inflammation extending through all layers of the intestinal wall results in a characteristic thickening or toughening of the wall and narrowing of the intestinal lumen. The inflammation tends to be patchy or segmented. In Crohn disease, all layers of the intestine may be involved, with normal healthy bowel found between diseased sections of bowel. Crohn disease affects men and women equally and seems familial in nature. It is most often diagnosed in people between ages 20 and 30. S/S:include intermittent or steady abdominal pain in the right lower quadrant, diarrhea, lack of appetite, and weight loss. A variety of sores, fissures (grooves or deep furrows), or fistulas (abnormal tubelike passages) may appear in the anal area of some individuals. Procedure:Crohn disease is diagnosed by differentiating its characteristic pattern of inflammation from those of other bowel disorders. A thorough medical history is essential. Barium enema, colonoscopy, and stool sample may be necessary. Only a biopsy provides a definitive diagnosis. Treatment:Treatment of Crohn disease is symptomatic and supportive. Currently, there are five basic categories of medications used in the treatment of Crohn disease. Oral forms of mesalamine (the generic name for 5-aminosalicylic acid [5-ASA]) and sulfasalazine have been found beneficial in treating Crohn disease and in preventing relapses. Corticosteroids (given orally, rectally, or by injection) are given when symptoms are more severe. Immunomodulators help reduce the inflammatory response. Antibiotics can help control symptoms, reducing intestinal bacteria and suppressing the intestine's immune system. Biological therapies are targeted to particular enzymes and proteins that are abnormal in people with Crohn disease. Surgical treatment of the disease is usually reserved for managing complications, but colectomy (surgical removal of all or a portion of the colon) or ileostomy (surgically creating an opening in the ileum, bringing it to the abdominal surface for the purpose of evacuating feces) may be necessary in persons with extensive disease. About 70% of individuals with Crohn disease eventually require surgery.

hernias

There are several types of hernias. They occur when an organ or tissue squeezes through a weak spot in a muscle or connective tissue called fascia. The most common types covered here are hiatal, abdominal, and inguinal hernias. Other types include incisional hernias that result from an incision and the umbilical hernia near the belly button.hiatal hernia is the protrusion of some portion of the stomach into the thoracic cavity through the opening in the diaphragm through which the esophagus passes abdominal hernia is the protrusion of an internal organ, typically a portion of the intestine, through an abnormal opening in the musculature of the abdominal wall. Abdominal hernias are categorized according to the location of the herniation and include umbilical, inguinal, and femoral hernias (Fig. 14.10). Inguinal hernias are the most common type and occur in men more often than in women. S/S:Over half of hiatal hernias may remain asymptomatic. If symptoms are present, they commonly include heartburn—aggravated by reclining, belching, esophageal reflux or GERD, dysphagia, or severe pain if a large portion of the stomach is caught above the diaphragm. nguinal and umbilical hernias are evidenced by the appearance of a lump over the herniated area that tends to disappear when the person is supine. Sharp, steady, accompanying pain may be present in the groin. Strangulation of a herniated portion of the intestine will cause severe pain and can cause bowel obstruction. Strangulation of the intestine is considered a medical emergency. Procedure:Diagnosis of hiatal hernias is made by chest x-ray, barium x-ray, endoscopy and biopsy, and pH studies of any reflux (to eliminate the possibility of gastric ulcer).Physical examination reveals the herniated area. A medical history of sharp abdominal pain when lifting or straining also may help confirm the diagnosis. An x-ray or CT scan is ordered if bowel obstruction is suspected. Treatment:goal in treatment is to alleviate symptoms. Surgery is not the first choice of treatment unless strangulation of the hernia is evident or symptoms cannot be controlled.Umbilical hernias may require only taping or binding the affected area until the hernia closes. Femoral and inguinal hernias require reduction of the hernia and trussing the weakened portion of the abdominal wall. Herniorrhaphy and/or hernioplasty (possibly laparoscopically) are the corrective surgical procedures used.

