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HEALTHY
STOMACH
GERD
STOMACH
ACID REFLUX
MEDICAL INFDGRAPHIC
Figure 11-7 Reflux esophagitis.
Healthy Highlight
Tips About Strep
Throat
S
ore throats need to be tested routinely to diagnose the Streptococcus infection
commonly called strep throat. Practitioners cannot determine this condition by
simply viewing the throat. The most accurate diagnostic test is a throat culture. Some
practitioners use a rapid strep test (RST) that produces results within 15 minutes, while
a routine culture takes two days. The main disadvantage of an RST is that it may give
a false negative. Symptomatic patients with negative tests are often then cultured and
thus are charged for two tests.
It is recommended that antibiotics be started within nine days of the appearance of
symptoms in order to prevent rheumatic fever and other streptococcal-related diseases.
Parents of children who have recurrent attacks of strep throat should also have throat
cultures because they might be carriers of the strep infection. Strep throat is usually
treated effectively with antibiotics.
Antibiotics should be taken as prescribed. They should always be taken until all
tablets or capsules are gone. Even if the affected individual begins to feel better, the
medication should be continued until completed because discontinuing the antibiotic or
saving some medicine for later can lead to bacterial resistance. If an individual does not
take the prescribed number of tablets, it is possible for many bacteria to survive the short
dosage time and actually build up a resistance to that antibiotic. These bacteria can then
cause another attack of strep throat that cannot be treated or cured with the previously
prescribed antibiotic. Taking all antibiotics as prescribed should destroy all the bacteria
and eliminate the risk of bacterial resistance.
218 Chapter 11
abdominal pressure might be restricted. Sleeping with
the head of the bed elevated is often helpful. Surgery on
the incompetent sphincter is usually not recommended
and considered only in extreme cases.
■ Prevention. Preventive measures include controlling
weight and avoiding smoking, caffeine, carbonated
beverages, chocolate, and high-fat foods as well as late-
night meals.
Hiatal Hernia
■ Description. Hiatal hernia is a sliding of part of the
stomach into the chest cavity.
■ Etiology. The stomach slides upward through the nat
ural hole in the diaphragm where the esophagus passes
through to the stomach (Figure 11-8). This herniation
can increase in frequency with age and weakening of the
cardiac sphincter.
■ Symptoms. Many hiatal hernias are asymptomatic
(a = without, symptomatic = symptoms), but those that
do cause discomfort are usually related to esophageal
reflux.
■ Diagnosis. Hiatal hernias are diagnosed by an upper
GI X-ray.
■ Treatment. Treatment is often the same as for reflux
esophagitis.
Pyloric
sphincter
Diaphragm
Stomach
Cardiac -
sphincter
This part of
the stomach
is normally
located below
the diaphragm.
Esophagus
Figure 11-8 Hiatal hernia.
■ Prevention. Although it is difficult to prevent hiatal
hernias totally, risk can be reduced by maintaining a
healthy weight, avoiding heavy lifting, and not smoking.
Esophageal Varices
■ Description. Esophageal varices are extremely dilated
varicose veins located in the esophagus (Figure 11-9).
■ Etiology. Unusually high pressure in the veins of the
esophagus causes them to enlarge and become tortuous,
resulting in esophageal varices. This increased venous pres
sure is due to blockage or reduced flow of blood into the
liver, causing poor venous return from the esophagus. (For
more information on liver disease, see Chapter 12, “Liver,
Gallbladder, and Pancreatic Diseases and Disorders.”) Any
condition that leads to venous congestion in the liver can
lead to esophageal varices, but they are most commonly
related to cirrhosis of the liver. The most common cause of
cirrhosis is excessive alcohol consumption. Hemorrhage of
the varices can be a life-threatening condition.
■ Symptoms. Symptoms include vomiting blood, black
stools, and, on endoscopic examination, dilated esoph
ageal blood vessels.
■ Diagnosis. Physical examination can reveal low blood
pressure, bloody stools, and signs of chronic liver dis
ease. Diagnosis is confirmed with an EGD.
