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Hépato-gastro-
entérologie
Chirurgie digestive
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Collégiale des Universitaires en Hépato-gastro-entérologie
4e édition
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Hépato-gastro-entérologie – Chirurgie digestive, 4e édition, sous l'égide de la Collégiale des Universitaires en
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Table des matières
Retrouvez toute l'actualité relative aux Référentiels des Collèges en vous connectant à l'adresse
suivante : http://www.blog-elsevier-masson.fr/2018/06/lactualite-referentiels-colleges/
Table des compléments en ligne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XVII

Comité de rédaction de la 4e édition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XXI
Avant-propos. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XXVII
Abréviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XXIX
I Connaissances
1 Item 74 – UE 3 – Addiction à l'alcool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
I. Définitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
A. Addiction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
B. Usage, mésusage et troubles d'usage d'alcool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
II. Étiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
III. Épidémiologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
IV. Dépistage, repérage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
V. Examens biologiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
VI. Signes cliniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
A. Intoxication alcoolique aiguë (ivresse) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
B. Coma alcoolique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
C. Dépendance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 V
D. Accidents du sevrage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
VII. Complications somatiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
VIII. Prise en charge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
A. Principes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
B. Modalités. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2 Item 163 – UE 6 – Hépatites virales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

I. Généralités sur les élévations des transaminases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
A. Causes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
B. Diagnostic et conduite à tenir en cas d'hépatite virale aiguë . . . . . . . . . . . . . . . . . . . . . . . . . . 23
II. Virus de l'hépatite A (VHA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
A. Caractéristiques virologiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
B. Épidémiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
C. Histoire naturelle et diagnostic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
III. Virus de l'hépatite B (VHB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
B. Épidémiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
C. Hépatite aiguë B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
D. Hépatite chronique B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
E. Connaître les grands principes du traitement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
IV. Virus de l'hépatite C (VHC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
B. Épidémiologie, histoire naturelle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
C. Hépatite aiguë C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
D. Hépatite chronique C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
E. Connaître les grands principes du traitement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
V. Virus de l'hépatite D (VHD). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
B. Épidémiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
C. Histoire naturelle et diagnostic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
D. Principes du traitement de l'hépatite chronique delta. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Table des matières
VI. Virus de l'hépatite E (VHE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

B. Épidémiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
C. Histoire naturelle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
VII. Conduite à tenir devant des anomalies isolées de la biologie hépatique. . . . . . . . . . . . . . . 35
A. Évaluation d'une élévation faible à modérée (chronique) des transaminases. . . . . . . . . . . . . . . 35
B. Évaluation d'une élévation forte (aiguë) des transaminases ou d'une élévation
modérée avec signe(s) de gravité . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
C. Évaluation d'un syndrome de cholestase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
`` Compléments en ligne. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3 Item 168 – UE 6 – Parasitoses digestives :

giardiose, amœbose, téniasis, ascaridiose, oxyurose, hydatidose. . . . . . . . . . . . 39
I. Téniasis à Taenia saginata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
A. Épidémiologie, modes de contamination et physiopathologie. . . . . . . . . . . . . . . . . . . . . . . . . 39
B. Clinique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
C. Diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
D. Traitement et prévention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
II. Autres téniasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
A. Taenia solium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
B. Hymenolepsis nana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
C. Diphyllobothrium latum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
III. Ascaridiose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
B. Clinique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
C. Diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
IV. Oxyurose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
VI A. Épidémiologie, modes de contamination et physiopathologie. . . . . . . . . . . . . . . . . . . . . . . . . 43
B. Clinique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
C. Diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
V. Giardiose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
B. Clinique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
C. Diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
VI. Amœbose et abcès amibien du foie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
B. Diagnostic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
C. Traitement et prévention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
VII. Hydatidose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
A. Agent pathogène . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
B. Cycle parasitaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
C. Clinique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
D. Diagnostic biologique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
E. Traitement et prophylaxie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
4 Item 197 – UE 7 – Transplantation d'organes : aspects épidémiologiques

et immunologiques, principes de traitement et surveillance,
complications et pronostic, aspects éthiques et légaux. . . . . . . . . . . . . . . . . . . . . 53
I. Aspects épidémiologiques de la greffe hépatique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
II. Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
III. Résultats de la greffe hépatique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
IV. Organisation administrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
V. Aspects éthiques et légaux. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Table des matières
5 Item 215 – UE 7 – Pathologie du fer chez l'adulte et l'enfant. . . . . . . . . . . . . . . . 57

I. Bases physiologiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
II. Exploration biologique du métabolisme du fer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
A. Ferritine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
B. Coefficient de saturation de la transferrine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
C. Autres paramètres biologiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
III. Anémie par carence martiale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
A. Mécanismes du déficit en fer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
B. Diagnostic de l'anémie ferriprive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
C. Enquête étiologique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
D. Traitement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
IV. Surcharge en fer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
A. Diagnostic d'une surcharge en fer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
B. Hémochromatose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
C. Hépatosidérose métabolique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6 Item 248 – UE 8 – Dénutrition chez l'adulte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

I. Besoins nutritionnels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
A. Besoins nutritionnels de l'adulte. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
B. Particularités chez le sujet âgé. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
C. Particularités chez la femme enceinte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
II. Évaluation de l'état nutritionnel chez l'adulte. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
A. Données cliniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
B. Mesures biologiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
C. Évaluation nutritionnelle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
III. Dénutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
A. Causes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 VII
B. Conséquences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
C. Prise en charge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
7 Item 267 – UE 8 – Douleurs abdominales et lombaires

aiguës chez l'enfant et chez l'adulte. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
I. Étape clinique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
A. Anamnèse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
B. Examen physique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
II. Examens complémentaires. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
A. Biologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
B. ECG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
C. Imagerie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
III. Principaux tableaux de douleurs abdominales. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
A. Douleur biliaire ou colique hépatique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
B. Douleur gastrique ou duodénale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
C. Douleur colique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
D. Douleur pancréatique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
E. Ischémie intestinale aiguë. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
F. Ischémie intestinale chronique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
IV. Grandes causes des douleurs abdominales en fonction de leur localisation . . . . . . . . . . . . . 95
A. Douleur épigastrique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
B. Douleur de l'hypochondre droit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
C. Douleur de l'hypochondre gauche . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
D. Douleur de l'hypogastre. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
E. Douleurs de la fosse iliaque droite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
F. Douleurs de la fosse iliaque gauche. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
G. Douleurs lombaires. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
H. Douleurs abdominales diffuses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
V. Douleurs abdominales aiguës médicales « pièges ». . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Table des matières
8 Item 268 – UE 8 – Reflux gastro-œsophagien chez le nourrisson,

chez l'enfant et chez l'adulte. Hernie hiatale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
I. Définition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
II. Épidémiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
III. Physiopathologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
A. Élément clé : la défaillance de la barrière antireflux œsogastrique . . . . . . . . . . . . . . . . . . . . . . 106
B. Autres facteurs possibles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
C. Relations entre RGO et hernie hiatale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
IV. Signes fonctionnels du RGO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
A. Symptômes digestifs du RGO non compliqué. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
B. Symptômes extradigestifs du RGO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
C. Symptômes de RGO compliqué . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
D. Endobrachyœsophage (EBO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
V. Conduite diagnostique en présence de symptômes de RGO. . . . . . . . . . . . . . . . . . . . . . . . . . 110
A. Examen clinique et examens biologiques standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
B. Examens complémentaires. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
VI. Traitement médical du RGO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
A. Options thérapeutiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
B. Traitement antisécrétoire à la base de la prise en charge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
VII. Chirurgie du RGO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
`` Complément en ligne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
9 Item 269 – UE 8 – Ulcère gastrique et duodénal. Gastrite . . . . . . . . . . . . . . . . . . . 117

I. Ulcère gastrique et duodénal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
A. Anatomopathologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
B. Physiopathologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
C. Épidémiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
VIII D. Diagnostic positif . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
E. Diagnostic différentiel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
F. Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
G. Traitement des UGD non compliqués . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
H. Traitement des UGD compliqués. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
II. Gastrite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
A. Définition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
B. Classification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
C. Gastrite chronique à H. pylori. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
D. Gastrites chroniques de mécanisme immunitaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
D. Gastrites aiguës. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
E. Diagnostic différentiel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
10 Item 270 – UE 8 – Dysphagie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

I. Définition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
II. Deux types de dysphagie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
III. Démarche diagnostique en cas de dysphagie œsophagienne . . . . . . . . . . . . . . . . . . . . . . . . 136
A. Étape 1 : recherche d'éléments d'orientation par l'interrogatoire. . . . . . . . . . . . . . . . . . . . . . . 136
B. Étape 2 : recherche prioritaire d'une lésion organique de l'œsophage . . . . . . . . . . . . . . . . . . . 136
C. Étape 3 : si l'endoscopie œsogastroduodénale est normale,
chercher un trouble moteur œsophagien. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
IV. Dysphagies lésionnelles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
V. Dysphagies non lésionnelles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
A. Achalasie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
B. Autres troubles moteurs de l'œsophage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
11 Item 271 – UE 8 – Vomissements de l'adulte. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

