There are a variety of disease conditions which affect the digestive tract. Some of these will necessitate surgical treatment. This system is subject to inflammatory, neoplastic, congenital, and traumatic abnormalities. There are a few conditions which are peculiar to the digestive system and not found in other systems; namely, peptic ulcer, appendicitis, swallowed foreign bodies, and obstructions along the course of the tract.
Inflammation of the appendix is the most common reason for abdominal operation. This useless tissue remnant becomes acutely inflamed, usually with no known specific cause. Often there is found food debris within the inflamed appendix and occasionally such material as fruit stones, seeds, nuts, small bones, worms, and other solid particles which would appear to be an initiating factor. Infection by germs is the most common cause.
The inflammatory process spreads rather rapidly. At first the inflammation is within the thin wall of the appendix, which swells and becomes distended. As the process continues there is leakage of the contents through a pinpoint opening. This may gradually or suddenly enlarge to spill the contents into the abdominal cavity, which then too becomes infected (“ruptured” appendix). This may localize into an abscess in the region of the appendix (appendiceal abscess) or may disseminate over the entire peritoneal surface (peritonitis). Frequently a mild case of appendicitis will subside spontaneously.
The symptoms experienced by appendicitis vary somewhat in different individuals but usually there is crampy abdominal pain with more severe pain in the right lower side. This is soon followed by nausea, vomiting, low fever, and usually constipation. If the process should continue untreated, there result marked distention of the abdomen, high fever, severe pain, and progressive malaise.
The treatment of appendicitis is by surgical removal of the appendix. Occasionally, with the newer antibiotics, a mild case of early appendicitis can be made to subside and operation can be deferred, but close medical observation for signs of progression of the disease must be maintained. In cases of appendiceal abscess and peritonitis, it is frequently necessary to operatively drain the purulent matter from the abdomen; often it is impractical to attempt removal of the appendix at this time.
The operation for removal of the appendix is called appendectomy. This of course, necessitates an incision through the front of the abdominal wall by one of those adapted for the right lower quadrant of the abdomen. The mesentery at the back of the appendix with the blood vessels and nerves to the appendix is divided up to the base of the cecum. The base of the appendix is tied and cut free. An antiseptic is applied to the stump of the appendix and the stump is inverted into the wall of the cecum, and the abdomen is then closed.
Ulcerations along the course of the intestinal tract are relatively common. When they occur in regions exposed to the stomach digestive juices, they are called peptic ulcers. The digestive juices are not the causative factor, but usually they are increased in the presence of an ulcer and do interfere with the healing of an ulcer. The peptic ulcer occurs most frequently in the first portion of the duodenum, just past the outlet of the stomach. This is called duodenal ulcer. Ulcers within the stomach are called gastric ulcers; these are only one tenth as frequent as duodenal peptic ulcers.
Rarely, peptic ulcers may occur in the lower part of the esophagus, or even farther along in the small intestine. There is a pronounced relationship between the formation of peptic ulcers and the emotions. Some persons react to emotional strains of apprehension, fear, and worry by increased stomach and intestinal activity, by increased motility and contractions, and by increased production of digestive juices. Peptic ulcers are indeed more common in persons who live under high emotional tension, and aggravation of the ulcer symptoms occurs at times of increased apprehension and distress.
The ulcers take a variety of sizes and shapes. Frequently they become deep enough to perforate through the wall to spill food contents and digestive enzymes out into the peritoneal cavity, perforated peptic ulcer. This condition is a surgical emergency.
The ulcers may erode into a blood vessel within the wall of the stomach or intestine, bleeding peptic ulcer. Bleeding may be slight or massive. It may subside spontaneously or may necessitate operative intervention. Replacement of blood by transfusions is often necessary.
There is little tendency for ulcers of the duodenum to undergo malignant change to become cancer. But in the stomach there is a much greater tendency that malignancy will ensue. In most cases it can be ascertained whether the stomach ulcer is benign or cancerous by x-ray studies and by evaluation of the stomach secretions. Occasionally tumors, benign or malignant, along the course of the digestive tract will develop an ulcerated surface; these may bleed or have any of the other features of peptic ulcers.
Ulcers of the duodenum have a tendency to recur. As the ulcer heals there is scar formation. With frequent ulceration and healing there may be abundant scar tissue formed. Scar tissue is not elastic and with time shrinks. This reduces the caliber of the tract at this point and may almost completely occlude the passageway (duodenal stenosis). This condition usually demands surgical treatment.