■ Treatment. The goal of treatment is to decrease
venous pressure by methods such as portal vein bypass
surgery and medication to lower blood pressure. Other
treatments include limiting the diet to soft, nonirritating
Figure 11-9 Esophageal varices.
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Digestive System Diseases and Disorders 219
foods and the use of stool softeners to prevent straining,
which increases esophageal venous pressure. Chronic
bleeding of the vessels can be treated with a sclerosing
agent that hardens or destroys the vessel. Treatment for
acute bleeding includes instillation of cold saline wash
ings, the application of pressure to the site through a
nasogastric tube, or both.
■ Prevention. Treating or preventing liver disease can
prevent this disease.
Diseases of the Stomach
Diseases of the stomach are common problems in the
digestive system. Complaints of stomach pain, especially
after eating, are frequently voiced to the physician. This
problem increases with age due to age-related changes
in the system and is also complicated by other chronic
diseases. Disorders of the stomach range from mild
acute gastritis to more serious diseases such as cancer
of the stomach.
Consider This...4
When an individual’s face blushes, the
color of their stomach tissue turns red, too.
■ Etiology. Common causes are use of anti-inflamma
tory medications or nonsteroidal anti-inflammatory
drugs (NSAIDs), such as aspirin or ibuprofen, smoking,
alcohol consumption, and infection with bacteria such
as Helicobacter pylori (H. pylori).
H. pylori are corkscrew-shaped bacteria that com
monly live and multiply within the mucous layer that
lines the stomach and small intestine (Figure 11-11).
About half of the world’s population is infected with H.
pylori (Mayo Clinic, 2021 ). These bacteria are usually
picked up during childhood and do not cause symp
toms in the majority of people. Those persons affected
often have pain and gastric ulceration as the H. pylori
weakens the protective mucous lining of the stomach,
allowing acid to contact the sensitive tissues under
neath. Why the bacteria cause ulcers in some people
and not in others is not known.
Gastritis also increases with age. As people age, the
number of acid-producing cells decreases, thus lead
ing to atrophic gastritis, or achlorhydria (AH-klor-
HIGH-dree-ah; no hydrochloric acid), because there
is not enough hydrochloric acid to kill off ingested
bacteria. Achlorhydria also leads to loss of intrinsic
factor (a protein produced by the gastric mucosa), lead
ing to pernicious anemia. (See Chapter 7, “Blood and
Blood-Forming Organs Diseases and Disorders,” for
more information on anemia.)
Gastritis
■ Description. Gastritis is not a specific disease but a
condition that results from several problems that all
cause inflammation of the stomach (Figure 11-10).
Figure 11-10 Gastritis. Figure 11-11 Helicobacter pylori.
220 Chapter 11
Healthy Highlight
HoW to Tell C everal conditions can cause pain in the chest, but the most common are heartburn
and heart attack. Telling the difference between the two is important for the indi
Heartburn fro
m a vidual so immediate treatment can occur if it actually is a heart attack. So how do you
Heart Attack tell if you are having heartburn or a heart attack? Sometimes the symptoms are almost
indistinguishable. It is more likely a heart attack if the symptoms also include shortness
of breath or sweating along with the chest pain. Heartburn is indigestion, whereas chest
pain (angina) is a sign of heart disease. Symptoms of heartburn include pain in chest
(below breastbone), pain after eating, belching, and/or a sour taste. The pain is often
relieved with the ingestion of antacids or histamine (H
2
) antagonists. Symptoms of a
heart attack include chest pain that is often described as crushing, pain or discomfort in
the arm, neck, or jaw, sweating, nausea, or dyspnea. Because heart attack symptoms are
often different in women than in men, careful evaluation is recommended. Women may
experience very little chest pain but often experience the other symptoms listed above.
Men are more likely to experience the crushing chest pain. Heartburn typically occurs
after eating, while chest pain may occur with exercise but can also occur after eating.
A heart attack is an emergency situation, whereas heartburn is not. However, in either
case, evaluation by a health care provider is recommended. Taking an aspirin is sug
gested if there is any delay in being evaluated by a professional medical care provider.
Source: Cleveland Clinic (2020)
■ Symptoms. The most common symptom is abdomi
nal pain. Other symptoms include nausea, belching, and
vomiting.
