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An Atlas of
Gastroenterology
A Guide to Diagnosis and Differential Diagnosis
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THE ENCYCLOPEDIA OF VISUAL MEDICINE SERIES
An Atlas of
GASTROENTEROLOGY
A Guide to Diagnosis and Differential Diagnosis
Cyrus R. Kapadia,
MD
Professor of Medicine and Director of the Internal Medicine Residency Training Program,
Department of Internal Medicine, Section of Digestive Diseases,
Yale University School of Medicine, CT
Caroline R. Taylor,
MD
Associate Professor, Department of Diagnostic Radiology,
Yale University School of Medicine;
Chief, Diagnostic Imaging, VA Connecticut Health Care System, CT
and
James M. Crawford, ,
MD PhD
Professor and Chair, Department of Pathology,
Immunology and Laboratory Medicine,
University of Florida College of Medicine, FL
CRC Press
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Contents
Preface 7
1 The patient with difficulty or pain during swallowing 9
2 The patient with heartburn 19
3 The dyspeptic patient 23
4 The patient with chronic diarrhea 35
5 The patient with abdominal pain and weight loss 55
6 Chronic anemia as a presentation of gastrointestinal disease 65
7 The patient with acute rectal bleeding 87
8 Maladies due to gallstones and things that may mimic them 97
9 The acute abdomen – a pot-pourri 119
Gastroenterology illustrated 147
Index 275
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Preface
All too often in medical education the word atlas diagnosis, and the differential diagnoses considered on
conjures up a mental image of a book containing pretty the way, clearly stated. The authors recognize that the
pictures. Gastroenterology lends itself readily to a com- explosion of technology in medicine, which has not
pilation of neat endoscopic and radiological illustra- escaped the practice of modern gastroenterology, has
tions for the reader to behold and perhaps to use as an greatly enhanced the ability of the clinician to arrive at
aid to the future recognition of the illustrated entities. a diagnosis more rapidly than in years gone by. There
That is not the purpose of the present atlas. The can be no doubt that technology has been a great boon
authors much prefer to assign the word a richer mean- to patient and doctor alike. However, it has not come
ing, one perhaps not as celestial as the Homeric conno- without cost. The cost is not only one that is measured
tation, nevertheless one that implies more than a mere in pounds sterling or dollars, but it has come at the
collection of colorful illustrations. The authors do not great risk of the temptation to sacrifice one’s clinical
make pretensions to their work being any more schol- reasoning at the altar of technology. One of the main
arly or even more utilitarian than the conventional atlas aims of the authors has been to encourage the prudent
of endoscopy or gastrointestinal radiology. Indeed, such use of recent technology, but to stress the importance
atlases have a very important educational role and pro- of the invaluable encounter at the bedside which ought
vide valuable learning experiences for gastroenterol- to serve as the basis for ordering laboratory and imag-
ogists. All they wish to state is that this work is different. ing studies. The importance of pathology to the prac-
As the subtitle to this book states without apology, this is tice of medicine is recognized and presented in a way
A Guide to Diagnosis and Differential Diagnosis. to meet the needs of the clinician. Above all, the
The table of contents of this atlas is quite unlike that authors are convinced that the practitioner who
of other atlases in gastroenterology and, in fact, quite ignores developments in the basic sciences does so at
unlike that of a textbook on the subject. The reader will his or her own peril and does not serve his or her
notice that it is patient-focused and deals with common patient well. Yet, textbooks of medicine and medical
gastrointestinal symptoms and symptom complexes journals often assume a more sophisticated under-
seen by physicians, physicians assistants and nurse prac- standing of the ever-expanding knowledge in the basic
titioners of all kinds, whether they be practitioners of sciences than can reasonably be expected from those
internal or family medicine or subspecialists, such as engaged in the busy practice of medicine. The authors
gastroenterologists and even surgeons. In fact, the have tried to the best of their ability to present recent
authors hope that several chapters will be of interest to concepts in pathophysiology without complexity and
their surgical colleagues as well. The authors have also as far as possible using illustrations. The only reward
had in mind the needs of house-officers, fellows and they seek is that their readers will have as much fun
registrars in a variety of disciplines as they grapple to browsing through this atlas, as they have had putting
make sense out of what their patients tell them. it together.
The information is presented largely using a series of
case histories, with the reasoning used to arrive at the Cyrus R. Kapadia, MD
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CHAPTER 1
The patient with difficulty
or pain during swallowing
The two major symptoms associated with swallowing Table 1.1 Problems with the oral phase of deglutition
recognized by patients are: difficulty swallowing (dys-
Poor dentition
phagia) and painful swallowing (odynophagia). Of Lesions of mouth or tongue
course, dysphagia and odynophagia may on occasion be Little or no saliva
medications with anticholinergic properties
present together.