Cirrhosis

a chronic, irreversible, degenerative disease of the liver characterized by the replacement of normal liver cells with fibrous scar tissue and other alterations in liver structure. The hepatic cells become necrotic, causing a change in liver structure that impairs the flow of blood and lymph. Scarring impairs the liver's ability to control infections; remove toxins from the blood; process nutrients, hormones, and medications; make proteins to regulate blood clotting; and produce bile to help emulsify fats. Hepatic insufficiency results. S/S:person may be asymptomatic for a prolonged period, or symptoms may be vague or unspecific. Symptoms may include nausea, vomiting, anorexia, dull abdominal ache, weakness, fatigability, weight loss, pruritus, peripheral neuritis, bleeding tendencies, edema of the legs, ascites (accumulation of fluid in the peritoneal cavity), and jaundice. Jaundice is a condition characterized by a yellowish discoloration of the skin, whites of the eyes, and bodily fluids that results from the accumulation of bilirubin in the blood. Procedure:Palpation reveals the liver to be enlarged and firm—if not hard—with a blunt edge. Laboratory findings may reveal anemia, folate deficiency, blood loss, and a rupturing of red blood cells with the resulting release of hemoglobin into the plasma, a process called hemolysis. Liver enzymes (alanine aminotransferase [ALT] and aspartate aminotransferase [AST]) are assayed to check for elevated enzyme levels. The bilirubin level will also be increased. CT scan, ultrasound, or magnetic resonance imaging (MRI) may be ordered. Treatment:Treatment is aimed at what is causing the cirrhosis in an attempt to prevent further liver damage. Adequate rest and diet are essential, as is restriction of alcohol. Vitamin and mineral supplements may be prescribed. In the event of gastric upset or internal bleeding, antacids may be given. If there is ascites, the fluid is removed with the use of diuretics or through paracentesis. Liver transplantation may be an option for persons with end-stage liver disease. There is a 1- and 5-year survival rate of 70% and 60%, respectively. However, more than 17,000 people in the United States have been approved and are waiting for a liver transplant, and fewer than 6,500 liver transplants will be performed.

peptic ulcer

an be found in the lower esophagus, the stomach, the pylorus, the duodenum, and the jejunum. However, these ulcers, or circumscribed lesions in the mucous membrane, are most likely found in the stomach and duodenum. S/S:Persistent "heartburn" and indigestion are the classic symptoms; there may be nagging stomach pain as well. GI bleeding, hematochezia (bright red bloody stools), nausea, vomiting, and weight loss can occur. The chronic, periodic heartburn pain may radiate into the back region. Often, a peculiar sensation of hot water bubbling in the back of the throat occurs. The symptoms of both gastric and duodenal ulcers appear about 2 hours after eating or after consuming orange juice, caffeine, alcohol, or aspirin. Although most peptic ulcers are small, they can cause a considerable amount of discomfort. Procedure:Diagnosis is made by EGD or upper GI barium swallow. Laboratory analysis to detect minute quantities of blood or occult blood in stools, serological testing to determine clinical signs of infection, studies of gastric secretions that show hyperchlorhydria, and a carbon 13 (13C) urea breath test result will reflect activity of H. pylori. Treatment:It is recommended that every person with an ulcer be treated at least once to eradicate H. pylori infection. Antibiotics prescribed to treat H. pylori include amoxicillin (Amoxil), clarithromycin (Biaxin), and metronidazole (Flagyl). Individuals who require NSAIDs may be given a prostaglandin analog to suppress ulceration, or a change of medication is ordered. Medications may be given to reduce acid secretion. Antacids and PPIs are likely prescribed. If GI bleeding occurs, EGD will reveal the site of bleeding, and coagulation by laser or cautery will control the bleeding. Surgery is indicated for perforation, suspected malignancy, or when conservative treatment is unsuccessful.

hemmorrhoids

are dilated, tortuous veins in the mucous membrane of the anus or rectum. They are common and usually insignificant unless they bleed or cause pain and itching. There are two kinds: external hemorrhoids, those involving veins below the anorectal line, and internal hemorrhoids, those involving veins above or along the anorectal line. About 50% of adults over age 50 have hemorrhoids, and they are common among pregnant women (Fig. 14.8). S/S:rectal bleeding, pruritus, and vague discomfort. In some cases, the hemorrhoids may protrude from the anus. There may be a discharge of mucus from the rectum, too. Procedure:Physical examination will reveal external hemorrhoids. Proctoscopy will reveal internal hemorrhoids and rule out rectal polyps. If there is significant bleeding, red blood cell and hemoglobin levels may be low. Treatment:generally includes measures to ease pain and discomfort such as taking warm sitz baths. A high-roughage diet and using stool softeners also may be recommended. Over-the-counter suppositories and creams can calm inflammation. Protruding hemorrhoids may be reduced manually with a lubricated gloved finger, by ligation, by sclerotherapy, or by cryosurgery. In the event of severe complications or chronic discomfort, complete internal or external hemorrhoidectomy may be advised.