■ Diagnosis. Diagnosis is made using several tests.
Urea breath tests determine presence of the bacteria in
the stomach. A stool antigen test determines whether
there is antigen present that triggers the immune sys
tem. An upper GI endoscopy or EGD may be used for
visual confirmation or to obtain a stomach biopsy.
■ Treatment. Medications to reduce stomach acid help
relieve symptoms and promote healing. Treatment for
H. pylori involves treatment with antibiotics. Avoiding
irritating foods, medications, smoking, and alcohol
is also helpful. Treating and resolving the underlying
cause usually leads to resolution of gastritis.
■ Prevention. Avoid irritating factors and promptly
treat those who are symptomatic with H. pylori aid in
prevention of gastritis.
Peptic Ulcer
■ Description. An ulcer is an area of tissue that has
eroded, leaving a crater-like appearance (Figure 11-12).
Peptic ulcers are those ulcers found in the stomach and
duodenum that are caused, in part, by the action of pep
sin. Peptic ulcers found in the stomach are called gastric
ulcers, and those located in the duodenum are called
duodenal ulcers.
■ Etiology. A common cause of these ulcers is H. pylori.
Other contributing factors include severe stress, heavy
intake of drugs (such as aspirin, steroids, and alcohol),
and smoking.
The stomach lining is normally protected by a thick
mucous membrane lining. Pepsin is an enzyme secreted
in the stomach that breaks down protein, but this same
enzyme, to some degree, breaks down the stomach’s
lining, causing ulcers.
■ Symptoms. Ulcer pain is caused by the hydrochloric
acid in the stomach irritating the raw ulcerated area.
Complications of peptic ulcers are massive bleeding,
perforation, and obstruction.
■ Diagnosis. Diagnosis is based on symptoms and the
results of a gastroscopy or visual examination of the
inside of the stomach.
■ Treatment. Treatment is aimed at reducing the gastric
acidity and healing the stomach lining. Antibiotics are
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Digestive System Diseases and Disorders 221
(A)
Gastric ulcer
Duodenal
ulcer
Figure 11-12 Peptic ulcers. (A) Location. (B) Gastric ulcer. (C) Duodenal ulcer.
also used to treat ulcers caused by Helicobacter bacte
ria. Other treatments include reduction or elimination
of contributory factors. Antacids to neutralize gastric
acids and other gastric medications might be helpful.
Surgery is warranted in severe cases that might lead to
hemorrhage, perforation, obstruction, or extreme pain.
■ Prevention. Infection with H. pylori is thought to
occur during childhood through water, food, or kiss
ing someone who has the bacteria. At this time, routes
of infection are unproven, and the fact that many peo
ple with H. pylori do not develop peptic ulcers makes
this cause unpreventable. Quick treatment of H. pylori,
when discovered as an irritant, along with avoiding
other irritants, is beneficial.
Cancer of the Stomach
■ Description. Cancer of the stomach often spreads
through the stomach tissue to nearby organs such as
the pancreas, intestine, and esophagus (Figure 11-13).
Figure 11-13 Stomach cancer.
These cancer cells can also spread through the blood
and lymphatic system to the liver, lungs, and lymph
nodes all over the body. Often, this cancer goes undi
agnosed until after it spreads outside the stomach and
into other organs.
■ Etiology. The cause of stomach cancer is unknown,
although research has proven certain causative factors.
These include some correlation to food additives and
foods that are smoked, salted, and pickled. Cigarette
smoking is another risk factor along with gender, in that
men are more affected than women.
■ Symptoms. Symptoms are often vague and include
loss of appetite, general stomach distress, and heart
burn. Prognosis is good if the cancer is discovered
early.
■ Diagnosis. Diagnostic testing includes upper GI stud
ies, endoscopy, and biopsy. Biopsy is the most definitive
diagnostic test.
■ Treatment. Treatment can include surgical resection,
chemotherapy, and radiation.
■ Prevention. Preventing causative factors might help
in prevention.
Consider This...
The stomach produces a new layer of
mucus every 2 weeks in order to prevent it
from digesting itself.