I. Définitions et diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
A. Définitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
B. Diagnostics différentiels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Table des matières
II. Physiopathologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

III. Complications et conséquences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
IV. Démarche diagnostique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
A. Explorations complémentaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
B. Vomissements aigus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
C. Vomissements chroniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
D. Vomissements de la grossesse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
E. Vomissements induits par la chimiothérapie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
V. Traitement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
A. Indications de l'hospitalisation en urgence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
B. Traitement symptomatique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
C. Traitement et prévention des vomissements induits par la chimiothérapie. . . . . . . . . . . . . . . . . 153
12 Item 273 – UE 8 – Hépatomégalie et masse abdominale . . . . . . . . . . . . . . . . . . . . 155

I. Hépatomégalie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
A. Diagnostic positif et différentiel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
B. Causes de l'hépatomégalie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
C. Moyens diagnostiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
D. Démarche diagnostique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
II. Conduite à tenir devant la palpation d'une masse abdominale. . . . . . . . . . . . . . . . . . . . . . . 160
A. Examen d'une masse abdominale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
B. Place des examens d'imagerie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
C. Hypothèses diagnostiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
13 Item 274 – UE 8 – Lithiase biliaire et complications. . . . . . . . . . . . . . . . . . . . . . . . . 167

I. Épidémiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
II. Facteurs de risque. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
A. Calculs cholestéroliques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 IX
B. Lithiase pigmentaire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
C. Calculs mixtes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
III. Dépistage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
IV. Diagnostic de la lithiase vésiculaire symptomatique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
A. Clinique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
B. Biologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
C. Imagerie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
V. Lithiase vésiculaire compliquée . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
A. Cholécystite aiguë. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
B. Migration lithiasique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
C. Angiocholite aiguë . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
D. Pancréatite aiguë. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
VI. Principes thérapeutiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
A. Calculs vésiculaires asymptomatiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
B. Colique hépatique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
C. Cholécystite aiguë. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
D. Angiocholite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
E. Calculs de la voie biliaire principale en dehors de l'angiocholite. . . . . . . . . . . . . . . . . . . . . . . . 176
F. Pancréatite aiguë biliaire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
14 Item 275 – UE 8 – Ictère. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

I. Argumenter les principales hypothèses diagnostiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
A. Définition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
B. Mécanismes d'augmentation de la bilirubinémie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
C. Étiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
D. Situations d'urgence associées à un ictère. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
II. Justifier les examens complémentaires pertinents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
A. Moyens du diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
B. Démarche diagnostique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Table des matières
15 Item 276 – UE 8 – Cirrhose et complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

I. Diagnostiquer une cirrhose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
A. Définition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
B. Différents stades évolutifs et complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
C. Diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
D. Diagnostic étiologique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
II. Identifier les situations d'urgence et planifier leur prise en charge . . . . . . . . . . . . . . . . . . . . 200
A. Hémorragies digestives par rupture de varices œsophagiennes et/ou gastriques . . . . . . . . . . . . 200
B. Encéphalopathie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
C. Infection spontanée du liquide d'ascite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
D. Syndrome hépatorénal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
III. Argumenter l'attitude thérapeutique et planifier le suivi du patient . . . . . . . . . . . . . . . . . . 205
A. Traitement de la cause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
B. Traitement de l'ascite et des œdèmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
C. Encéphalopathie hépatique chronique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
D. Prise en charge des comorbidités . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
E. Orientation vers la transplantation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
IV. Décrire les principes de la prise en charge au long cours. . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
A. Hypertension portale : prévention des hémorragies digestives. . . . . . . . . . . . . . . . . . . . . . . . . 208
B. Contrôle de l'ascite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
C. Prévention de l'encéphalopathie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
D. Dépistage du carcinome hépatocellulaire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
E. Utilisation de scores pronostiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
16 Item 277 – UE 8 – Ascite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

I. Définition – Diagnostic positif. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
II. Diagnostic différentiel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
X
III. Physiopathologie et étiologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
A. Rupture intrapéritonéale d'un conduit liquidien. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
B. Gêne à la résorption du liquide péritonéal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
C. Excès de production du liquide péritonéal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
IV. Diagnostic étiologique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
A. Examen clinique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
B. Examens de laboratoire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
C. Imagerie et examens fonctionnels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
V. Situations d'urgence en rapport avec une ascite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
A. Infection du liquide d'ascite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
B. Complications mécaniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
VI. Démarche diagnostique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
A. Des signes de cirrhose sont-ils présents ?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
B. Des signes d'insuffisance cardiaque sont-ils présents ?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
C. Des signes manifestes de cancer sont-ils présents ?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
D. Dans tous les autres cas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
17 Item 278 – UE 8 – Pancréatite chronique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

I. Définition et incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
II. Facteurs de risque et causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
III. Diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
A. Clinique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
B. Biologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
C. Imagerie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
D. Vue synthétique du diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
IV. Évolution et pronostic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
V. Principes thérapeutiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
A. Sevrage en alcool et tabac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
B. Traitement de la douleur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Table des matières
C. Traitement de l'insuffisance pancréatique exocrine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

D. Traitement de l'insuffisance pancréatique endocrine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
E. Traitement des autres complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
18 Item 279 – UE 8 – Maladies inflammatoires chroniques

de l'intestin chez l'adulte et l'enfant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
I. Maladie de Crohn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
A. Définition, épidémiologie et physiopathologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
B. Quand évoquer le diagnostic ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
C. Confirmation du diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
D. Diagnostic différentiel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
E. Évolution et traitement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
II. Rectocolite hémorragique (RCH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
A. Définition et épidémiologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
B. Quand évoquer le diagnostic ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
C. Confirmation du diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
D. Diagnostic différentiel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
E. Évolution et traitement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
III. Colites microscopiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
19 Item 280 – UE 8 – Constipation chez l'enfant et l'adulte

(avec le traitement). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
I. Définition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
III. Physiopathologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
A. Constipation occasionnelle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
B. Constipations secondaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
XI
C. Constipation idiopathique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
IV. Diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
A. Examen clinique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
B. Explorations complémentaires. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
V. Traitement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
A. Constipation organique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
B. Constipation idiopathique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
20 Item 281 – UE 8 – Colopathie fonctionnelle – Syndrome

de l'intestin irritable. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
I. Épidémiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
II. Physiopathologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
A. Troubles de la motricité digestive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
B. Troubles de la sensibilité digestive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
C. Inflammation et microbiote . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
D. Influence des troubles psychologiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
III. Clinique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
IV. Conduite diagnostique pratique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
A. Importance de l'étape clinique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
B. Explorations complémentaires. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
V. Traitement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
A. Moyens thérapeutiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
B. Utilité des régimes ?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
C. Médicaments ou aliments agissant sur le microbiote. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
D. Prise en charge psychologique et médecines alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
E. Indications thérapeutiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
VI. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
VII. Annexe – Critères de Rome IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Table des matières
21 Item 282 – UE 8 – Diarrhée chronique

chez l'enfant et chez l'adulte. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
I. Définitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
II. Interrogatoire et examen clinique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
A. Interrogatoire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
B. Examen clinique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
III. Examens complémentaires. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
A. Examens biologiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
B. Examens morphologiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
IV. Stratégie d'exploration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
V. Principales causes de diarrhée chronique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
A. Diarrhée motrice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
B. Diarrhée osmotique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
C. Malabsorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
D. Diarrhée sécrétoire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
E. Colites microscopiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
F. Diarrhée exsudative ou lésionnelle (entéropathie exsudative) . . . . . . . . . . . . . . . . . . . . . . . . . . 278
22 Item 283 – UE 8 – Diarrhée aiguë et déshydratation

chez le nourrisson, l'enfant et l'adulte. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
I. Définitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
III. Interrogatoire et examen clinique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
IV. Conduite à tenir en fonction du contexte. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
A. Diarrhée aiguë en dehors de la diarrhée des antibiotiques et nosocomiale . . . . . . . . . . . . . . . . 283
B. Diarrhée des antibiotiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
XII
C. Diarrhée aiguë nosocomiale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
V. Traitement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
A. Mesures thérapeutiques générales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
B. Traitement d'urgence de la diarrhée . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
C. Traitement de la diarrhée et des colites des antibiotiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
23 Item 284 – UE 8 – Diverticulose colique et diverticulite

aiguë du sigmoïde. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
I. Définitions – Anatomie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
II. Épidémiologie – Physiopathologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
III. Prise en charge de la diverticulose non compliquée . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
IV. Complications de la diverticulose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
A. Diverticulites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
B. Hémorragies d'origine diverticulaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
24 Item 285 – UE 8 – Pathologie hémorroïdaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299

