In older patients, the major disorders of the pancreas are injuries from blunt trauma, gallstone pancreatitis, and cancer. Exocrine and endocrine neoplasms of the pancreas are discussed in Ch. 60. Traumatic Injury Diagnosing and treating penetrating wounds present no problems. However, diagnosing an injury from blunt trauma is often difficult, and the treatment is controversial. [...]
In the elderly, the most common hepatic lesion requiring surgery is metastatic cancer. (Cirrhosis and its complications are more common in younger persons.) Because hepatic surgery is not well tolerated in the elderly, heroic measures that might enable long-term survival but that carry a high mortality rate are not attempted frequently. Hepatic neoplasms are discussed [...]
The differential diagnosis of jaundice is extensive, and many diagnostic methods are available. The first task is to determine whether jaundice is obstructive. Often, the history is helpful, and the physical examination can give important information. A symmetrically enlarged liver in an alcoholic usually results from cirrhosis; in a temperate or abstaining elderly person, from [...]
Fistulas form between the gallbladder and the intestine, allowing gallstones to migrate and causing intestinal obstruction. Patients usually present with signs of distal small-bowel obstruction, often with tenderness over the gallbladder. Abdominal x-ray may show the stone and usually shows gas in the biliary tree. The proper surgical procedure is removal of the stones (if [...]
\hese stones arc common, particularly if multiple hepatic duct stones were found during the initial exploration. The surgeon prepares for this possibility in questionable cases by placing a large T-tube (No. 14 French) lo drain the common duct. The radiologist can extract the stones later. As mentioned above, endoscopic removal also is feasible.
This condition tends to occur in patients in intensive care units and in those whose oral intake is poor (eg, because of total iy alimentation). Symptoms are minimal. Unexplained lever and vague abdominal distress warrant ultrasound examination of the gallbladder, which may show edemaof the gallbladder wall and increasing distention on successive examinations. Either cholecystectomy [...]
A sinus tract between the rectum and the skin. Fistulas form for several reasons. The most common follow inflammation in rectal crypts or glands, progressing to perirectal abscesses that track internally into the rectum and externally to the skin. Other diseases (eg. Crohn’s disease, tuberculosis, and lymphogranuloma) may involve the rectum and cause fistulas. Intraperitoneal [...]
Patients present with symptoms and signs similar to those of acute cholecystitis, except that the pain is more likely to be epigastric and is associated with elevated serum amylase levels and often with increased bilirubin and alkaline phosphatase levels. Initial treatment is conservative with the patient taking nothing by mouth and receiving IV alimentation. Typically, [...]
Localized collections of pus in cavities resulting from infections, followed by tissue disintegration. Perianal abscesses are located close to the anus and are relatively superficial; ischiorectal abscesses are deep and located at a higher level. perianal abscesses, the more common type, usually develop from inflammation of glands located between the sphincters at the dentate line [...]
Abnormally large or symptomatic conglomerates of blood vessels, supporting tissues, and overlying mucous membrane or anorectal skin. Internal hemorrhoids occur above the anorectal (dentate) line. Prolapsed internal hemorrhoids extend down into the anal canal or through the anus. External hemorrhoids occur below the anorectal line and form so-called piles. A thrombosed external hemorrhoid is a [...]