222 Chapter 11
Diseases of the Small Intestine
The small intestine, consisting of the duodenum, jeju
num, and ileum, secretes enzymes and absorbs nutri
ents for cellular functions. Disorders of the small
intestine frequently manifest themselves by pain that
radiates across the abdomen, although this symptom
alone is not enough to diagnose the specific disease
process. Additional evaluation is needed, such as X-ray
or computerized tomography (CT) scan. The disorders
of the small intestine can range from mild intestinal
upset to more severe chronic problems such as ulcers
or regional enteritis.
Duodenal Ulcer
A duodenal ulcer, also called a peptic ulcer of the duo
denum, has been discussed previously under “Peptic
Ulcer.”
Malabsorption Syndrome
■ Description. The primary purpose of the small intes
tine is to absorb nutrients. Malabsorption syndrome
occurs when this process is altered and nutrients are
not adequately absorbed into the blood.
■ Etiology. Persons with malabsorption syndrome can
be unable to absorb nutrients (especially fat) and min
erals. Other diseases such as diabetes mellitus, cystic
fibrosis, pancreatic deficiencies, lactose intolerance, and
gluten enteropathy can also lead to malabsorption syn
drome. Malabsorption syndrome can range from mild
intestinal upset to more severe chronic problems such
as ulcers or regional enteritis.
■ Symptoms. Symptoms include anemia, diarrhea,
edema, muscle cramping, and weight loss. Heart
arrhythmias can result from potassium deficiency, and
blood-clotting disorders can also occur. Children who
are affected might exhibit signs of failure to grow.
■ Diagnosis. Diagnosis is often very difficult and
requires extensive testing. Basic testing will include a
thorough medical and physical examination followed by
a variety of blood tests, X-rays, stool samples, endosco
pies, ultrasound, and CT and magnetic resonance imag
ing (MRI) scanning. All these tests aid in measuring
abnormalities of the GI tract.
■ Treatment. Most treatments include diet therapy
for control. One of the complications of the disorder
is a bleeding tendency due to the lack of vitamin K
absorption.
■ Prevention. Many of the malabsorption syndromes
are hereditary, so there are no preventive solutions.
Genetic screening followed by early detection through
routine physical exams and testing is of benefit. Preven
tion, in some cases, is as easy as avoiding the foods or
substances that cause problems.
Regional Enteritis (Crohn’s Disease)
■ Description. Regional enteritis is a chronic inflam
matory disease most commonly affecting the small
intestine, but it can also affect the large intestine. It is
characterized by bouts of remission (slowing or stop
ping of symptoms) and exacerbation (eg-ZAS-er-BAY-
shun; flaring up of symptoms) (Figure 11-14) and is
commonly classified as inflammatory bowel disease
(IBD) until complete diagnosis is made. As regional
(A)
Figure 11-14 (A) Regional enteritis: location. (B) Regional enteritis: view through endoscope. (C) Regional enteritis: view
of internal colon wall.
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Digestive System Diseases and Disorders 223
enteritis progresses, the intestinal wall thickens, result
ing in a narrowing of the lumen.
■ Etiology. The cause of the disease has not yet been
determined, although genetic, immunologic, infectious,
and psychological factors have been considered.
■ Symptoms. Symptoms include anorexia, flatulence,
abdominal pain, diarrhea, and constipation. Individu
als with regional enteritis tend to experience relapse or
exacerbations of the condition during periods of stress
or emotional upset, factors that support the psycho
genic theory. Young females are most often affected by
regional enteritis.
■ Diagnosis. Symptoms, along with blood tests, upper
GI series, CT scanning, and colonoscopy, help deter
mine the diagnosis. Recently, video capsule endoscopy
has been added to diagnostic testing.
■ Treatment. Treatment is supportive but not likely to
be curative. Approaches can involve a low-residue diet
and medications to control diarrhea, inflammation,
infection, and depression. Surgical resection is not
curative and is performed to treat complications such
as perforation and obstruction.
■ Prevention. Because Crohn’s is thought to have some
inherited tendency, there are no known preventive mea
sures. To prevent flare-ups, maintaining a healthy diet
and reducing stress are helpful.