I. Données épidémiologiques et facteurs de risque . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
A. Épidémiologie et filières de soins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
B. Facteurs de risque . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
C. Implication symptomatique sur le plan du dépistage du cancer colorectal. . . . . . . . . . . . . . . . . 300
II. Expression symptomatique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
A. À un stade précoce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
B. À un stade tardif. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
C. Maladies associées . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
III. Examen clinique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
IV. Explorations complémentaires. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
V. Critères du diagnostic et principaux cadres étiologiques
différentiels des douleurs anales aiguës. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Table des matières
VI. Principes thérapeutiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306

A. Traitement médical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
B. Traitement endoscopique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
C. Traitement chirurgical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
VII. Critères utiles à la prise en charge thérapeutique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
VIII. Suivi et surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
25 Item 286 – UE 8 – Hernie pariétale chez l'enfant et l'adulte. . . . . . . . . . . . . . . . . 313
I. Anatomie – Définitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
II. Diagnostic d'une hernie de l'aine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
A. Diagnostic positif . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
B. Diagnostic différentiel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
C. Hernie étranglée. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
III. Argumenter l'attitude thérapeutique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
A. Moyens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
B. Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
C. Résultats. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
26 Item 298 – UE 9 – Tumeurs du côlon et du rectum : Item 287 – UE 9 –

Incidence, prévalence, mortalité, facteurs de risque, prévention
primaire et secondaire, dépistage des cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
I. Tumeurs bénignes du côlon et du rectum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
A. Définition des polypes et polyposes colorectales. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
B. Histologie des polypes colorectaux bénins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
C. Filiation adénome – cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
D. Circonstances de découverte et moyens diagnostiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
E. Conduite à tenir en cas de découverte de polypes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
F. Surveillance après exérèse de polypes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
G. Polyposes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 XIII
II. Cancers du côlon et du rectum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
A. Épidémiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
B. Facteurs de risque et stratégie de dépistage en fonction du niveau de risque . . . . . . . . . . . . . . 328
C. Circonstances de diagnostic (en dehors de la découverte fortuite et du dépistage) . . . . . . . . . . 330
D. Examens utiles au diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
E. Bilan préthérapeutique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
F. Classification histopronostique des cancers colorectaux. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
G. Grands principes du traitement des cancers colorectaux non métastatiques. . . . . . . . . . . . . . . 333
H. Surveillance après un traitement à visée curative d'un cancer colorectal. . . . . . . . . . . . . . . . . . 334
I. Principes thérapeutiques des cancers colorectaux métastasés . . . . . . . . . . . . . . . . . . . . . . . . . . 334
27 Item 300 – UE 9 – Tumeurs de l'estomac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339

I. Définitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
II. Épidémiologie de l'adénocarcinome gastrique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
III. Facteurs de risque . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
A. Helicobacter pylori (H. pylori). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
B. Facteurs génétiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
C. Facteurs environnementaux. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
D. Lésions précancéreuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
IV. Diagnostic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
A. Circonstances de découverte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
B. Clinique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
C. Diagnostic positif . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
V. Bilan d'extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
VI. Principes du traitement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
VII. Pronostic et surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
VIII. Formes particulières. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
A. Adénocarcinome du cardia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
B. Adénocarcinome superficiel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
C. Linite gastrique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
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D. Lymphomes gastriques primitifs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347

E. Tumeurs stromales gastro-intestinales (GIST). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
F. Tumeurs endocrines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
28 Item 301 – UE 9 – Tumeurs du foie, primitives et secondaires . . . . . . . . . . . . . . . 353

I. Définition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
III. Circonstances de découverte. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
IV. Éléments de caractérisation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
A. Tumeurs bénignes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
B. Tumeurs infectieuses et parasitaires (abcès et kystes). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
C. Tumeurs malignes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360
V. Démarche diagnostique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
A. Première étape : y a-t-il une maladie chronique du foie ?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
B. En cas de maladie chronique du foie : est-ce un carcinome hépatocellulaire ? . . . . . . . . . . . . . . 365
C. En l'absence de maladie chronique du foie documentée :
détermination de la nature kystique ou solide par échographie. . . . . . . . . . . . . . . . . . . . . . . . . . 366
29 Item 302 – UE 9 – Tumeurs de l'œsophage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

I. Épidémiologie des cancers de l'œsophage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
II. Facteurs de risque et conditions précancéreuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
A. Cancer épidermoïde . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
B. Adénocarcinome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
III. Prévention et dépistage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
IV. Symptômes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
A. Au stade précoce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
XIV B. À un stade avancé. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
V. Examen clinique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
VI. Explorations complémentaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
A. Examen utile au diagnostic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
B. Bilan préthérapeutique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
VII. Traitement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
A. Cancers de stade I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
B. Cancers de stade II. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
C. Cancers de stade III. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
D. Cancers de stade IV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
30 Item 305 – UE 9 – Tumeurs du pancréas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379

I. Épidémiologie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
II. Facteurs de risque. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
A. Facteurs de risque exogènes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
B. Facteurs de risque endogènes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
III. Dépistage et traitement préventif. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
IV. Diagnostic positif. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
A. Clinique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
B. Biologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
C. Imagerie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
D. Confirmation histologique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
V. Bilan d'extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
VI. Pronostic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
VII. Principes thérapeutiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
A. Traitement à visée curative. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
B. Traitements palliatifs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
VIII. Tumeurs neuroendocrines pancréatiques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
IX. Cas particulier des TIPMP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
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“Oh, Dave will do for a substitute,” said Henderson candidly. “If
you get off probation, Lester, you’ll have the position cinched.”
“I’ll get off all right. It won’t be such a job either—now that some
one else will take Mr. Dean’s place.”
That remark, more than Henderson’s frankness, made David
wince. That Wallace could imagine any advantages accruing to
himself from Mr. Dean’s misfortune was most unpleasant.
Upon the impulse David spoke. “You know perfectly well there
isn’t a fairer-minded man than Mr. Dean in this school.”
Wallace flushed. “I wasn’t trying to run him down, even if he
always has had it in for me.”
David made no response; the disclaimer was as unkind as the
innuendo.
Two days later Mr. Dean returned to the school. He sent for David
at noon; David, entering his study, found him sitting at the desk with
a pen in his hand.
“I’m trying to learn to write,” Mr. Dean explained as he laid down
the pen and held out his hand. “Take up the page, David, and tell
me whether I overrun it or crowd lines and words together. What is
my tendency?”
“It’s all perfectly clear, only you waste a good deal of paper; you
space your lines far apart and get only a few words to a line,” David
said.
“That’s erring on the safe side, anyway. What’s going to bother me
most will be to know when the ink in my fountain pen runs dry. It
would be exasperating to write page after page and then learn that I
hadn’t made a mark!” Mr. Dean laughed cheerfully. “Well, the trip to
Boston didn’t result in any encouragement; I knew it wouldn’t. I’ve
been talking with the rector this morning, and I’m to go ahead with
my work here. The fact is, I’ve been teaching Cæsar, Vergil, and
Horace for so many years that I know them almost by heart—
sufficiently well to be able to follow the translation if some one reads
the Latin passage to me first. I wanted to ask you if you would pilot
me to the classroom and home again—for a few days at least; I
expect in a short time to be able to get about all alone.”
“Of course,” said David, and then he exclaimed, “It’s fine that
you’ll be able to keep on; it’s wonderful!”
“It’s generous of the rector to permit it,” said Mr. Dean. “I shan’t
be of any use for disciplinary purposes any more; I shall be relieved
of the side of teaching that I have always disliked, so my misfortune
is not without its compensations.”
“I’m awfully glad you’re not going to leave us,” David said. “And
you’ll find that all the fellows will want to help you.”
That afternoon when all the boys were assembled in the
schoolroom for the first hour of study, Dr. Davenport entered and,
mounting the platform, stood beside Mr. Randolph, the master in
charge. The boys turned from their desks and looked up at him
expectantly.
“As you have all been grieved to learn,” said Mr. Davenport, “of the
affliction that has come upon the oldest and best loved of our
masters, so, I am sure, you will be glad to hear that he is not to be
lost to us, but will continue to do his work here, even under this
heavy handicap. We have all of us always respected and admired his
scholarship; we must do so even more now when it is equal to the
task of conducting recitations without reference to the printed page.
We have all of us always respected and admired his spirit of
devotion; even more must we admire it now and the fortitude that
accompanies it. I do not believe there is a boy here who would take
advantage of an infirmity so bravely borne, and I hope that those of
you who have classes with him will try to show by increased
attention and considerateness your appreciation of his spirit.”
Dr. Davenport stepped down from the platform and walked out of
the room, leaving it to its studious quiet.
At the end of the hour, in the five-minute intermission, David
heard Monroe say to Wallace, “Pretty good little talk of the rector’s;
right idea.”
“Oh, sure,” Wallace answered.
CHAPTER VIII
WALLACE’S EXAMINATION
L oneliness was at least one misery that the afflicted schoolmaster