Pancreatitis

inflammation of the pancreas, may occur in acute or chronic forms. In this disease, pancreatic enzymes that normally remain inactive until reaching the duodenum begin digesting pancreatic tissue, causing varying degrees of edema, swelling, tissue necrosis, and hemorrhage. The pancreas is both an exocrine and endocrine organ; thus, if the islet cells are damaged, diabetes mellitus results (see Chapter 11). The disease can be mild and self-limiting or chronic and fatal. It is more common in men than in women. S/S:only symptom of mild pancreatitis is steady epigastric pain. The most important symptom of acute pancreatitis is the sudden onset of severe, persistent abdominal pain that is centered over the epigastric region and that may radiate toward the back. The abdomen is tender. Severe attacks of acute pancreatitis also may cause abdominal distention, persistent vomiting, fever, and tachycardia. Vital signs show rapid, shallow respirations, a fall in blood pressure, and an elevated temperature. Someone with acute pancreatitis usually looks and feels very ill and needs immediate medical attention. Procedure:clinical history of acute onset of the characteristic abdominal pain may suggest the diagnosis. A blood test revealing an elevated level of the enzyme amylase in the serum generally confirms the diagnosis and rules out many other disorders. Abdominal or endoscopic ultrasonography and abdominal CT scans may reveal pancreatic enlargement and bile duct involvement. Magnetic resonance cholangiopancreatography (MRCP) may be ordered. MRCP allows the provider to visualize the pancreas, gallbladder, and pancreatic and bile ducts. Treatment:is largely symptomatic but may require hospitalization. The aim is to maintain circulation and fluid volume, decrease pain and pancreatic secretions, and control any complications. Treatment for acute pancreatitis requires IV fluids, antibiotics, and medication to relieve pain. The person should refrain from eating or drinking as much as possible for a few days to allow the pancreas to rest and recover. Unless complications arise, acute pancreatitis usually resolves in a few days. In severe cases, the person may require nasogastric feeding—a special liquid given in a long, thin tube inserted through the nose and throat and into the stomach—for several weeks while the pancreas heals.

ulcerative colitis

is a chronic inflammation and ulceration of the colon, often beginning in the rectum or sigmoid colon and extending upward into the entire colon. Ulcerative colitis and Crohn disease are often referred to as inflammatory bowel disease (IBD). Ulcerative colitis is distinguished from closely related bowel disorders by its characteristic inflammatory pattern. The inflammation involves only the mucosal lining of the colon, which exhibits erythema and numerous hemorrhagic ulcerations. In addition, the affected portion of the colon is uniformly involved, with no patches of healthy mucosal tissue evident (compare with Crohn disease). Together, ulcerative colitis and Crohn disease affect approximately 500,000 to 2 million people in the United States. Men and women are affected equally. S/S: classic symptom is recurrent bloody diarrhea, often containing pus and mucus, accompanied by abdominal pain and severe urgency to move the bowels. Other symptoms may include fever, weight loss, and signs of dehydration. There is a tendency toward periodic exacerbation and remission of symptoms. Procedure:The disease is diagnosed by the characteristics of the inflammatory process. Sigmoidoscopy may reveal the mucosal lining to be friable (easily broken or pulverized) with thick, inflammatory exudate. Colonoscopy may be necessary to determine the extent of the disease. A biopsy may be done at the same time to rule out carcinoma. Treatment:treatment program generally includes measures to suppress the inflammatory response, permit healing, and relieve the symptoms. Treatment of ulcerative colitis with medications is similar, though not always identical, to treatment of Crohn disease. Medications used to treat ulcerative colitis include (1) anti-inflammatory agents, such as 5-ASA compounds, systemic corticosteroids, topical corticosteroids in the form of suppositories, liquid or foam enemas, and (2) immunomodulators. Sulfasalazine (a compound derived from sulfapyridine and 5-ASA) is an effective anti-inflammatory agent used for mild to moderate episodes of ulcerative colitis. Oral forms of 5-ASA compounds appear to be effective in treating active ulcerative colitis and in preventing relapses. Corticosteroid treatment is also effective against ulcerative colitis. Surgical excision or resection of the entire colon is reserved for management of serious complications. This procedure necessitates an ileostomy. Removing or reducing all products with linoleic acid in the diet may prove beneficial for some clients.

