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Alterations of the digestive function
- 1. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 1
Alterations of Digestive Function
- 2. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 2
Clinical Manifestations of
Gastrointestinal Dysfunction
Anorexia
A lack of a desire to eat despite physiologic
stimuli that would normally produce hunger
Vomiting
The forceful emptying of the stomach and
intestinal contents through the mouth
Several types of stimuli initiate the vomiting
reflex
- 3. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 3
Clinical Manifestations of
Gastrointestinal Dysfunction (cont’d)
Nausea
A subjective experience that is associated with
a number of conditions
The common symptoms of vomiting are
hypersalivation and tachycardia
Retching
Nonproductive vomiting
- 4. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 4
Clinical Manifestations of
Gastrointestinal Dysfunction (cont’d)
Projectile vomiting
Projectile vomiting is spontaneous vomiting
that does not follow nausea or retching
- 5. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 5
Clinical Manifestations of
Gastrointestinal Dysfunction (cont’d)
Constipation
Constipation is defined as infrequent or difficult
defecation
Pathophysiology
• Neurogenic disorders
• Functional or mechanical conditions
• Low-residue diet
• Sedentary lifestyle
• Excessive use of antacids
• Changes in bowel habits
- 6. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 6
Clinical Manifestations of
Gastrointestinal Dysfunction (cont’d)
Diarrhea
Increased frequency of bowel movements
Increased volume, fluidity, weight of the feces
Major mechanisms of diarrhea:
• Osmotic diarrhea
• Secretory diarrhea
• Motility diarrhea
Associated with malabsorption syndromes
- 7. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 7
Clinical Manifestations of
Gastrointestinal Dysfunction (cont’d)
Abdominal pain
Abdominal pain is a symptom of a number of
gastrointestinal disorders
Parietal pain
Visceral pain
Referred pain
- 8. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 8
Clinical Manifestations of
Gastrointestinal Dysfunction (cont’d)
Gastrointestinal bleeding
Upper gastrointestinal bleeding
• Esophagus, stomach, or duodenum
Lower gastrointestinal bleeding
• Below the ligament of Treitz or bleeding from the
jejunum, ileum, colon, or rectum
Hematemesis
Hematochezia
Melena
Occult bleeding
- 9. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 9
Clinical Manifestations of
Gastrointestinal Dysfunction (cont’d)
- 10. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 10
Disorders of Motility
Dysphagia
Dysphagia is difficulty swallowing
Types:
• Mechanical obstructions
• Functional obstructions
Achalasia:
• Denervation of smooth muscle in the esophagus and
lower esophageal sphincter relaxation
- 11. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 11
Achalasia
- 12. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 12
Disorders of Motility
Gastroesophageal reflux disease (GERD)
GERD is the reflux of chyme from the stomach
to the esophagus
If GERD causes inflammation of the
esophagus, it is called reflux esophagitis
A normal functioning lower esophageal
sphincter maintains a zone of high pressure to
prevent chyme reflux
- 13. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 13
Disorders of Motility (cont’d)
Gastroesophageal reflux disease (GERD)
(cont’d)
Conditions that increase abdominal pressure
can contribute to GERD
Manifestations:
• Heartburn
• Regurgitation of chyme
• Mid-epigastric pain within 1 hour of eating
- 14. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 14
Disorders of Motility (cont’d)
Hiatal hernia
Sliding hiatal hernia
Paraesophageal hiatal hernia
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Hiatal HerniaHiatal Hernia
- 16. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 16
Disorders of Motility
Pyloric obstruction
The blocking or narrowing of the opening
between the stomach and the duodenum
Can be acquired or congenital
Manifestations:
• Epigastric pain and fullness
• Nausea
• Succussion splash
• Vomiting
• With a prolonged obstruction, malnutrition,
dehydration, and extreme debilitation
- 17. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 17
Disorders of Motility (cont’d)
Intestinal obstruction and paralytic ileus
An intestinal obstruction is any condition that
prevents the flow of chyme through the
intestinal lumen or failure of normal intestinal
motility in the absence of an obstructing lesion
An ileus is an obstruction of the intestines
Simple obstruction
Functional obstruction
- 18. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 18
Intestinal Obstruction
- 19. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 19
Gastritis
Inflammatory disorder of the gastric
mucosa
Acute gastritis
Chronic gastritis
Chronic fundal gastritis
Chronic antral gastritis
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Gastritis (cont’d)
- 21. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 21
Peptic Ulcer Disease
A break or ulceration in the protective
mucosal lining of the lower esophagus,
stomach, or duodenum
Acute and chronic ulcers
Superficial
Erosions
Deep
True ulcers
Zollinger-Ellison syndrome
- 22. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 22
Peptic Ulcer Disease (cont’d)
Duodenal ulcers
Most common of the peptic ulcers
Developmental factors:
• Helicobacter pylori infection
Toxins and enzymes that promote inflammation and