did not have to experience. His colleagues were all attentive to
him and tried to relieve the monotony of the hours. Among the older
boys were many who came to see him in his rooms and offered their
services for reading or for guiding him on walks or for writing at his
dictation. He welcomed them all, he gave each one the pleasure of
doing something for him and himself took pleasure in the friendly
thought, but it soon became evident that there were two or three
out of the whole number of volunteers on whom he especially
depended. Mr. Randolph, the English teacher, and Mr. Delange, the
French teacher, were his most intimate and devoted friends among
the masters; but on David even more than on them he seemed to
rely for little services. Thus it was David that every morning after
breakfast walked with him to chapel; it was David that led him back
to his house at the end of the daily fifth-form Latin recitation; it was
David that usually conducted him in the afternoons to the athletic
grounds. Always an interested observer of the sports, Mr. Dean
declared now that he would continue to follow them even if he could
not see; and so on almost every pleasant day during the recreation
hour he was to be found seated on the piazza of the athletic house
that overlooked the running track and the playing field. One boy
after another would come and sit beside him and tell him what was
going on; in the intervals of their activity ball-players and runners
would visit him and receive a word of congratulation for success or
of joking reproof for failure; sometimes he would ask his companion
of the moment not to enlighten him as to the progress of the game,
but to let him guess from the sounds and the shouts what was
taking place; his pleasure when he guessed correctly was
enthusiastic and touching.
“Try watching a game sometime with your eyes shut,” he
suggested to David. “You’d find there’s a certain amount of interest
in it. You’ll be surprised to find how successfully ears are capable of
substituting for eyes.”
Just then Lester Wallace, who had made a run in the Pythians’
practice game, came up saying, “How are you, Mr. Dean? This is
Wallace.”
“Good; that was a fine clean hit of yours just now. I said to David
the moment I heard the crack, ‘There goes a base hit.’ Don’t forget
that the Pythians need your batting, Wallace.”
“That’s one thing I wanted to ask you about, Mr. Dean.” Wallace
glanced at David somewhat sheepishly. “When do you think I’ll get
off probation?”
“I wouldn’t undertake to predict about that.” If there was no
longer any twinkle behind the dark glasses that Mr. Dean now wore,
there was a genial puckering of the wrinkles at the corners of his
eyes. “But I can tell you perhaps when you’ll have an opportunity to
get off probation. The game with the Corinthians is a week from to-
day, isn’t it? Well, you come to me in the noon intermission that day,
and I’ll give you an oral examination.”
“You don’t think I could get off any earlier?”
“I’m very much afraid, Wallace, that you need all the time I can
give you.”
“Haven’t my recitations been better lately, Mr. Dean?”
“Yes, there has been a decided improvement. I’ve noticed it, and
I’ve appreciated it, Wallace. For I thought that it was due not only to
a regard for your own welfare, but also to a kindly consideration for
me.”
He put out his hand gropingly and patted the boy’s leg. David
noticed that Wallace flushed and looked momentarily unhappy; then
an unpleasant, sulky expression appeared on his face.
“If my mark has improved so much and I go on reciting well in
class, I don’t see why I should have to stand an examination.”
“Only because it’s the rule, and we can’t make exceptions. I shall
let your work in the classroom count towards your efforts to regain
your freedom, but the examination must be important, too.”
Wallace’s acceptance of that decision did not seem to David
particularly gracious, nor did the dissatisfied look vanish from his
face. He withdrew after a few moments.
Mr. Dean remarked rather sadly to David; “I don’t seem ever quite
to get hold of Wallace. There’s something there, but I don’t reach
him.”
“He’ll be all right when he’s off probation,” David said. “And I think
he really has been working harder; I’ve thought his recitations were
much better lately.”
“Yes, there’s no doubt of that, and perhaps it’s my fault that when
we meet he’s not more responsive. Every one of us is Dr. Fell to
somebody, I suppose, and there’s no use in blaming that somebody
for what he can’t help. There, who hit that crack? That must have
been a good one.”
“Henshaw—long fly to center; Morris got under it all right. The
Corinthians are going out for practice now, Mr. Dean.”
“All right; good luck. Put up a star game at first, so that you can
tell me about it when you come in.”
David laughed and departed; looking back, he was glad to see
that some one already had taken his place beside Mr. Dean’s chair.
He played well that afternoon and had the satisfaction of being
commended by the captain, Treadway, as well as by Mr. Dean. When
he came out of the athletic house after dressing, the master was
gone; David walked up to the dormitory with Wallace.
“I wish I were off probation now,” Wallace said. “It seems to me
Mr. Dean likes to keep me in suspense; this idea of not knowing until
the day of the game whether I can play or not!”
“Oh, you’ll be able to play,” David assured him. “You’ve been doing
well in class lately; there’s no doubt about your getting through the
examination. If you want me to help you at all, I’ll be glad to do it.”
“I guess I can get off probation without your help,” said Wallace
ungraciously.
“Excuse me for speaking,” replied David, and he walked on,
flushed and silent.
Wallace spoke after a moment. “Hold on, Dave; don’t be so short
with a fellow. I didn’t mean to speak as I did. It was just that I—
well, I don’t want you to feel that I need to be helped all the time—
as if I couldn’t do anything for myself.”
He looked at the ground and seemed in spite of his words
somewhat shamefaced. But David paid no heed to that; his response
to the appeal was immediate.
“Of course you can do anything you set your mind to,” he said
heartily, linking arms with Wallace. “And I should think you would
feel I was a fresh, conceited lobster to come butting in always as if I
thought you couldn’t get along without me. The recitations you’ve
been giving lately have been as good as any one’s; and of course
you ought to have all the credit yourself when you get off probation.
Your father will be awfully pleased.”
“Oh, I guess he won’t care. Just so long as I get through my
examinations—that’s all that he takes any interest in.”
“He probably takes more interest than you think—of course he
does—an old St. Timothy’s boy himself!”
“Oh, well, I dare say.” For some reason Wallace was out of sorts.
He added, however, with more spirit: “Of course he’d like to see me
play on the nine. He was on it when he was here. I wish I could
always be sure of lining them out the way I did to-day.”
They talked baseball during the rest of the walk, and Wallace’s
spirits seemed to improve.
Indeed, as the days went on David could see no reason for
Wallace’s moodiness. On the ball field Wallace was playing so
brilliantly and received from team mates and spectators so much
appreciation that he had no reason to feel dissatisfied; never had his
popularity and importance in the school been greater. And so far as
scholarship was concerned, the improvement that he was making
was notable. In mathematics, French, and English he had never
been under any disqualifications, but he now was taking rank among
the first in the class. In Latin, the study in which he had always been
weak and indifferent, his translations had become surprisingly fluent
and correct. He sat by himself in a corner of the recitation room,
holding his book down between his knees and bending over it in an
attitude of supreme concentration; his nearest neighbor seldom saw
him raise his eyes and never had a glimpse of the text over which he
pored. When Mr. Dean called on him, he rose and, raising the book
in his arms and with bent head, read the Latin lines, then slowly but
accurately translated, scarcely ever stumbling over a word. Mr. Dean
had a variety of commendatory expressions for his work—“Good,”
“Very well rendered indeed,” “Good idiomatic English—the kind of
translation I like; I wish some of you other fellows would not be so
slavishly literal.” Wallace would sit down with a face unresponsive to
such comments and would again huddle over his book with absorbed
attention.
David and some of the other fellows commented among
themselves upon those recitations.
“I didn’t know Lester was so bright,” said Monroe. “I guess there’s
nothing that boy can’t do if he puts his mind to it.”
“I guess there isn’t,” David agreed loyally. “He gets it from his
father; Dr. Wallace is a wonder.”
So impressive was the sudden manifestation of Wallace’s
intellectual prowess and so widely heralded the report of it that he
was elected into the Pen and Ink Society, an organization of boys
with scholarly and literary inclinations. The news of this election,
however, he took with bad grace; he declared himself entirely out of
sympathy with the purposes of the institution and expressed
violently a resolve not to be drafted into the ranks of the “high-
brows.” The dejected emissaries of the Pen and Ink had to report to
their society that Wallace had declined the election without even
seeming sensible of the honor that had been done him, and the
popularity that Wallace had achieved suffered somewhat in
consequence. Some of the aggrieved members told Ruth Davenport
of the slight that had been put on their society, and Ruth, when next
she met Wallace, took him to task for it.
“Why,” she asked, “did you want to be so grouchy?”
“I wasn’t grouchy,” Wallace replied, though his manner at the
moment might have been so described. “I just felt I didn’t belong in
that crowd.”
“You might have shown them you appreciated the honor.”
“Oh, I might have if I’d felt I deserved it.”
“If you’d only said something like that to them!”
“Well, I didn’t deserve it, and I knew it better than they did; and I
didn’t want to be bothered.” He looked past Ruth with an expression
at once discontented and defiant.
“You’re an awfully funny person.” Ruth’s eyes twinkled and her lips
curved into a smile. “You’re so modest that you think you’re not
good enough for them, and yet you make them think they’re not
good enough for you!”
He did not respond to her gayety, but said in a rather surly voice:
“I don’t care what they think. I’m interested in baseball, not in silly
scribblings.”
The bell rang, summoning him to the schoolroom, and Ruth
walked away, feeling that she had been rebuffed by one of her
friends.
It was impossible for her, however, and for such members of the
Pen and Ink as were daily spectators of the Pythians’ baseball
practice, not to admire Wallace’s playing, not to be enchanted by the
speed and accuracy of his throwing, the cleanness of his fielding,
and the strength and sureness of his batting. “The best infielder in
the school,” the fellows said; “the best infielder there’s ever been in
the school,” asserted the younger enthusiasts, as if from a fullness of
knowledge. Any way, Ruth and even the most incensed members of
the scorned society felt as they watched his enviable performances
that they must forgive much to the possessor of such talent—and
sighed in their different ways over his inaccessibility to advances.
“You’ve certainly got to get off probation,” said Henshaw to
Wallace the day before the game.
“Oh, I’ll get off all right,” Wallace assured him. “I’m to have a
special oral examination to-morrow at noon. You can count on me.”
The fifth-form Latin recitation came at the hour immediately
preceding that set for Wallace’s test. On the way to the classroom he
showed annoyance and irritation to those who crowded round him to
express their eager wishes for his success. “You needn’t hang about
and wait for news,” he said when Hudson, the Pythian short-stop,
had hoped that the suspense would not last long. “I’ll be all right,
and I don’t want a gang looking round when I come out.”
Hudson dropped back and remarked to David that he was afraid
Wallace’s nerves were pretty much on edge.
At the end of the recitation hour, while all the other fellows were
moving toward the door, Wallace kept his seat at the back of the
room. Mr. Dean asked David to stop and speak with him a moment;
he told him that Wallace’s examination would last about fifteen
minutes, and that then he would as usual be glad to have David’s
assistance in walking home. So David returned to the schoolroom
and proceeded to work on the problems in algebra assigned for the
afternoon. He had finished one and was halfway through another
when a glance at the clock told him that it was time to be going to
Mr. Dean’s assistance—and also, no doubt, to Wallace’s relief.
The examination was still proceeding when he entered the
classroom and sat down near the door. Wallace had moved forward
and was occupying a seat immediately under Mr. Dean; he looked
up, startled, when David appeared and then at once huddled himself
over his book, which he entirely embraced with arms and knees. He
continued in a rather mumbling and hesitating voice with his
translation, but the halting utterance did not disguise the accuracy of