irritable bowel syndrome (IBS)

is a complex group of symptoms marked by abdominal pain and altered bowel function—typically constipation, diarrhea, or alternating constipation and diarrhea—for which no organic cause can be determined. The disorder is chronic, with the onset of symptoms usually occurring in early adulthood and lasting intermittently for years. IBS is a frequently occurring GI disorder in the United States. Its management often proves frustrating to clients and providers alike. S/S:hallmark of IBS is abdominal pain with constipation or with constipation alternating with diarrhea. The totally diarrheal form of IBS is often painless. Heartburn, abdominal distention, back pain, weakness, and faintness also may accompany the primary symptoms. Stool may be reported as mucus covered. Symptoms usually are experienced as acute attacks that subside within 1 day, but recurrent exacerbations are likely. Women are more likely to have IBS during menstruation. Procedure:chronic, intermittent nature of the symptoms without obvious cause suggests the diagnosis; however, IBS must be differentiated from other GI diseases. A careful client history, especially of psychological factors, is essential. A complete blood cell count and stool examination for occult blood, ova, parasites, and pathogenic bacteria will help rule out closely related conditions. Colonoscopy, sigmoidoscopy, barium enema, and rectal biopsy may provide similarly useful information. Treatment:no one successful treatment for controlling IBS. Dietary modification may be attempted, such as avoiding irritating foods or adding fiber if constipation is a symptom. Diet guidelines include avoiding caffeine and alcohol; limiting intake of fatty foods, dairy products, and artificial sweeteners; increasing fiber in the diet; and avoiding beans, cabbage, and uncooked cauliflower and broccoli. Clients are advised to get adequate sleep and exercise and alleviate as much stress as possible. A sedative or an antispasmodic drug may be ordered.

appendicitis

is an inflammation of the vermiform appendix due to an obstruction. Between 7% and 8% of individuals in the United States have appendicitis each year. S/S:Pain usually starts near the belly button and moves slowly down to the lower right quadrant. The classic symptoms are generalized abdominal pain followed by pain localized in the upper right quadrant. Nausea, vomiting, and anorexia will likely occur. The pain eventually settles over the appendix in the right lower abdomen (McBurney point) with "boardlike" rigidity, increased tenderness, and abdominal spasms (Fig. 14.7). Fever, malaise, diarrhea or constipation, and tachycardia are among the later symptoms. Procedure:Physical examination and the characteristic symptomatology generally indicate appendicitis. Tenderness on pressure at the McBurney point and the client's ability to pinpoint the area of maximum tenderness are the strongest diagnostic indicators of appendicitis. Laboratory findings may reveal leukocytosis and pyuria. CT scan of the abdomen and pelvis can evaluate abdominal pain suspected of being caused by appendicitis. Ultrasound can identify enlarged appendix abscesses and is commonly used in small children to test for appendicitis. Children with appendicitis have a biomarker in their urine, leucine-rich alpha-2 glycoprotein (LRG) that may indicate acute appendicitis. A simple urine test, rather easy to obtain, would make diagnosis for children much easier. Studies need to be conducted to determine if the same biomarker is found in adults. Treatment:Appendectomy is the only recommended treatment for acute appendicitis.

Diverticulitis

is the acute inflammation of the small, pouchlike herniations in the intestinal wall. The presence of diverticula (diverticulosis) usually produces no symptoms; rather, it is the rupture and infection of the diverticula that produces the clinically significant condition. S/S:usually exhibits no symptoms. The symptoms of diverticulitis vary from case to case in both intensity and duration. If a diverticulum ruptures, the bacteria within the colon spread into the tissues surrounding the colon, causing diverticulitis. Such an attack is characterized by fever, and there is pain in the left lower abdomen that is relieved following a bowel movement and/or flatulence. Abdominal muscle spasms, guarding, and tenderness may occur. The person usually experiences alternating constipation and diarrhea. Procedure:Abdominal x-rays, computed tomography (CT) scan, and stool specimen examination may be sufficient for diagnosis. A barium enema or a colonoscopy may be attempted but not if the disease is in the active phase because of the possibility of perforation and hemorrhage. Treatment:Treatment of uncomplicated diverticular disease consists of a high-residue diet that includes bran, bulk additives, and stool softeners. Antibiotics or anticholinergic drugs may be ordered for diverticulitis. Anticholinergic drugs inhibit the action of the neurotransmitter acetylcholine, blocking parasympathetic nerve impulses, with consequent reduction in smooth muscle contractions and various body secretions. If diverticular disease is not relieved by conservative treatment and if perforation or hemorrhage occurs, hospitalization, surgery, and blood transfusions may be necessary. Surgery usually involves a colon resection with a temporary colostomy while the colon heals.