ulceration
• Hypersecretion of stomach acid and pepsin
• Use of NSAIDs
• High gastrin levels
• Acid production by cigarette smoking
- 23. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 23
Duodenal Ulcer
- 24. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 24
Gastric Ulcer
Gastric ulcers tend to develop in the antral
region of the stomach, adjacent to the
acid-secreting mucosa of the body
Pathophysiology
The primary defect is an increased mucosal
permeability to hydrogen ions
Gastric secretion tends to be normal or less
than normal
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Gastric Ulcer (cont’d)
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Stress Ulcer
A stress ulcer is a peptic ulcer that is
related to severe illness, neural injury, or
systemic trauma
Ischemic ulcers
• Within hours of trauma, burns, hemorrhage, sepsis
Cushing ulcers
• Ulcers that develop as a result of a head/brain injury
- 27. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 27
Postgastrectomy Syndromes
Dumping syndrome
Alkaline reflux gastritis
Afferent loop obstruction
Diarrhea
Weight loss
Anemia
Bone and mineral disorders
- 28. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 28
Dumping Syndrome
Dumping syndrome is the rapid emptying
of chyme from a surgically created residual
stomach into the small intestine
Dumping syndrome is a clinical
complication of partial gastrectomy or
pyloroplasty surgery
- 29. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 29
Dumping Syndrome (cont’d)
Developmental factors:
Loss of gastric capacity
Loss of emptying control
Loss of feedback control by the duodenum
when it is removed
Late dumping syndrome
- 30. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 30
Malabsorption Syndromes
Maldigestion
Failure of the chemical processes of digestion
Malabsorption
Failure of the intestinal mucosa to absorb
digested nutrients
Maldigestion and malabsorption frequently
occur together
- 31. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 31
Malabsorption Syndromes (cont’d)
Pancreatic insufficiency
Insufficient pancreatic enzyme production
• Lipase, amylase, trypsin, or chymotrypsin
Causes:
• Pancreatitis
• Pancreatic carcinoma
• Pancreatic resection
• Cystic fibrosis
Fat maldigestion is the main problem, so the
patient will exhibit fatty stools and weight loss
- 32. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 32
Malabsorption Syndromes (cont’d)
Lactase deficiency
Inability to break down lactose into
monosaccharides and therefore prevent
lactose digestion and monosaccharide
absorption
Fermentation of lactose by bacteria causes
gas (cramping pain, flatulence, etc.) and
osmotic diarrhea
- 33. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 33
Malabsorption Syndromes (cont’d)
Bile salt deficiency
Conjugated bile salts needed to emulsify and
absorb fats
Conjugated bile salts are synthesized from
cholesterol in the liver
Can result from liver disease and bile
obstructions
Poor intestinal absorption of lipids causes fatty
stools, diarrhea, and loss of fat-soluble
vitamins (A, D, E, K)
- 34. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 34
Malabsorption Syndromes (cont’d)
Fat-soluble vitamin deficiencies:
Vitamin A
• Night blindness
Vitamin D
• Decreased calcium absorption
• Bone pain
• Osteoporosis
• Fractures
Vitamin K
• Prolonged prothrombin time
• Purpura
• Petechiae
Vitamin E
• Uncertain
- 35. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 35
Inflammatory Bowel Diseases
Chronic, relapsing inflammatory bowel
disorders of unknown origin
Genetics
Alterations of epithelial barrier functions
Immune reactions to intestinal flora
Abnormal T cell responses
- 36. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 36
Ulcerative Colitis
Chronic inflammatory disease that causes
ulceration of the colonic mucosa
Sigmoid colon and rectum
Suggested causes:
Infectious
Immunologic (anticolon antibodies)
Dietary
Genetic (supported by family studies and
identical twin studies)
- 37. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 37
Ulcerative Colitis (cont’d)
Symptoms:
Diarrhea (10 to 20/day)
Bloody stools
Cramping
Treatment:
Broad-spectrum antibiotics and steroids
Immunosuppressive agents
Surgery
An increased colon cancer risk
demonstrated
- 38. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 38
Crohn Disease
Granulomatous colitis, ileocolitis, or
regional enteritis
Idiopathic inflammatory disorder; affects
any part of the digestive tract, from mouth
to anus
Difficult to differentiate from ulcerative
colitis
Similar risk factors and theories of causation
as ulcerative colitis
- 39. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 39
Crohn Disease (cont’d)
Causes “skip lesions”
Ulcerations can produce longitudinal and
transverse inflammatory fissures that
extend into the lymphatics
Anemia may result from malabsorption of
vitamin B12 and folic acid
Treatment similar to ulcerative colitis
- 40. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 40
Diverticular Disease of the Colon
Diverticula
Herniations of mucosa through the muscle
layers of the colon wall, especially the sigmoid
colon
Diverticulosis
Asymptomatic diverticular disease
Diverticulitis
The inflammatory stage of diverticulosis
- 41. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 41
Appendicitis
Inflammation of the vermiform appendix
Possible causes:
Obstruction, ischemia, increased intraluminal
pressure, infection, ulceration, etc.