the rendering; David, listening, was glad to be assured that Wallace
was acquitting himself so brilliantly. Mr. Dean interrupted the
translation after a moment to say:
“Is that you, David?”
“Yes, right here,” David answered.
“Lester and I will be finished in a few moments. We won’t keep
you waiting long.”
“If it’s just about walking home, Mr. Dean,” Wallace said, “David
needn’t stay; I shall be glad to walk home with you if you’ll let me.”
He spoke with eagerness, and Mr. Dean in his reply showed
pleasure.
“Thank you. All right, David; I won’t detain you then any longer.”
As David departed he felt that Wallace had found his presence
unwelcome, and he was glad to remove himself from his position of
involuntary listener and critic. Besides, he could make good use of
the time in finishing his algebra exercises.
He returned to the schoolroom and was hard at work when
Wallace entered, passed him with brisk steps crying, “I’m all right;
off probation!” and, opening his desk, which was just behind David’s,
tossed his book into it. Then, without waiting for any
congratulations, Wallace hurried out to join Mr. Dean.
David, to his annoyance and perplexity, found that he had gone
astray in some of his processes and that his solution was wrong.
Inspection showed him where he had blundered; he opened his desk
and looked for his eraser. It was not there, and he remembered
having lent it to Wallace the night before. He got up and opened
Wallace’s desk; the confusion of books and papers daunted him, but
he proceeded to search. Then the topmost book, the one that
Wallace had deposited there a few moments before, arrested his
attention; it was not the edition of Vergil that the class used. He
opened it out of curiosity and stood there gazing at its pages with a
stricken interest.
The book was of that variety known in St. Timothy’s parlance as a
“trot.” Alternating with the lines of Latin text were lines of English
translation. The correctness and fluency of Wallace’s recitations were
explained. So also was his huddling over his book, his shielding it so
carefully from any one’s gaze.
David put the book down and closed the desk without carrying
any further the search for the eraser.
CHAPTER IX
DAVID’S ENLIGHTENMENT
A fter closing Wallace’s desk upon his secret David walked slowly
over to the dormitory. He felt bewildered and uncertain.
Something that had been precious to him, something to which he
had clung, had suddenly and utterly been shattered. To get the
better of a master in any way that you could was, he knew, the code
of many fellows, and in ordinary circumstances, where the master
had what the boys termed “a sporting chance,” a resort to
subterfuges and deceptions did not necessarily imply depravity. But
to take advantage of a blind man—that was base.
David arrived at his room five minutes before the hour for
luncheon. Happy excitement over the contest of the afternoon in
which he was to play a part had faded; in its place there seemed
only a dull ache of disappointment and loss. There came to him
memories of Wallace’s generous friendship—of the day when he had
supported him in his fight with Henshaw, of the time when he had
given him his running shoes, of the little acts of kindness; and he
wondered now why it was that he could not overlook the discovery
that he had just made and feel toward Wallace as he had always
done.
The dinner bell rang; descending the stairs, David encountered
Wallace at the bottom. Wallace was radiant, slapped him on the
shoulders and cried: “I’ll get your goat this afternoon, Dave. How
are you feeling? Fine?”
“Not especially,” David answered; indeed, he felt himself shrinking
under his friend’s touch. He knew now that he could not assume the
old exuberant geniality and that until he had given Wallace an
opportunity to explain he could not keep up even the pretense of
warm friendship.
Wallace did not notice his coolness; he saw another friend and
made for him. At the luncheon table Henshaw and Monroe and
others expressed their satisfaction that Wallace was saved to the
Pythian team and, more important still, to the school team. David
wondered whether they thought he was jealous or envious or
unsportsmanlike because he did not join in the remarks. He
supposed they did think so, but that could add little to his
unhappiness.
As a matter of fact, once out on the field he was able to forget his
depressing preoccupations; the lively work of the preliminary
practice restored his zest for the game. And when it began he was
as keen to do his best, as eager to win, as any one on the Corinthian
nine. But victory did not perch on the Corinthian banner, in spite of
the loyal support of the “rooters” along the third-base line, in spite
of the desperate efforts of catcher and captain and whole infield to
steady a wavering pitcher, in spite of a ninth-inning rally, when a
shower of hits by seemingly inspired batters brought in three runs
that were within one of tying the score. The Pythians triumphed,
eight runs to seven, and unquestionably the chief honors belonged
to Wallace. His home run, a smashing hit to left center in the third
inning, brought in two others; and his double in the seventh sent
what proved to be the winning tally across the plate. Moreover, it
was his leaping one-hand catch of a hot liner from Treadway’s bat
that closed the game when the Corinthians were most threatening.
David, crouched forward on the players’ bench in nervous
intentness when that incident happened, felt a pang of
disappointment, then a throb of admiration for the brilliant catch and
of gladness for him who had made it, and then the chill of
despondency; there could be no real heartiness in any
congratulations that he might offer to his old friend. The Pythian
crowd was rallying round Wallace; in another moment he was
hoisted on their shoulders and was being borne exuberantly toward
the athletic house, while spectators and players streamed in his
wake. David, walking slowly, overtook Mr. Dean, who arm in arm
with Mr. Randolph was leaving the field.
“A pretty good rally that you fellows made, David,” said Mr.
Randolph. “If it hadn’t been for that catch of Wallace’s you might
have beaten them.”
“Yes, yes!” Mr. Dean chuckled. “Wallace was too much for your
team, David. It seemed to me that I kept hearing the crack of his
bat and the thud of his glove all through the game. Well, he earned
his right to play, and I’m glad he distinguished himself.”
“He certainly played a wonderful game,” was all that David could
say in reply.
In the athletic house Wallace was still surrounded by his admirers.
David dressed hastily and went to his room. He shut himself in there
and thought. If he told Wallace what he had discovered and what he
suspected and how the suspected act of dishonesty had made him
feel, what would be the result? Wallace would probably always shun
him henceforth, and he would always be uncomfortable when
Wallace was present. Intimacy between them would die. And then—
David knitted his brows over this question—could he afford to return
to St. Timothy’s for another year at Dr. Wallace’s expense? Would he
not feel ashamed to do it? Would not Lester Wallace be justified in
that case in looking at him with a sneer? It did not take David long
to determine what must be the answer. No; in such circumstances to
continue to be the beneficiary of Dr. Wallace’s bounty would be
intolerable. David realized that his career at St. Timothy’s must come
to an untimely end.
With that thought in mind, gazing out of the window at the
pleasant, sun-swept lawns and the ivy-covered buildings, he felt sad
and sorrowful. He did not want to leave prematurely this place that
he had learned to love and that was to have been—had already
been—so helpful in his development. But schooling purchased at the
sacrifice of self-respect would cost too dear. To preserve his self-
respect he must not play any false part toward Wallace; he must let
him know exactly what he had discovered and what a change in his
feelings the discovery had made.
Fifteen minutes later, on his way to the study, he met Ruth
Davenport and Lester Wallace. David touched his cap and was
passing on when Ruth stopped him.
“Wasn’t he the wonder, David!” she exclaimed with a sidelong
laugh at Wallace. “Do you suppose that after all he did to-day he’ll
have anything left to show against St. John’s?”
“Oh, just as much,” David answered lightly.
Wallace laughed; he was in high spirits. “Well, if I don’t, they’ll
have a mighty good substitute to use in my place.” He clapped David
on the shoulder.
“Yes,” Ruth agreed. “It’s a shame, David, that you both can’t play.
But anyway it will be much nicer for Mr. Dean; he told me that you
help him to see a game better than any one else. There he comes
now with father. Good-bye.” She darted across the road and went
skipping to meet the rector and Mr. Dean.
Wallace linked arms with David and started toward the study. “You
put up a cracking good game, too, Dave. Next year you must try
playing second base. Adams won’t be coming back, and you ought
to be able to get the place on the school nine. We’d make a good
team, you and I, at first and second.”
“I probably shan’t be coming back next year,” David answered.
Wallace dropped his arm and looked at him with amazement and
consternation.
“Why? What’s the trouble?”
“Oh, it just looks as if it wouldn’t be possible. But I want to talk to
you about something else, Lester. You remember I was sitting in the
schoolroom when you came in after your examination at noon?”
“Yes.” Wallace shot at him a glance of sharp suspicion.
“After you’d gone,” David continued with a tremor of nervousness
in his voice, “I wanted an eraser; I couldn’t find mine, and I looked
in your desk for it. I saw the book that was lying on top of the
others. I suppose it was the one you had just been using in your
examination.”
Wallace’s face had turned a dull red. He hesitated a moment, then
he said quietly, “Yes, it was.”
“I didn’t suppose you’d do that kind of thing, Lester,” said David.
“If you’d done it to anybody else—but to a man that’s blind!”
Wallace was silent. David, glancing at him as they walked, saw
that his head was downcast and his face still red. The sight made
David, who had been steeling himself to be hard, soften and want to
say, “O Lester, we’ll forget it, we’ll never think of it again!” But he
knew that could not be true, and he walked on, silent.
“I was ashamed of it, Dave,” Wallace said at last in a low voice. “I
used the book in class—that’s how my recitations happened to be so
good. That’s how I got a reputation for being so bright—my election
to the Pen and Ink. You know I wouldn’t take it, Dave.” He spoke
with appeal in his voice. “I was ashamed to do that.”
They were approaching the study; they crossed the road to avoid
groups of boys who were standing in front of the building. “What
you fellows having a heart-to-heart about?” called Adams, who had
played second base on the Corinthian nine. Wallace made no
answer; David waved a hand in reply. They walked slowly on—for a
time in silence. Then Wallace spoke again:
“I found the book just by chance in a second-hand bookstore in
town. It wasn’t as if I’d done anything to injure Mr. Dean. It couldn’t
hurt him in any way.” His tone was pleading rather than defiant.
“No,” David said. “But it wasn’t straight. Don’t you see?”
“I didn’t always read the translation,” Wallace pleaded. “I only
looked at it when I had to.”
“If it had been anybody but a blind man.”
“Lots of fellows crib any way they can.”
“Not with Mr. Dean.”
“You’re dippy about him; you take it worse than he would
himself!” Wallace’s manner had become resentful instead of
appealing.
“I can’t help it, Lester. Here’s a thing that I’ve found out about
you, and I’ve got to be honest and tell you how it’s made me feel.”
“All right; it’s just the opinion of a prig. I guess you’re right in
leaving; you’re too good to live in this school.”
Wallace’s voice had grown suddenly bitter with anger, and his
eyes, raised at last to meet David’s fairly, were hard and bright.
“Well,” said David flushing, “perhaps I am a prig. Anyway, you
can’t be more disappointed in me than I am in you.”
The study bell rang out; David wheeled and walked briskly to the
schoolroom while Wallace followed at a slower pace. In the hour of
study David’s thoughts kept straying from his books. He knew now
that he had hoped Wallace might have some explanation, some
defense. His little world was in ruins, and he had done his best. He
was not sure that he had not been the prig that Wallace styled him.
Anyway, it was the end of friendship between him and Wallace—and
that meant the end of his term at St. Timothy’s School.
That evening after supper Clarence Monroe brought David word
that Mr. Dean would like to see him at his house for a few minutes.
He found the master lying on his lounge, with his hands under his
head.
“I was fortunate enough to learn a lot of poetry in my youth,” said
Mr. Dean when David entered. “It helps me now to while away the
time, and passages that I thought I had long since forgotten keep
coming back to me. Of course there are gaps, and it’s very trying not
to be able to fill them at once—to have to wait until I can find some
one to look the missing lines up for me. Just now I’ve been dredging
my memory in vain; do you remember the lines:
“Therefore am I still
A lover of the meadows and the woods
And mountains?”
“No,” David acknowledged. “I don’t know where they’re found.”

