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Gastroenterol Clin North Am

Abdominal pain during pregnancy.

Year 1998
Mayer IE. Hussain H.
Division of Gastroenterology, Maimonides Medical Center, Brooklyn, New York, USA.
In evaluating the pregnant patient with abdominal pain, the physician is presented with a wide range of diagnostic possibilities, including disorders that can occur in nonpregnant individuals and disorders that are unique to pregnancy. The development of modern laboratory testing methods and diagnostic imaging techniques has led to a decline in the morbidity and mortality from many of these disorders. With an understanding of the physiologic changes occurring during pregnancy, a careful history and physical examination, and judicious use of laboratory tests and imaging studies, the physician should be able to determine the cause of the patient's pain in the great majority of cases and, in the words of Babler, avoid "the mortality of delay."

The safety and efficacy of gastrointestinal endoscopy during pregnancy.

Year 1998
Cappell MS.
Department of Medicine, Maimonides Medical Center, Brooklyn, New York, USA.
More than 12,000 pregnant patients in the United States per year have conditions normally evaluated by esophagogastroduodenoscopy (EGD). More than 6000 pregnant patient in the United States per year have conditions normally evaluated by sigmoidoscopy or colonoscopy. Endoscopy during pregnancy raises the unique issue of fetal safety, and endoscopic medications comprise a significant component of fetal risks from endoscopy. This article analyzes the safety of endoscopic medications during pregnancy, reviews the literature on the safety of gastrointestinal endoscopy during pregnancy, proposes guidelines for endoscopic indications during pregnancy, and describes modifications of gastrointestinal endoscopy during pregnancy to increase fetal and maternal safety.

Gastrointestinal surgery during pregnancy.

Year 1998
Firstenberg MS. Malangoni MA.
Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
Gastrointestinal surgical problems often mimic symptoms and signs of nonsurgical conditions that occur during pregnancy. This mimicry presents a particular challenge to diagnosis because avoiding a delay in treatment is critical to successful management. Some of these conditions, such as acute appendicitis and biliary colic, are common in younger women; however, the anatomic and physiologic changes of pregnancy can alter their usual manner of presentation. Many elective and urgent operations can be performed during pregnancy with minimal risk to the mother and fetus. The mother's condition should always take priority because her proper treatment usually benefits the fetus as well.

Nausea and vomiting of pregnancy.

Year 1998
Broussard CN. Richter JE.
Department of Gastroenterology, Cleveland Clinic Foundation, Ohio, USA.
NVP is a spectrum of disorders ranging from the physiologically typical mild to moderate nausea and vomiting that is usually self-limited, to the pathologic, intractable symptoms of hyperemesis gravidarum that are associated with metabolic and electrolyte disturbances and weight loss. Up to 90% of pregnant women experience NVP. The pathogenesis remains poorly understood with multifactorial theories proposed combining both biologic and psychological factors. Diagnosing this syndrome is straightforward, but other organic sources should be excluded when symptoms are severe or prolonged. The overall prognosis is excellent for typical NVP, but whether hyperemesis gravidarum increases the risk to the fetus is controversial. Initial management should be conservative, including reassurance of the transient nature of the symptoms and the good prognosis, in addition to dietary modifications. Pharmacologic therapy is reserved for patients with persistent symptoms and is appropriate after discussion of the risks and benefits with informed consent. Alternative treatments, including psychotherapy and other nonpharmacologic modalities, are less proven but potentially safe and effective, thus providing additional therapeutic options. In refractory cases, nutritional supplementation becomes life-saving for both the mother and the fetus. Therapeutic abortion is a rare and last resort, to be used only when maternal life is threatened.

Gastroesophageal reflux disease during pregnancy.

Year 1998
Katz PO. Castell DO.
Comprehensive Chest Pain and Swallowing Center, Allegheny University of the Health Sciences, Philadelphia, Pennsylvania, USA.
Pregnant patients with symptomatic GERD should be managed aggressively with lifestyle modification and dietary changes. Antacids and antacids/alginic acids combination or sucralfate should be considered first-line medical therapy. If symptoms are not adequately relieved or complications develop, treatment with cimetidine or ranitidine should be considered; these H2 receptor antagonists are preferred during pregnancy. Nizatidine cannot be recommended. Proton-pump inhibitors should be used with caution because little human experience is available. Despite this caveat, both proton-pump inhibitors are likely to be safe during pregnancy.