The medical treatment of peptic ulcer is by diet, by which is attempted to avoid all foods which may irritate the ulcerated area or may stimulate the production of stomach digestant juices; the diet includes between-meal feedings in efforts to keep something within the stomach at all times to absorb, dilute, and neutralize the stomach acids. Medications include drugs which will inhibit the production of stomach acids and stomach motility, drugs which will help sedate and allay emotional tension, and alkalis which will neutralize stomach acids. A further adjunct is by correction of situational conditions which cause worry or other emotional strain.
The surgical treatment of peptic ulcers becomes necessary when there has been complete failure of adequate trials of medical treatment and the patient is severely disabled or progressively debilitated by the disease. In many cases of bleeding peptic ulcer, and in all cases of perforated peptic ulcer, operative treatment is imperative. Surgery is usually necessary for duodenal stenosis. There are many different surgical procedures employed, depending on the size and position of the ulcer, the general state of health of the individual, the degree of acidity of the stomach secretions, and whether or not malignancy is probable.
Other Intestinal Ulcerations
Ulcerations of the lining wall along the remainder of the digestive tract are less common. They may occur in the esophagus from the ingestion of hot and caustic substances. Ulcerative ileitis is a specific disease wherein a segment of the ileum develops many ulcerated areas. A segment may be involved at any level of the ileum (segmental ileitis) but most often involves the very last portion (terminal ileitis). A not uncommon condition of the large intestine is ulcerative colitis. This may involve any portion of the colon or even the entire large bowel.
This is often a serious debilitating disease. Ulcers along the course of the small and large intestines often are associated with bleeding and occasionally with perforation. In some instances surgery is indicated.
Anywhere along the course of the hollow tube known as the small and large intestines there may be sac-like bulges. Such a pouch is called a diverticulum. These are usually multiple and occur most frequently in the lower portion of the colon but may appear less frequently at other levels. Their cause is usually due to weakness of the muscular layer. The condition where several of these exist in a section of bowel is called diverticulosis. These are usually without symptoms or complications. With time they may slowly enlarge. It is estimated that diverticula are present in at least 5 per cent of adults. Occasionally food debris may become impacted in these and inflammation set up in the wall of the pouch, a condition called diverticulitis. This usually gives rise to symptoms often simulating appendicitis. In some cases, the wall of a diverticulum becomes so inflamed and distended that it perforates, discharging its contents with germs into the peritoneal cavity, initiating severe and acute peritonitis. This condition usually demands surgery. The incidence of cancer of the bowel is slightly higher where diverticula exist.
Inflammation of the wall of the colon not infrequently occurs, a disease called colitis. This may be from germ invasion of the wall, but also the term colitis is used for functional disturbances of the colon.
Spastic Colitis. This is a condition where the usual peristaltic action is more vigorous in certain segments without the usual rhythmic progression of contractions. This usually gives rise to symptoms of constipation alternately with diarrhea.
Flaccid Colitis. Flaccid colitis is a condition where the peristaltic contractions are weak and fail to move the intestinal contents along the course in the usual manner, usually giving rise to constipation. These functional disturbances are actually not associated with inflammation of the colon wall, so therefore the term “colitis” is in reality a misnomer. However, there are other specific colon wall infections which occur; namely, amebic colitis (amebic dysentery) and typhoid colitis. Other germ infections may also occur.
Mucous Colitis. Mucous colitis is a functional disturbance of the mucus-secreting glands lining the colon.
Ulcerative Colitis. Colitis resulting from ulcerated areas within the colon is called ulcerative colitis.
There are several types of animal parasites, or worms, which may gain entrance into the intestinal tract. These usually enter in the form of larvae or eggs to hatch and mature into adult worms within the intestine. They vary in size from minute microscopic forms to worms several feet in length. The more common ones encountered are pork, beef, and fish tapeworms; roundworms; hookworms; pinworms, and flukes. Pinworm infestations are quite common. The symptoms produced by worms may be negligible or may be severe abdominal cramping, nausea, vomiting, loss of appetite, diarrhea, and genital itching.
The adult forms produce more eggs which are expelled from the intestinal tract and may gain entrance to another animal or human through food and water contamination. Occasionally these parasites irritate the intestinal tract so that germ infections are initiated. Pinworms may in this manner initiate appendicitis, but rarely do worms otherwise give rise to lesions necessitating surgery. Often the pork worm gains entrance to the blood stream and migrates in the body to other tissues, especially to the muscles, where it continues to live, a disease known as trichinosis.