“They’re from Wordsworth’s poem on Tintern Abbey. But I can’t
remember just what comes after; you’ll find Wordsworth on that
second shelf.”
David soon turned to the passage and began to read it, but Mr.
Dean took the words out of his mouth and recited them to the close.
“Now, I shouldn’t lose them again,” he said. “But you see how it is
—living alone here. Sometimes I can call my housekeeper to my
assistance, but she hasn’t much feeling for poetry, excellent
housekeeper though she is; and a sympathetic soul in such a matter
is important—an ear to hear and a mind to comprehend! Well,
David, I sent for you because I wanted to talk to you a little about
my plans.”
David waited, silent in mystification.
“I told Dr. Davenport that I should of course resign my position at
the end of the year,” continued Mr. Dean. “I felt that I was too
seriously handicapped to be of much service. To my surprise Dr.
Davenport said that if I presented my resignation he wouldn’t accept
it. He seemed to think that I could still be of use to the school. Of
course it pleased and touched me very much that he should think
so. But I realize that I shall need a regular helper in my work; this
term I’ve been depending on the good nature of this person or that
person. I’ve hesitated to ask you; yet I’ve wondered if you would
make the sacrifice of coming and living here with me instead of with
the fellows of your age and class?”
“It wouldn’t be any sacrifice, Mr. Dean. But”—David hesitated a
moment—“I’m afraid I shan’t be coming back next year.”
“Not coming back!” Mr. Dean’s voice rang with astonishment, and
he turned his head toward David as if he still could see. “Is it some
family difficulty, David? Your mother needs you at home, you think?”
“No, it isn’t that,” David answered reluctantly. “She doesn’t know
yet that I can’t come back.”
“It’s a matter, then, of very recent decision?”
“Yes. Just within a day or two I—I found it out.”
“Couldn’t you take me a little into your confidence, David?”
“It’s—it’s just that Lester Wallace and I aren’t on good terms any
more,” David said. “And I can’t let his father go on helping me, even
if he should be willing to.”
“Is that a necessary conclusion? Just because you and Wallace
have had a falling-out that, I hope, will be only temporary—”
“No, Mr. Dean, it isn’t that. It’s more serious. After what has
happened I simply couldn’t accept anything more from Dr. Wallace—
I couldn’t, that’s all.”
Mr. Dean deliberated for a few minutes. “I’m very sorry that your
friendship has been broken. But as to the other matter—has it ever
occurred to you to doubt that it is Dr. Wallace that is sending you to
St. Timothy’s?”
“Why, no; who else could it be?”
Mr. Dean smiled. “Oh, that you may try to guess. But it is not Dr.
Wallace; that I happen to know.”
“It isn’t!” The master could not see David’s wide, astonished eyes,
but he could recognize the sound of amazement in his voice. “Then
who can it be? Oh, I know! Mr. Dean! Mr. Dean!”
David dropped on one knee beside the couch and grasped his
friend’s hand.
“I didn’t intend to take you into my secret until the end of your
school career,” said Mr. Dean, squeezing the boy’s hand
affectionately. “I thought it would be better for you, less
embarrassing, if you didn’t feel under obligation to one in the
immediate neighborhood. But since you’ve guessed it—well, you
must try to go on regarding me exactly as before.”
“All right; I’ll try.” The very sound of David’s laugh was grateful
and affectionate. “But I don’t see why you ever did all this for me,
Mr. Dean.”
“I did it because I liked you and because I liked your father. I
haven’t any near relatives, David, and I have more money than I
need for my own use. You see, the reasons were very simple. And
now that you’ve wormed all this out of me—which you never should
have done—will you come and live here with me next year?”
“Of course I will! What is there that I should like better?”
At that moment there was a knock on the door.
“Come in,” said Mr. Dean.
It was Lester Wallace that entered.
CHAPTER X
MR. DEAN PROVIDES FOR THE FUTURE
“O h, yes,” said Mr. Dean when Wallace announced himself. “Sit