Gastroenteritis
■ Description. Gastroenteritis (gastro = stomach,
entero = intestines, itis = inflammation), as its name
suggests, is inflammation of both the stomach and intes
tines (Figure 11-15).
Oral cavity
Pharynx
Esophagus
Small intestine - Jejunum
Ileum
Sigmoid colon
Rectum
Duodenum
----- Ascending colon
— Descending colon
-Appendix
Anus
Pathway of food/feces
Figure 11-15 Gastroenteritis.
224 Chapter 11
■ Etiology. Causes can include bacterial, viral, or para
sitic invasion; ingestion of tainted food; lactose intoler
ance; allergic reaction to food or drugs; and stress.
■ Symptoms. Gastroenteritis can have an acute and
violent onset with nausea, vomiting, abdominal cramp
ing, and diarrhea, leading to rapid fluid and electrolyte
loss. Or, symptoms may be less violent, with stomach
rumbling, malaise (ma-LAZE; general ill feeling), nau
sea, and mild diarrhea.
■ Diagnosis. The symptoms usually help identify this
illness. Identifying the cause might require stool sam
ples to examine for viruses, bacteria, and parasites.
■ Treatment. Treatment focuses on symptoms and can
include antinausea medication, antidiarrheal medica
tion, antibiotics, fluids, and nutritional support and
stress management. Prognosis is generally good.
■ Prevention. If the gastroenteritis is caused by a
virus, it probably cannot be prevented. With bacterial
gastroenteritis, the best preventive measures include
handwashing and properly preparing and storing food
because bacteria easily grow and multiply in poultry,
egg, and cream products. Keeping foods such as potato
and chicken salad refrigerated, especially during warm
weather, is helpful. Avoiding contaminated food and
water, especially in underdeveloped countries, also pre
vents gastroenteritis.
If stress is the cause of the upset, then controlling
this with stress reduction, healthy diet, and regular
exercise will help with prevention.
Inguinal Hernia
■ Description. An inguinal hernia is a common prob
lem that affects the digestive system.
■ Etiology. A pouching of the small intestine and the
peritoneum (abdominal cavity lining) into the groin area
(Figure 11-16) causes this condition. Inguinal hernias
are more common in males, perhaps due to a congenital
defect that developed as the testes descended from the
abdomen into the scrotum, thus pulling part of the perito
neum into the inguinal area. Inguinal hernias also develop
in both sexes due to a weakness in the abdominal wall.
The portion of the intestine that herniates can
become caught and twisted, thus cutting off blood sup
ply to the organ. If this occurs, it is called a strangulated
hernia, which can be life threatening and needs imme
diate surgical intervention.
■ Symptoms. Symptoms include a bulge in the groin or
scrotum and groin pain that increases with bending or
lifting and is relieved by lying down. If there is sudden
pain, nausea, and vomiting, chances are the hernia has
become strangulated.
■ Diagnosis. Diagnosis depends on a thorough history
and physical exam of the groin area. Ultrasound and CT
scans can be used to finalize the diagnosis.
■ Treatment. Fortunately, inguinal hernias can
be repaired surgically to prevent this potentially
life-threatening situation.
Portions of the small intestine can also herniate
through other openings in the body such as the fem
oral canal or the umbilicus. The femoral hernia, like
the inguinal hernia, is more common in males. The
umbilical hernia is most common in infants. Like the
inguinal hernia, both are corrected surgically to prevent
complications.
■ Prevention. Preventive measures include maintaining
proper body weight, stopping smoking, using proper
body mechanics during lifting, and avoiding constipation
Figure 11-16 Hernias. (A) Inguinal-bilateral hernia. (B) Umbilical hernia.
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Digestive System Diseases and Disorders 225
because straining to have a bowel movement increases
abdominal pressure and can lead to a hernia.
Diseases of the Colon
Diseases of the colon or large intestine are com
mon to all ages but are found most frequently in the
middle-aged and older adult with the exception of
appendicitis. Some colon diseases may require surgical
removal of part or all of the colon, called colon resection.