Benign and malignant tumors are quite common along the course of the gastrointestinal tract. These may cause hemorrhage or obstruction. Usually they demand operative removal of a segment of the tract; reconstruction of the tract. One of the more common types of benign tumors is the intestinal polyp. These may be solitary or multiple, and may give rise to bleeding or obstruction. These are tumors with a small pedicle holding them to the intestinal lining. They are more common in the large intestine. Malignant tumors, or cancer, are most common in the stomach and last portion of the large intestine, but may occur at any level.
For the body to prepare food for its utilization, the ingested substances must pass through the digestive and absorption areas of the digestive tract, and the remaining food residues must be expelled. Any blockage along the course of the tract impedes this process. Intestinal obstruction may be partial or complete, may be at any level, and may be caused by a variety of conditions.
Fecal Impaction. The commonest cause of intestinal obstruction is by fecal impaction, wherein a hard bolus of food residue blocks the passageway. This is more common in infants and the aged. It occurs most often with prolonged bed rest, cathartic habituation, and dehydration.
Tumors. Tumors, both benign and malignant, may cause obstruction.
Adhesions. Adhesions, which are merely bands of scar tissue, may initiate obstruction by causing the bowel to fold or kink on itself, thereby occluding its passageway. Adhesions may also hold the bowel fixed at one point so that it cannot make its normal movements; this is usually partial obstruction. Such adhesions may be from previous healed infections within the peritoneal cavity or from prior operations. Herniae may produce intestinal obstruction, as a loop of bowel becomes caught in the hernial bulge.
Volvulus. This is a condition of obstruction produced as the intestine twists and knots on itself as its peristalic waves attempt to force the contents along the tract. This looping of the bowel may be partial or complete obstruction, and may be temporary or continuous.
Intussusception. Intussusception is a condition wherein a segment of intestine enters a succeeding segment. This invagination of one portion of the intestine into another may occur spontaneously or in the presence of a tumor, particularly polyps, where the bowel attempts to push the attached tumor onward just as it would a bolus of food, and the attached portion of bowel is pulled and inverted into the next portion. Intussusception occurs in several sites more frequently than others: ileocolic intussusception is where the last portion of the ileum passes into the first portion of the colon; jejuno-ileal, jejuno-jejunal, and ileo-ileal are other varieties. Intussusception is most common in infants and in the presence of tumors in adults. This condition usually necessitates surgery.
When intestinal obstruction occurs there is marked distention of that part of the intestine preceding the obstruction site, as food, gases and digestive juices accumulate. Pain and vomiting are prominent symptoms. Intubation is imperative. Frequently this procedure alone may relieve the obstruction, but most often operative correction is necessitated.
Congenital deformities of the digestive tract are not common. Originally in the embryo the digestive system is a straight tube from mouth to anus, but as the bowel increases in length by disproportionate growth, it becomes folded into the abdominal cavity in a specific manner; various portions dilate, or rotate, or become fixed to the abdominal wall. Any error in this natural process may give rise to congenital (inborn) defects. Such may be manifested as a narrowed segment, an obstructed segment, a volvulus, a dilated loop, or a variety of other rare poorly functioning conditions. Congenital defects of the digestive tract are usually correctable by operation.
Injuries to the digestive tract may be by penetrating wounds such as those from a bullet or a knife, or may be by blunt objects striking the abdominal wall. Since the advent of the automobile, injuries to the digestive tract have been increasing in incidence. Such injuries are associated with injury to the abdominal wall and frequently with injury to other parts of the body. Injuries by sharp objects may penetrate the stomach or intestine at one or several sites, allowing food particles, digestants, and germs to leak into the peritoneal cavity. Such injuries demand immediate surgical repair before massive peritonitis ensues. Blunt blows on the abdomen may also cause internal bleeding, disruption of the blood supply to parts of the digestive tract, bruises of the intestinal wall, or perforation of the hollow organ by severe sudden compression. Again operative intervention is most often urgent.
An abnormal communication between two body surfaces is called a fistula. In the digestive tract such abnormal openings may exist between the skin surface and any loop of the digestive tract or between one portion of the tract and another, or between one site of the tract and another hollow organ. The nomenclature for these is derived from the components involved, as follows:
- Gastrocutaneous Fistula
- Enterocutaneous Fistula
- Between Intestine and Kidney ………………….. Enterorenal Fistula
- Between Intestine and Bladder………………….. Enterovesicle Fistula
- Between Intestine and Bile System……………. Enterobiliary Fistula
- Between Intestine and Vagina…………………… Enterovaginal Fistula
Other internal surfaces may be involved in such abnormal communication. These are correctable by surgery.