down, Wallace. You’re going, David? Then we may consider
the matter settled?”
“If you’re sure you really want it so.”
“I’m sure. Good-bye.”
As David passed out, Wallace was still standing by the door,
embarrassed, with downcast eyes. He had given David no greeting
and seemed to desire none. Such evidence of his bitterness
shadowed David’s happiness—shadowed it, but not for long. How
could he help being happy? The sacrifice that he had been prepared
to make was unnecessary; the friend who was helping him was a
friend whom he knew and loved and understood, not one who in all
essentials was a remote stranger. The only disappointment involved
in the discovery was his loss of the vague belief that Dr. Wallace had
chosen generously to testify his professional admiration for an
unappreciated confrère. And that disappointment was balanced by
satisfaction in Mr. Dean’s declaration that he had been actuated by
his liking for David’s father as well as for David himself.
How splendid it was of Mr. Dean! And then David thought how
thrilled and excited his mother would be at learning the unexpected
solution of the mystery. He began a letter to her as soon as he
reached his room; he had not finished it when Wallace stood in his
doorway.
“Hello, Lester!” David could not quite keep the note of surprise out
of his voice. “Come in and sit down.”
Wallace closed the door quietly behind him and dropped into a
chair.
“I’ve just told Mr. Dean of my cribbing in the examination. I
decided it was the only thing to do.”
“That took sand all right!”—The old admiration shone from David’s
eyes.
“No, it didn’t. After the way you talked to me I felt I didn’t want to
go on always knowing I’d done such a crooked thing without ever
trying to make it right. I told Mr. Dean that I should never have
confessed if you hadn’t found me out. So he knows I didn’t deserve
much credit.”
“Just the same, I think you do, and I guess he thinks so,” David
said warmly.
“He was mighty good to me,” Wallace acknowledged. “He asked
me what I thought should be my status now, and I had to say that,
as I hadn’t honestly passed the examination, I supposed I ought to
be put on probation again. He said he supposed so, too, but he said
he didn’t want the school to know the reason for it all; he thought
that, as I had come to him, the story needn’t be made public. I said
I was willing to take my medicine, but of course I should be grateful
if I wasn’t shown up before everybody. So he’s just going to let it be
known that I’m on probation again, after all, and that there was
some mistake made in letting me off it; people can draw whatever
conclusions they please.”
David went over and seated himself on the arm of Wallace’s chair;
he slipped his own arm round Wallace’s shoulders.
“Lester,” he said, “I feel somehow as if I’d done a mighty mean
thing to you. I guess I did talk like a prig.”
“You were right about it, anyway. And I’m glad I’ve got the thing
off my chest. I don’t want you to think of me as crooked, Dave.”
“I won’t! I never will! I was afraid you didn’t care any more what I
thought of you!”
“Well, I do!” Wallace reached up and gripped David’s hand. “Look
here, Dave—what was all that about your not coming back next
year?”
“Oh, that was a mistake. I was feeling blue; I am coming back all
right.”
“Good enough! Don’t you think we might make a go of it if we
roomed together, Dave?”
“I’d rather room with you than any other fellow here, Lester. I’ve
often hoped you’d suggest it. But Mr. Dean has asked me to live with
him next year. He needs some one. That was what we were talking
about this evening.”
“Well, I’m sorry.” Wallace hesitated a moment and then said, “You
know, I like Mr. Dean. He’s making an awfully plucky fight. I never
stopped to think about that. The way he talked to me this evening—
he was white clear through. I’ll tell you one thing, Dave.” Wallace
got slowly out of his chair. “Nobody’s going to have any chance to
put me on probation next year.”
That resolve, however, as David knew, did not make it any easier
for Wallace to face the surprise, the disappointment, and the
inquiries of the school. The next day all St. Timothy’s buzzed with
rumor and excitement; the strangeness of Wallace’s case, off
probation one day, on again the next, and his own reticence as to
the cause, led to gossip and speculation. All he would say in reply to
the questions of his best friends was that Mr. Dean was not to be
blamed in any way for thus disqualifying him for the school nine; it
was all his own fault, and he did not care to talk about it.
Henshaw, captain of the nine, came to David.
“I’ve got to try you now at first,” he said. “I guess you’ll hold your
end up all right. But Lester makes me tired! He was the best batter
on the team.”
Wallace himself tried to make amends to the team for failing
them. He gave the members batting practice; he played on the
scrub; he heartened and encouraged the players with his praise. And
his spirit of willing service went far toward reëstablishing him in the
affections of the school.
The game that year was played at St. John’s, and thither on the
day appointed all St. Timothy’s journeyed—even Mr. Dean. And
during the game Mr. Dean and Wallace sat side by side on the
players’ bench, and Wallace reported to him the progress of events.
He clapped his hands with the rest when in the second inning David
made a hit that brought in a run—the only hit, to be sure, that he
made during the game. It was a hard-fought game, in which Carter,
the St. Timothy’s pitcher, had a little the better of it up to the ninth
inning. Then, with the score four to three against them, St. John’s
came to the bat. The first man struck out, but the next singled and
the third was given his base on balls. Carter seemed nervous and
unsteady. Henshaw came in from third base to encourage him; the
St. John’s supporters had taken heart and were keeping up a
distracting tumult along the third-base line. Wallace leaned forward,
gripping cold hands together; Mr. Dean sat with an expression of
patient expectancy. Henshaw returned to his position, and Carter
faced the captain of St. John’s. The captain had determined to “wait
them out,” but Carter recovered control, and after having two balls
called sent two strikes over the plate. Then the batter hit a hard
grounder toward Adams, the second baseman; Adams made a
brilliant stop and tossed the ball to the short-stop, who was covering
second, and the short-stop shot it to David at first just ahead of the
runner. The game had been won in an instant; the St. Timothy’s
crowd burst into a tremendous roar.
Mr. Dean cried, in the midst of the bellowing, into Wallace’s ear,
“What happened?” and Wallace shouted back:
“Double play—Adams to Starr to Dave.”
And then Mr. Dean stood up and waved his hat and shouted with
the rest.
David sat with Mr. Dean in the train going home. Near by sat
Wallace and Ruth Davenport, and David noticed that they talked
together seriously and did not seem affected by the jubilation and
jollity that prevailed throughout the car.
It was growing dusk when they reached St. Timothy’s, and lights
were glowing in the windows of the buildings. The hungry swarm
poured into the dining-room and rattled into their places at the
tables; the clatter of knife and fork did not, however, subdue the
clamor of tongues. Inexhaustibly they dwelt upon the afternoon’s
triumph. David, receiving congratulations and compliments from
every side, was fairly simmering with happiness. Then he caught
sight of Wallace, sitting at a distant table, quiet and forgotten, and
compassion for Wallace, who was missing all the pleasure and the
satisfaction that might have been his, checked the laughter on
David’s lips. After supper Wallace was not to be found. David walked
down to the study; Ruth Davenport, waiting at the rectory gate,
called him across the road to her.
“Lester told me the whole story in the train to-day, David,” she
said. “You know, he’s awfully glad that you put him right. So am I.”
“Lester’s all right,” said David. “He was always all right.”
“He’ll be all right next year, anyway,” Ruth answered. “I always
liked Lester, but he’s had the idea that nothing mattered much so
long as he had his own way. You know, I like him better because he
told me!” she added irrelevantly.
“Nobody could help liking him,” David answered.
“Or you, either, David.”
And for David that little speech from Ruth put the crown upon a
glorious day. The study bell rang and summoned him, but for some
minutes after he was seated at his desk his mind was elsewhere
than on his books; his eyes saw, not the printed page, but the girl in
white standing by the gate and looking up at him with her honest,
friendly eyes.
It was a pleasant and happy summer vacation that David passed.
He was gratified to find that Ralph had grown in strength and
athletic promise, and he complimented him with fraternal frankness
on the fact that he had acquired more sense. His mother seemed to
grow younger; at any rate, she was more cheerful than when he had
last seen her; only occasionally did the look of sadness and of
longing for the past come into her eyes.
They spent a month camping in the woods on the shore of a lake;
Maggie went with them, though she protested that she did not see
why they wanted to leave a nice, tidy little apartment and run wild
like the Indians. She made that protest to Mrs. Ives and to Ralph,
not to David. Somehow she could not feel quite so free and easy
with David as formerly; he was not any longer just a boy. He had
grown older and bigger, and involuntarily Maggie found herself
treating him with a deference almost like that which she had been
accustomed to observe toward his father. To be sure, before the
summer was over a good part of that constraint wore off; but she
never again could open her heart to him in full and whole-souled
criticism as in the old days.
For Mrs. Ives the ideal that Dr. Wallace had embodied was
shattered. David laughed to see how much she begrudged the
grateful thoughts that she had entertained toward the distinguished
surgeon through all those months.
“You know, he didn’t commit a wrong, mother, in not sending me
back to St. Timothy’s,” David reminded her. “You seem almost to feel
that he’s done us an injury.”
“No, of course not, David, but it does make me cross to think of all
the feelings I’ve had about him, and he never caring in the least!
And all the time I never once thought of that good, kind, poor Mr.
Dean!”
From Mr. Dean came letters; he was passing the summer in
Boston, getting instruction in a school for the blind. “Interesting, but
not very encouraging,” he wrote. “If I were younger, perhaps I
shouldn’t be so stupid. But I’ve made some progress, and perhaps
next year I shall find that the lack of sight is not so troublesome.”
As David’s vacation drew to a close, his mother became again
subdued and wistful. She talked hopefully, she was glad that Mr.
Dean had intimated his intention to prepare David for the career that
the boy’s father had intended, but she could not readily resign
herself to the wrench of another parting.
“We live so far away,” she lamented on the last morning. “It takes
so long for letters to go and come. I can’t help feeling that you’ll be
less and less my boy, David, dear.”
He scoffed at her, but nevertheless her words struck home to a
tender spot. Of course he would never grow away from her in his
heart, but he realized that he would be away from her more and
more continuously as the years went on, and with a pang of shame
he suddenly knew that the separation would mean more to her than
to him. He determined then and there that he would try his best to
make up to her through his letters for the loss that she must always
feel, to convince her that she always had his confidence as well as
his love. And during the next year he fulfilled faithfully that resolve.
It was a busy year, for besides doing his own work he had to give a
good deal of help to Mr. Dean; moreover, as a sixth-former he had
responsibilities and offices that demanded a considerable amount of
attention; his athletic avocations, in which he had a gratifying
success, were numerous. But the more he had to do the more he
found to write home about and the gayer and cheerier was the spirit
of what he wrote. It pleased him when in the short vacations at
Christmas and Easter his mother said: “I can hear you in your
letters, David. You write me such good letters!”
Between Mr. Dean, dependent on David in so many little matters,
and David, dependent on Mr. Dean in one large affair, the friendship
grew stronger and closer. The boy admired the man for his learning,
his kindness, his courtesy, and most of all for his courage; David
wondered how any one stricken with such an affliction could make
so little of it. And the man liked the boy for his responsiveness and
for a certain stanch and honest quality that could not fail to impress
even one who was blind. So the association was a happy one—so
happy that the masters commented upon it among themselves and
wondered how Mr. Dean would manage the next year; he seemed to
have nobody in training to take David’s place. David himself often
wondered about it, but refrained from asking any questions; and Mr.
Dean kept his own counsel, kept it, indeed, until one evening two
weeks before the end of the school year, the evening of the day on
which St. Timothy’s had again met St. John’s upon the ball field and
been victorious. The members of the nine had been cheered at the
bonfire built in their honor, Lester Wallace, the captain, had made a
little speech, and then David had slipped away to go to his room.
But as he passed the open door of Mr. Dean’s study the master
called him.
“A great celebration, David?”
“Yes, pretty fine.” David came in and described the scene round
the bonfire.
Mr. Dean smiled. “Yes, I could hear the cheering. It was a great
game! I wish I could have really seen it! And you played well at
second base?”
“I managed to pull through without any errors. But Lester was a
wonder at first—just like lightning!”
“You and he seemed to develop some fine team play together. And
not just on the ball field, either. You have shown good team play in
everything this year. At Harvard next year I hope it will continue;
there will be just as many opportunities for it.” Mr. Dean hesitated a
moment and then said, with a shade of diffidence and
embarrassment, “And I think our team play has been pretty good,
David, don’t you?”
“Yours has been splendid, Mr. Dean.”
“You’ve done your share, David. So well that I don’t know how I
shall get on without you. In fact, I don’t want to get on without
you.”
David was silent for a moment in embarrassment, not knowing
what to say. “Anybody else would be of just as much help, Mr.
Dean,” he said finally.
“Nobody else could be, because I couldn’t feel about anybody else
as I do about you, David. Well, I can’t ask you to stay on and be a
schoolboy indefinitely, can I?” Again Mr. Dean paused; he was
apparently finding it hard to say something that he had in mind.
“I’ve talked with the rector and told him that I shouldn’t come back
next year. He was very kind and urged me to reconsider—but I told
him no. I’m not so useful as I once was, and I can’t help being
aware that in some ways I hamper the administration. So it’s best
for St. Timothy’s and for me that I should withdraw.”
“The school will be awfully sorry to lose you, fellows and masters
both,” said David.
“I hope they’ll feel a friendly regret, the same that I feel at parting
from them. But the step is one that I’ve decided to take. And now
the question is, What am I to do with myself? I have enough money
to live comfortably. I was wondering, David, if your mother wouldn’t
like to take a house in Cambridge or Boston, since you’re to be at
Harvard, and take me in as a boarder? I know it’s asking a
tremendous lot—to suggest that she undertake the care of a blind
man; she mustn’t feel under any obligation to say she’ll do it. But I
thought perhaps she might like to be near you; and then there’s
your brother Ralph—we might arrange about his education, too.
How do you feel about it, David? And how do you think your mother
would feel about it?”
“I think she’d feel it was too good to be true!” said David
enthusiastically. “Oh, Mr. Dean, I’m sure she’d feel it was the finest
thing in the world!”
Mr. Dean could recognize the eager ring in David’s voice even if he
could not see the eager sparkle in the boy’s eyes.
“Of course she mightn’t feel so at all,” he said, smiling. “She might
not want to move away from the place that had been her home. But