Sjögren’s syndrome
DYSPHAGIA
Dysphagia may occur because of problems with the
Table 1.2 Causes of neuromuscular or transfer dysphagia
oral, pharyngeal or esophageal phases of deglutition.
Strokes – cortical,subcortical,brainstem
Tumor – brainstem
ORAL PHASE Progressive bulbar palsy
Degenerative – e.g.multiple sclerosis
Problems with the oral phase of deglutition are shown
Extrapyramidal lesions – e.g.Parkinsonism
in Table 1.1. Cranial neuropathies
Myasthenia gravis
Clinical characteristics Bulbar poliomyelitis
Dermatomyositis,polymyositis
The patient is unable to prepare a suitable bolus in Myotonia dystrophica
order to swallow, resulting in difficulty in the passage of Occulopharyngeal dysphagia – ptosis and dysphagia
the bolus into the pharynx. Aspiration may occur.
Diagnosis This is established clinically by history and
Clinical characteristics
physical examination.
The patient complains of a severe sore throat with
or without systemic symptoms and pharyngitis, or
PHARYNGEAL PHASE
a retropharyngeal abscess is obvious on clinical
Problems with the pharyngeal phase of deglutition
examination.
occur because of either mechanical or neuromuscular
impediments. Diagnosis This is established by examination of the
mouth and pharynx for pharyngitis or a retropharyngeal
abscess.
Mechanical
Mechanical problems with the pharyngeal phase of
Neuromuscular or transfer dysphagia
deglutition can result from severe pharyngitis or a
retropharyngeal abscess. This can result from various causes (Table 1.2).
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AN ATLAS OF GASTROENTEROLOGY
Clinical characteristics of transfer dysphagia Table 1.3 Mechanical disorders involving the esophageal
phase of deglutition
Transfer dysphagia is the inability to transfer the bolus
from the mouth or pharynx into the esophagus. Upper third of the esophagus
Zenker’s diverticulum
Difficulty is greater with liquids than with solids. There
Webs (when in association with koilonychia and iron
can be nasal regurgitation. As a consequence, patients
deficiency anemia,this is called the Plummer–Vinson or
are likely to aspirate liquids, and perhaps solids as well, the Kelley–Patterson syndrome)
into the lungs and develop pneumonia and a lung Cervical spine osteophyte (spur)
Thyromegaly
abscess.
Dysphagia lusoria – aberrant right subclavian artery
Dysphagia aortica – aortic enlargement or aneurysm
Diagnosis of aspiration This is established by: history,
Squamous cell carcinoma – post-cricoid carcinoma
as above – often a history of repeated episodes of aspira-
Foreign body
tion pneumonia; videoesophagogram or pharyngeal
Middle third of the esophagus
intubation study (Figure 1.1). Right-sided aorta
Diverticula
Barrett’s esophagus
ESOPHAGEAL PHASE
Squamous cell carcinoma
Foreign body
Problems with the esophageal phase of deglutition
occur as a result of mechanical or motility disorders. Lower third of the esophagus
Diverticula – epiphrenic
Clinical characteristics of esophageal causes of dysphagia
Peptic stricture – from gastroesophageal reflux disease or
depend upon whether the cause is secondary to a mechani-
scleroderma
caldisorder or a motility disorder. In the case of mechani- Benign ulcer – frequently in Barrett’s epithelium
cal disorders, solid food dysphagia always antecedes Squamous cell cancer
Adenoma carcinoma arising from Barrett’s epithelium
dysphagia due to liquids. When the dysphagia is secondary
Adenoma carcinoma of the gastric cardia
to a peptic stricture or esophageal squamous or adeno- Foreign body
carcinoma, the solid food dysphagia is progressive, present
Diffuse
with most meals unless the food is pureed and eventually Lesions described under Odynophagia
leads to liquid dysphagia. The dysphagia due to a lower
esophageal ring is intermittent and frequently follows Case history 1
the rapid ingestion of a bolus of meat or even bread. In
A 60-year-old Caucasian man presents with a history of
contrast, symptoms in motility disorders arise as often
dysphagia for the past 8 months. He first noticed diffi-
with liquids as with solids, although the patient may
culty with eating an apple, then with foods such as roast
perceive more problems with one or the other.
beef, over the past month with scrambled eggs and
mashed potatoes, and now even has to swallow liquids
Mechanical disorders slowly and feels them ‘hold up’ before they go down. He
has not had chest pain. He has had moderate heartburn
Mechanical disorders causing problems with the
over the years, usually taken care of by antacid tablets
esophageal phase of deglutition are shown in Table 1.3.
taken when necessary, although he has off-and-on taken
Diagnosis H receptor antagonists. Barium swallow revealed an
2
irregular, ulcerated circumferential mass in the lower
A barium swallow will most often identify the cause.
third of the esophagus causing dilatation proximally.