Epigastric and RLQ pain
Rebound tenderness
The most serious complication is
peritonitis
- 42. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 42
Irritable Bowel Syndrome
A functional gastrointestinal disorder with
no specific structural or biochemical
alterations as a cause of disease
Characterized by recurrent abdominal pain
and discomfort associated with altered
bowel habits that present as diarrhea or
constipation or both
Associated with anxiety, depression, and
chronic fatigue syndrome
- 43. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 43
Irritable Bowel Syndrome (cont’d)
Cause unknown but mechanisms
proposed:
Visceral hypersensitivity
Abnormal intestinal motility and secretion
Intestinal infection
Overgrowth of small intestinal flora
Food allergy/intolerance
Psychosocial factors
- 44. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 44
Irritable Bowel Syndrome (cont’d)
Manifestations:
Can be diarrhea-predominant or constipation-
predominant
Alternating diarrhea/constipation, gas, bloating,
and nausea
Symptoms are usually relieved with
defecation and do not interfere with sleep
- 45. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 45
Vascular Insufficiency
Blood supply to the stomach and intestine
Celiac axis
Superior and inferior mesenteric arteries
Two of three must be compromised to cause
ischemia
Mesenteric venous thrombosis
Acute occlusion of mesenteric artery blood
flow
Chronic mesenteric arterial insufficiency
- 46. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 46
Obesity
An increase in body fat mass
Body mass index greater than 30
A major cause of morbidity, death, and
increased health care costs
Risk factor for many diseases and
conditions
- 47. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 47
Obesity (cont’d)
Hypothalamus
Hormones that control appetite and
weight:
Insulin
Ghrelin
Peptide YY
Leptin
Adiponectin
Resistin
Leptin resistance
Hyperleptinemia
- 48. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 48
Obesity (cont’d)
- 49. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 49
Anorexia Nervosa and Bulimia
Nervosa
Characteristics:
Abnormal eating behavior
Weight regulation
Disturbed attitudes toward body weight, body
shape, and size
- 50. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 50
Anorexia Nervosa and Bulimia
Nervosa (cont’d)
Anorexia nervosa
A person has poor body image disorder and
refuses to eat
Anorexic patients can lose 25% to 30% of their
ideal body weight as a result of fat and muscle
depletion
Can lead to starvation-induced cardiac failure
In women and girls, anorexia is characterized
by the absence of three consecutive menstrual
periods
Binge eating/purging anorexia nervosa
- 51. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 51
Anorexia Nervosa and Bulimia
Nervosa (cont’d)
Bulimia nervosa
Body weight remains near normal but with
aspirations for weight loss
Findings
• Recurrent episodes of binge eating
• Self-induced vomiting
• Two binge-eating episodes per week for at least 3
months
• Fasting to oppose the effect of binge eating, or
excessive exercise
- 52. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 52
Anorexia Nervosa and Bulimia
Nervosa (cont’d)
Bulimia nervosa (cont’d)
Continual vomiting of acidic chyme can cause:
• Pitted teeth
• Pharyngeal and esophageal inflammation
• Tracheoesophageal fistulas
Overuse of laxative can cause rectal bleeding
- 53. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 53
Malnutrition and Starvation
Starvation
Decreased caloric intake leading to weight loss
Cachexia
Short-term starvation
• Glycogenolysis
• Gluconeogenesis
Long-term starvation
• Marasmus
• Kwashiorkor
- 54. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 54
Liver Disorders
Portal hypertension
Abnormally high blood pressure in the portal
venous system caused by resistance to portal
blood flow
• Prehepatic
• Intrahepatic
• Posthepatic
- 55. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 55
Liver Disorders (cont’d)
Portal hypertension (cont’d)
Consequences:
• Varices:
Lower esophagus
Stomach
Rectum
• Splenomegaly
• Ascites
• Hepatic encephalopathy
- 56. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 56
Varices
- 57. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 57
Ascites
- 58. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 58
Ascites (cont’d)
- 59. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 59
Liver Disorders
Hepatic encephalopathy
A neurologic syndrome of impaired cognitive
function, flapping tremor, and EEG changes
The condition develops rapidly during fulminant
hepatitis or slowly during chronic liver disease
Cells in the nervous system are vulnerable to
neurotoxins absorbed from the GI tract that,
because of liver dysfunction circulate to the
brain
- 60. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 60
Liver Disorders (cont’d)
Jaundice (icterus)
Obstructive jaundice
• Extrahepatic obstruction
• Intrahepatic obstruction
Hemolytic jaundice
• Prehepatic jaundice