Gastric and duodenal ulcers during pregnancy.

Year 1998
Cappell MS. Garcia A.
Department of Medicine, Maimonides Medical Center, Brooklyn, New York, USA.
The frequency, symptoms, and complication rate of peptic ulcer disease appear to decrease during pregnancy significantly. Clinicians, however, often have to treat dyspepsia or pyrosis of undetermined cause because the frequency of pyrosis increases during pregnancy. Physicians are reluctant to perform esophagogastroduodenoscopy (EGD) during pregnancy for pyrosis to reliably differentiate gastroesophageal reflux from peptic ulcer disease. Dyspepsia or pyrosis during pregnancy first should be treated with dietary and lifestyle changes, together with antacids or sucralfate. When symptoms persist, H2 receptor-antagonists are recommended. If symptoms continue and are severe despite these interventions, the patient should be evaluated for possible EGD or proton pump inhibitor therapy during the second or third trimester.

Constipation and diarrhea in pregnancy.

Year 1998
Bonapace ES Jr. Fisher RS.
Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA.
Constipation and diarrhea are common during pregnancy, occurring in up to one-third of women. Constipation is often the result of physiologic changes that occur during pregnancy, usually from hormonal effects on gastrointestinal motility. Diarrhea, on the other hand, is often caused by the same disorders responsible for diarrhea in the nonpregnant patient. The incidence, pathophysiology, evaluation, and treatment of constipation and diarrhea during pregnancy are reviewed in this article.

Inflammatory bowel disease and pregnancy.

Year 1998
Korelitz BI.
Department of Medicine, Lenox Hill Hospital, New York, New York, USA.
Despite the lack of prospective studies on the relationship between inflammatory bowel disease (IBD) and pregnancy, the evidence strongly supports the conclusions that fertility is compromised in active Crohn's disease; heredity plays an important role in type and location of disease; fetal outcome is essentially no different than in the general population, except in the presence of active Crohn's disease during pregnancy; and the course of IBD during pregnancy is influenced by disease activity or lack of it before pregnancy. The major influence on outcome of pregnancy, fetal outcome, and course of IBD is the favorable effect of drug therapy on the disease. Most drugs, including sulfasalazine, 5ASA products, corticosteroids, and immunosuppressives, are safe, certainly safer than permitting the disease to be active and allowing for the possibility of surgical intervention during pregnancy. Episiotomy is contraindicated in women with Crohn's disease and perirectal complications. Cesarean section probably is indicated in most patients with Crohn's disease with colonic involvement.

Colon cancer during pregnancy. The gastroenterologists perspective.

Year 1998
Cappell MS.
Department of Medicine, Maimonides Medical Center, Brooklyn, New York, USA.
Colon cancer during pregnancy is uncommon but not rare, with an estimated incidence of several hundred cases per year in the United States. This type of cancer tends to have a poor prognosis that is attributable to delays in diagnosis and advanced disease at diagnosis. The diagnosis frequently is delayed because symptoms of colon cancer, such as rectal bleeding, nausea and vomiting, and constipation, often are attributed to normal pregnancy or minor complications of pregnancy. Pregnancy affects the diagnostic evaluation and therapy of colon cancer because of fetal risks of diagnostic tests and therapy. Appropriate medical evaluation of significant lower gastrointestinal complaints during pregnancy can lead to an earlier and improved diagnosis.

Cancer of the colon, rectum, and anus during pregnancy. The surgeons perspective.

Year 1998
Walsh C. Fazio VW.
Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio, USA.
Colorectal carcinoma presenting during pregnancy is uncommon. Most patients present late in pregnancy, and greater than 80% have rectal tumors. Pregnant patients with unexplained rectal bleeding should be evaluated by anorectal examination and flexible sigmoidoscopy. Treatment is individualized to each patient, but a strategy of proceeding immediately with a surgical resection when a diagnosis is made early in pregnancy and allowing the fetus to develop to safe delivery before treating when the diagnosis is made late in pregnancy is recommended. Most patients present with advanced tumors and have a poor prognosis, but prognosis by stage is not different from that in the general population. Adjuvant radiation and chemotherapy have limited roles in the treatment of pregnant women with colon and rectal carcinoma. Future challenges are aimed at improving survival through earlier diagnosis and the development of adjuvant therapies that are effective in patients with advanced disease.

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