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He■pato-gastro-ente■rologie, chirurgie digestive

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He■pato-gastro-ente■rologie, chirurgie digestive 4e

Adobe Illustrator CC For Dummies David Karlins

Adobe Premiere Pro CC For Dummies 1st Edition John

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Urologie 4e édition. Edition Descazeaud

Table des compléments en ligne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XVII

2 Item 163 – UE 6 – Hépatites virales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

VI. Virus de l'hépatite E (VHE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

3 Item 168 – UE 6 – Parasitoses digestives :

4 Item 197 – UE 7 – Transplantation d'organes : aspects épidémiologiques

5 Item 215 – UE 7 – Pathologie du fer chez l'adulte et l'enfant. . . . . . . . . . . . . . . . 57

6 Item 248 – UE 8 – Dénutrition chez l'adulte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

7 Item 267 – UE 8 – Douleurs abdominales et lombaires

8 Item 268 – UE 8 – Reflux gastro-œsophagien chez le nourrisson,

9 Item 269 – UE 8 – Ulcère gastrique et duodénal. Gastrite . . . . . . . . . . . . . . . . . . . 117

10 Item 270 – UE 8 – Dysphagie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

11 Item 271 – UE 8 – Vomissements de l'adulte. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

II. Physiopathologie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

12 Item 273 – UE 8 – Hépatomégalie et masse abdominale . . . . . . . . . . . . . . . . . . . . 155

13 Item 274 – UE 8 – Lithiase biliaire et complications. . . . . . . . . . . . . . . . . . . . . . . . . 167

14 Item 275 – UE 8 – Ictère. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

15 Item 276 – UE 8 – Cirrhose et complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

16 Item 277 – UE 8 – Ascite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

17 Item 278 – UE 8 – Pancréatite chronique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

C. Traitement de l'insuffisance pancréatique exocrine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

18 Item 279 – UE 8 – Maladies inflammatoires chroniques

19 Item 280 – UE 8 – Constipation chez l'enfant et l'adulte

20 Item 281 – UE 8 – Colopathie fonctionnelle – Syndrome

21 Item 282 – UE 8 – Diarrhée chronique

22 Item 283 – UE 8 – Diarrhée aiguë et déshydratation

23 Item 284 – UE 8 – Diverticulose colique et diverticulite

24 Item 285 – UE 8 – Pathologie hémorroïdaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299

VI. Principes thérapeutiques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306

26 Item 298 – UE 9 – Tumeurs du côlon et du rectum : Item 287 – UE 9 –

27 Item 300 – UE 9 – Tumeurs de l'estomac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339

D. Lymphomes gastriques primitifs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347

28 Item 301 – UE 9 – Tumeurs du foie, primitives et secondaires . . . . . . . . . . . . . . . 353

29 Item 302 – UE 9 – Tumeurs de l'œsophage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

30 Item 305 – UE 9 – Tumeurs du pancréas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379

L oneliness was at least one misery that the afflicted schoolmaster

“No,” David acknowledged. “I don’t know where they’re found.”

“O h, yes,” said Mr. Dean when Wallace announced himself. “Sit

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3 Item 168 – UE 6 – Parasitoses digestives :

4 Item 197 – UE 7 – Transplantation d'organes : aspects épidémiologiques

7 Item 267 – UE 8 – Douleurs abdominales et lombaires

8 Item 268 – UE 8 – Reflux gastro-œsophagien chez le nourrisson,

18 Item 279 – UE 8 – Maladies inflammatoires chroniques

19 Item 280 – UE 8 – Constipation chez l'enfant et l'adulte

20 Item 281 – UE 8 – Colopathie fonctionnelle – Syndrome

21 Item 282 – UE 8 – Diarrhée chronique

22 Item 283 – UE 8 – Diarrhée aiguë et déshydratation

23 Item 284 – UE 8 – Diverticulose colique et diverticulite

26 Item 298 – UE 9 – Tumeurs du côlon et du rectum : Item 287 – UE 9 –