GASTROESOPHAGEAL REFLUX DISEASE (BARRETT ESOPHAGUS)

is the backup of gastric or duodenal contents into the esophagus and past the lower esophageal sphincter (LES) without belching or vomiting. The liquid contents can inflame and damage the lining of the esophagus. About one-third of Americans have GERD. S/S:symptoms may not always be present (especially in older clients), and it is not always possible to confirm physiological reflux. The most common symptoms, however, are heartburn, regurgitation, and nausea. For some, the first sign of GERD is a dry cough and laryngitis, or what is now called reflux laryngitis. Symptoms may be relieved by taking antacids or by sitting upright and are worsened by vigorous exercise, bending, or lying down. Procedure:areful history and physical examination, medications to suppress the production of stomach acid are given. If the heartburn diminishes, the diagnosis of GERD is confirmed. Further tests to determine GERD include upper GI endoscopy, esophageal acid testing, esophageal probe, and esophageal manometry. Recurrent GERD after 6 weeks is abnormal. An acid perfusion test (Bernstein) can show reflux, but endoscopy and biopsy allow visualization and confirmation of any pathological changes in the mucosa. Treatment:Decreasing esophageal irritation is helpful. This can be partially accomplished by eating low-fat, high-fiber foods and avoiding caffeine, tobacco, alcohol, chocolate, peppermint, and carbonated beverages. Elevating the head portion of the bed may decrease night symptoms. It is best to eat several small meals instead of two or three large meals. Antacids can neutralize gastric acid and relieve heartburn. Proton pump inhibitors (PPIs), a group of medications that decrease the amount of acid in the stomach and intestines, may be prescribed. Metoclopramide is a GI stimulant that improves gastric emptying and increases LES pressure. Surgery that creates an artificial closure of the gastroesophageal junction may be necessary in severe cases that do not respond to other treatment.

Cholecystitis

is the formation or presence of stonelike masses called gallstones within the gallbladder or bile ducts. These stones may be formed of either cholesterol or calcium-based compounds and range from a few millimeters to a few centimeters in size. Cholelithiasis is a common condition in the United States, with women affected more than twice as frequently as men, until after age 50, when men and women are equally affected. Most individuals with gallstones remain asymptomatic. Clinically significant symptoms result when a gallstone obstructs a biliary duct. Acute cholecystitis is a severe inflammation of the interior wall of the gallbladder. S/S: many individuals with gallstones remain asymptomatic. If bile ducts are obstructed, a classic "gallbladder attack," more properly referred to as biliary colic, results. The telltale symptom is the acute onset of upper right quadrant abdominal pain radiating to the shoulder and back. Nausea and vomiting may accompany the attack. Flatulence, belching, and heartburn also may occur at intervals. Gallbladder attacks typically tend to follow ingestion of large meals or fatty foods. The pain and other symptoms of an attack gradually subside on their own over a period of several hours. characteristic symptom of acute cholecystitis is the gradual onset of upper right quadrant pain that usually remains localized over the area of the gallbladder. Unlike the pain of biliary colic, which ceases once the gallstones are passed, the pain of acute cholecystitis does not tend to subside after a few hours. Anorexia, nausea, vomiting, and a low-grade fever and chills also may accompany the pain. The pain may be severe enough to cause an individual to seek emergency treatment. Procedure:clinical history of the characteristic pain of biliary colic suggests a diagnosis of gallstones. Various methods of visualizing the stones are used to provide a definitive diagnosis, typically including a gallbladder ultrasound, oral cholecystogram, IV cholangiogram, or a plain abdominal x-ray. A hepatobiliary iminodiacetic acid (HIDA) scan tracks production and flow of bile through the small intestine and will show any blockage. If the common bile duct is obstructed, the serum bilirubin is elevated. Oral cholecystography shows stones in the gallbladder and biliary duct obstruction. Treatment:Hospitalization is often required. If the condition is asymptomatic, treatment is nonsurgical unless the symptoms appear or there is a history of previous gallstones with complications. Bowel rest, analgesia, and IV antibiotics and hydration may be necessary. In elective surgery, a laparoscopic cholecystectomy is performed. Cholecystectomy is the treatment of choice for symptomatic cholelithiasis. A nonsurgical treatment involves insertion of a flexible catheter, guided by fluoroscopy, directly to the stone. A Dormia (stone) basket is threaded through the catheter, opened, and twirled to entrap the stone. It is then closed and withdrawn. Another nonsurgical option is extracorporeal shock wave lithotripsy with litholytic therapy that fragments the stones. Still another nonsurgical approach involves dissolving cholesterol-based stones through bile acid therapy. This therapy inhibits the synthesis and secretion of cholesterol within the liver, altering the composition of the bile. Existing stones may be decreased in size or dissolved entirely.