Resection is a major surgery and involves removing
part of the colon (partial or hemicolectomy) or the entire
colon (colectomy). If only part of the colon is removed,
reconnecting the two healthy bowel ends together is
possible and is called an anastomosis; however, if a large
amount of the colon is removed, an anastomosis might
not be possible. In this case, a permanent or temporary
opening called a colostomy might be required.
A colostomy is developed by bringing the end of the
colon through an opening in the abdominal wall. The
new opening is called a stoma (Greek word for mouth),
so named because it is pink in color like the inside of the
mouth (Figure 11-17). This stoma will excrete feces. Man
agement of a stoma requires education and special supplies.
The basic supplies are a face plate that sticks to the skin and
a collection bag for the feces. These supplies come in one-
and two-piece systems. The system used depends on the
thickness of the stool excreted and patient preference.
Appendicitis
■ Description. The appendix is located near the junc
tion of the small and large intestines, and although it
is primarily composed of lymphoid tissues, the exact
function is yet unknown.
■ Etiology. Appendicitis is the inflammation of the
vermiform (VER-mih-form; wormlike) appendix.
Infection or obstruction usually causes appendicitis.
The position of the appendix near the colon allows
bacteria-laden fecal contents to drop into the appen
dix, causing obstruction and infection. The inflamed
appendix swells (Figure 11-18), decreasing circulation
and potentially leading to gangrene.
Figure 11-18 Appendicitis. (A) Location. (B) Inflammation
of appendix.
Courtesy of Mark L. Kuss
Figure 11-17 (A) Ostomy stoma. (B) Ostomy: one-piece appliance. (C) Ostomy: two-piece appliance.
226 Chapter 11
■ Symptoms. The pain of appendicitis usually begins
with generalized abdominal pain that shifts to the lower
right quadrant. Other signs and symptoms include nau
sea, vomiting, fever, and leukocytosis. This combination
of signs and symptoms also mimics other abdominal
diseases such as kidney stones, pelvic inflammatory dis
ease, and pancreatitis, which can lead to an incorrect
diagnosis.
As appendicitis progresses, the wall of the appendix
thins and can rupture. Rupture of the appendix usually
relieves the pain for a short time but leads to the more
severe complication of peritonitis. Before the develop
ment of antibiotics, peritonitis was usually fatal.
■ Diagnosis. A physical examination revealing
increased pain when gentle pressure is applied in the
area of the appendix and then released, called rebound
tenderness, is helpful in diagnosis. Blood tests revealing
an elevated white blood cell count, along with a urinaly
sis to rule out bladder infection, are helpful. Ultrasound
and CT are used to confirm the diagnosis.
■ Treatment. Surgical removal of the appendix, prefer
ably before rupture occurs, is the common treatment.
■ Prevention. There is no proven way to prevent appen
dicitis, but eating a healthy diet, including fruits and
vegetables, might aid in prevention.
Intestinal Obstruction
■ Description. Intestinal obstruction may be classi
fied as a symptom of a disease process or as a disease
itself.
■ Etiology. Regardless of the classification, it is identi
fied as an inability to move intestinal contents through
the bowel. An obstruction can be due to a blockage of
the intestine or to a disease or ileus (ILL-ee-us; absence
of peristalsis).
Blockage can occur due to tumors, hernias, or
adhesions (ad-HE-zhuns) (Figure 11-19). Adhe
sions are areas within the colon that abnormally link
together, resulting from a previous abdominal sur
gery or from inflammation. Blockage also can occur if
the colon becomes twisted (volvulus; VOL-view-lus)
(Figure 11-20). If the colon telescopes on itself, the
condition can lead to a blockage called intussusception
(IN-tus-sus-SEP-shun).
A decrease or absence of peristalsis that causes intes
tinal obstruction is classified as a paralytic obstruction—
colon action is paralyzed (unable to move). This type of
obstruction can be a postoperative complication or a
result of peritonitis.
■ Symptoms. Symptoms depend on the type and sever
ity of the obstruction. The individual might experience
Cecum
Appendix
Large intestine
Ileum
Colon blockage
Sigmoid colon
Rectum
Figure 11-19 Colon blockage.
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