Early carcinomas can be missed if a barium marshmallow
Endoscopy revealed narrowing of the lumen of the distal
or barium soaked in bread is not administered to deter-
third of the esophagus with ulceration. Biopsy revealed
mine whether there is a hold-up in the passage of the
an adenocarcinoma (Figures 1.2, 1.3 and 1.4).
bolus. A barium swallow is not generally indicated prior
to the removal of a foreign body, although a chest X-ray is.
Endoscopy is almost always performed, even when Case history 2
the diagnosis is clear on a barium study. The two pro- A 66-year-old Caucasian man has a history of dyspha-
vide complementary information; when a tumor or gia over the past year, rather similar in terms of its
stricture is present, endoscopic biopsies and cytology progression to that in Case history 1. This patient,
are obtained. however, had a history of heavy smoking and alcohol
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THE PATIENT WITH DIFFICULTY OR PAIN DURING SWALLOWING
consumption. The barium swallow revealed a long anemia of any etiology). The cause of the iron
irregular stricture in the mid-esophagus with proximal deficiency is not well understood. The Kelley–Patterson
esophageal dilatation. Biopsy upon endoscopy revealed syndrome is seen in northern latitudes (Scotland,
an esophageal stricture (Figures 1.5 and 1.6). Sweden, Nova Scotia, Minnesota), and occurs more
commonly in women. The patient reports the food
Esophageal carcinoma For years squamous cell cancer being stuck just below the throat, at the site of the ring.
was more common than adenocarcinoma. Taken
worldwide, that statement is still true. However, in Case history 4
Western countries over the past 10 years, adenocarci-
An 80-year-old man presented with dyspeptic symp-
noma, probably arising from Barrett’s epithelium, is
toms and refused an endoscopy. A barium swallow
increasing in prevalence among middle-aged Caucasian
was ordered and, in addition to gastroesophageal
males. It therefore appears to be related to chronic
reflux, an incidental finding was a Zenker’s diverti-
gastroesophageal reflux. Squamous cell cancer, in con-
culum (Figure 1.8).
trast, has been associated with heavy smoking and alco-
hol consumption, frequently both, as well as with Esophageal diverticulum Esophageal diverticula are of
tobacco chewing. Cancers of the esophagus tend to three types:
arise in the upper, middle or lower third of the esophagus.
(1) Upper esophageal – Zenker’s diverticulum.
The hallmarks of the disease are:
(2) Mid-esophageal – at the level of the hilum of the
(1) Progressive solid food dysphagia. Ultimately diffi- lung. These are rare. They were thought in the
culty with liquids also arises and patients may not past to be ‘traction’ diverticula, pulled by inflam-
even be able to swallow their own saliva. mation in the mediastinum, as in tracheobronchial
tuberculosis.
(2) Dysphagia that is not intermittent. Each time food
of a certain size and consistency is eaten, the (3) Lower esophageal – epiphrenic diverticulum (see
patient experiences dysphagia. For example, some- Case history 9) (Figure 1.9).
one who has difficulty with apples or roast beef has
In Zenker’s diverticulum, an area of weakness is nor-
trouble with apples and roast beef each time they
mally present in the posterior part of the pharynx
eat it. If at the next meal they eat softer and more
between the oblique fibers of the inferior constrictor and
pureed food, they might not experience difficulty.
the horizontal fibers of the cricopharyngeus muscle. This
area of weakness is called Killian’s dehiscence. During
Case history 3
swallowing, normally the cricopharyngeus opens easily.
A 42-year-old man underwent a barium swallow for a
However, if for some reason it is tight or does not relax
complaint of solid food occasionally sticking in the
physiologically, pressure is transmitted in all directions.
region just below his sternal notch, at times causing
On account of Killian’s dehiscence a small portion of the
him to choke. The symptoms occurred intermittently, esophageal wall protrudes like a hernia and forms a
were not progressive and had been present for some
diverticulum. This is the proposed mechanism.
years. The barium swallow (Figure 1.7) shows an upper
A Zenker’s diverticulum may be asymptomatic, as in
esophageal web. The patient’s problems were no longer
the patient described here. In this patient the diverti-
present after he underwent esophageal bougienage.
culum was discovered when a barium study was ordered
for the investigation of dyspeptic symptoms. On the
Esophageal webs Most often a web is seen in the upper
other hand, many patients are very symptomatic
part of the esophagus, anteriorly, as an isolated finding
(Figure 1.10).
of unknown etiology. A web may give rise to solid food
dysphagia that is either not progressive or very slowly
Case history 5
progressive. A rare syndrome, (the Kelley–Patterson
syndrome, also termed Plummer–Vinson syndrome), A 40-year-old man presents to the emergency depart-
is the presence of a web together with iron deficiency ment of the hospital with acute dysphagia. He was at a
anemia and associated koilonychia (i.e. spoon-shaped buffet dinner party, had been drinking moderately and
nails that are seen with severe chronic iron deficiency ‘having fun with the boys’. He thinks he took a rather
11