pancreatic cancer

is usually an adenocarcinoma that occurs most frequently in the head of the pancreas. Pancreatic cancer is a leading cause of cancer deaths in the United States. The highest incidence is among people ages 60 to 70. S/S:The classic symptoms are abdominal pain that may radiate to the back, anorexia, jaundice, and weight loss. Other symptoms include weakness, fatigue, diarrhea, nausea and vomiting, and low-back pain. If the disease affects the islets of Langerhans, symptoms of insulin deficiency appear. These symptoms include glucosuria; hyperglycemia, or abnormally high levels of sugar in the blood; and glucose intolerance. Procedure:Percutaneous needle aspiration biopsy of the affected portion of the pancreas is used to confirm the diagnosis. Ultrasonography, CT scanning, MRI, and endoscopic retrograde cholangiopancreatography (ERCP) are useful in establishing a diagnosis. X-ray series and blood tests may be ordered to help in staging the cancer. Treatment:Treatment for pancreatic cancer depends on the stage, the location of the cancer, the person's age, and overall health. Treatment quite often is palliative because most pancreatic cancers are diagnosed after they have metastasized to the lungs, liver, and bones. If surgical resection is possible, localized tumors are removed. Radiation therapy and multidrug chemotherapy may be administered, but pancreatic carcinomas usually respond poorly. It is important to manage the pain and to correct any nutritional defects.

CELIAC DISEASE (GLUTEN-INDUCED ENTEROPATHY)

or gluten-induced enteropathy, is a disease of the small intestine marked by malabsorption, gluten intolerance (gluten is a protein found in wheat, barley, and rye), and damage to and characteristic changes in the mucosal lining of the intestine. Because of the gluten intolerance characterizing celiac disease, it is sometimes referred to as gluten-induced enteropathy, a disease of the intestine. The incidence of celiac disease is high among siblings. More than 3 million individuals in the United States are afflicted. S/S:may include weight loss, anorexia, abdominal distention, flatulence, intestinal bleeding, peripheral neuritis, dermatitis, and muscle wasting. The condition is also marked by the passage of abnormally large diarrheal stools that are characteristically light yellow to gray, greasy, and foul smelling. The resultant chronic malnutrition may cause mineral depletion that may be revealed in the musculoskeletal system as bone pain; tenderness; compression deformities; and sharp, painful, periodic muscle contractions called tetany. Anemia from the poor absorption of folate, iron, and vitamin B12 can also be a symptom. Neurological effects may include neuropathy and seizures. Dry skin, eczema, and psoriasis can be the result of celiac disease. Amenorrhea and hypometabolism are endocrine symptoms. Procedure:disease often is difficult to diagnose and to differentiate from other intestinal disorders. An initial serological test followed by biopsy is recommended. The serology includes testing for antigliadin antibodies (IgA), antiendomysium antibodies (EMA), and tissue transglutaminase (tTG) antibody to screen persons suspected of having celiac disease. If these antibody tests are positive, there is a 99.6% chance that the individual has celiac disease, and a biopsy is ordered to confirm the diagnosis. For a definitive diagnosis of celiac disease, the following are necessary: biopsy of the small intestine indicating destruction of the villi, tiny fingerlike projections lining the interior of the small intestine that absorb fluid and nutrients, and remission of symptoms and improvement in the condition of the villi after the institution of a gluten-free diet. Treatment:consists of lifelong strict adherence to a gluten-free diet. A few persons who do not experience improved small bowel function after instituting a gluten-free diet may be treated with corticosteroid drugs. Supportive treatment may include supplemental iron, vitamin B12, and folic acid. Research is currently under way to develop medications that prevent an immune response to gluten and block the action that makes the intestine permeable. Microbiome also plays a role in celiac disease. It is believed that the variance of microbiome from person to person enables many to go undetected for years. The microbiome seem able to influence which genes are active at any given time, thus allowing some to tolerate gluten for many years and then suddenly lose that ability, causing celiac disease to develop.