• Excessive hemolysis of red blood cells or absorption
of a hematoma
- 61. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 61
Jaundice
- 62. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 62
Hepatorenal Syndrome
Renal failure demonstrating oliguria,
sodium and water retention, hypotension,
and peripheral vasodilation as a result of
advanced liver disease
- 63. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 63
Viral Hepatitis
Systemic viral disease that primarily
affects the liver
Hepatitis A
• Formally known as infectious hepatitis
Hepatitis B
• Formally known as serum hepatitis
Hepatitis C, D, E, and G
- 64. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 64
Hepatitis A
Hepatitis A can be found in the feces, bile,
and sera of infected individuals
Usually transmitted by the fecal-oral route
Risk factors:
Crowded, unsanitary conditions
Food and water contamination
- 65. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 65
Hepatitis B
Transmitted through contact with infected
blood, body fluids, or contaminated
needles
Maternal transmission can occur if the
mother is infected during the third trimester
The hepatitis B vaccine prevents
transmission and development of hepatitis
B
- 66. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 66
Hepatitis C
Hepatitis C is responsible for most cases
of post-transfusion hepatitis
Also implicated in infections related to IV
drug use
50% to 80% of hepatitis C cases result in
chronic hepatitis
- 67. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 67
Hepatitis
Hepatitis D
Depends on hepatitis B for replication
Hepatitis E
Fecal-oral transmission
Developing countries
Hepatitis G
Recently discovered
Parentally and sexually transmitted
- 68. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 68
Hepatitis (cont’d)
Sequence:
Incubation phase
Prodromal (preicteric) phase
Icteric phase
Recovery phase
Chronic active hepatitis
Fulminant hepatitis
Results from impairment or necrosis of
hepatocytes
- 69. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 69
Cirrhosis
Irreversible inflammatory disease that
disrupts liver function and even structure
Decreased hepatic function caused by
nodular and fibrotic tissue synthesis
(fibrosis)
- 70. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 70
Cirrhosis (cont’d)
Biliary channels become obstructed and
cause portal hypertension
Because of the hypertension, blood can be
shunted away from the liver, and a hypoxic
necrosis develops
- 71. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 71
Cirrhosis (cont’d)
Alcoholic
The oxidation of alcohol damages hepatocytes
Biliary (bile canaliculi)
Cirrhosis begins in the bile canaliculi and ducts
Primary biliary cirrhosis (autoimmune)
Secondary biliary cirrhosis (obstruction)
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Cirrhosis (cont’d)
- 73. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 73
Disorders of the Gallbladder
Obstruction or inflammation (cholecystitis)
is the most common cause of gallbladder
problems
Cholelithiasis—gallstone formation
Types:
• Cholesterol (most common)
• Pigmented (cirrhosis)
Risks:
• Obesity
• Middle age
• Female
• Native American ancestry
• Gallbladder, pancreas, or ileal disease
- 74. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 74
Disorders of the Gallbladder
(cont’d)
Gallstones
Obstruction or inflammation (cholecystitis) is
the most common cause of gallbladder
problems
Cholesterol stones form in bile that is
supersaturated with cholesterol
Theories:
• Enzyme defect increases cholesterol synthesis
• Decreased secretion of bile acids to emulsify fats
• Decreased resorption of bile acids from ileum
• Gallbladder smooth muscle hypomotility and stasis
• Genetic predisposition
• Combination of any or all of the above
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Gallstones
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Disorders of the Pancreas
Pancreatitis
Inflammation of the pancreas
Associated with several other clinical disorders
• Caused by an injury or damage to pancreatic cells
and ducts, causing a leakage of pancreatic enzymes
into the pancreatic tissue
These enzymes cause autodigestion of
pancreatic tissue and leak into the
bloodstream to cause injury to blood
vessels and other organs
- 77. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 77
Disorders of the Pancreas (cont’d)
Pancreatitis (cont’d)
Manifestations and evaluation:
• Epigastric pain radiating to the back
• Fever and leukocytosis
• Hypotension and hypovolemia
Enzymes increase vascular permeability
• Characterized by an increase in a patient’s serum
amylase level
Chronic pancreatitis
• Related to chronic alcohol abuse
- 78. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 78
Cancer of the Gastrointestinal
Tract
Esophagus
Stomach
Colon and rectum
Liver
Gallbladder
Pancreas
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Stomach Cancer
- 80. Mosby items and derived items © 2012 Mosby, Inc., an imprint of Elsevier Inc. 80
Colon Cancer