Arthritis Australia

By N. Josh. Virginia Intermont College.

Above the level of the inferior rectal nerve sensory distribution buy deltasone 10mg with amex, there are only dull perceptions buy deltasone 5mg without a prescription, mediated by parasympathetic fibers. Anorectal Spaces Around the anorectum there are a number of potential spaces filled with fat or connective tissue. The perianal space is at the anal verge, and is continuous with the intersphincteric space. The inferior boundary is the skin of the perineum, and the apex is the origin of the levator ani from the obturator fascia. Posteriorly is the gluteus maximus muscle, and anteriorly the transverse perinei muscles. On the obturator fascia is Alcocks canal, containing the internal pudendal vessels and pudendal nerve. The fossa is filled with fat, and contains the inferior rectal nerve and vessels, as well as the fourth sacral nerve. The two ischiorectal spaces communicate with one another behind the anal canal via the deep post-anal space. Diverticulosis In Western societies diverticulosis occurs in at least one person in two over the age of 50 years. Diverticulosis or diverticular disease of the colon is due to pseudodiverticula in that the wall of the diverticulum is not full-thickness colonic wall, but rather outpouchings of colonic mucosa through points of weakness in the colonic wall where the blood vessels penetrate the muscularis propria. These diverticula are prone to infection or diverticulitis presumably because they trap feces with bacteria. If the infection spreads beyond the confines of the diverticulum, an abscess is formed. Patients present with increasing left lower quadrant pain and fever, often with constipation and lower abdominal obstructive symptoms such as bloating and distention. Other causes of these symptoms include Crohns colitis with stricture formation, colonic cancer, and ischemic colitis. On physical examination the patient often has localized tenderness in the left lower quadrant (the most prevalent site of diverticulae). Treatment consists of intravenous fluids, bowel rest by placing the patient on no oral intake or just a clear liquid diet, and broad-spectrum intravenous antibiotics. Antibiotics selection should be to cover both gram-negative enteric bacteria and anaerobic bacteria that are normally found in the colon. Colonic stricture after resolution of diverticulitis is described further in Section 3. Bleeding occurs in less than 5% of diverticulosis patients; it is abrupt in onset, painless, and often massive. Even though bleeding is more likely to occur in right colonic diverticulosis, the bleeding frequency is approximately equal because of the much higher frequency of left colonic diverticulosis. Complications of diverticulitis o Abdominal abscess/Liver abscess o Colonic obstruction o Fistulas o Colovesical o Colovaginal o Colocutaneous Over 80% of diverticulosis patients will stop bleeding spontaneously. Segmental colonic resection is reserved for that small group of patients who continue bleeding or have recurrent bleeding. Patients under the age of 40 with symptomatic diverticulitis should have surgical resection because this small subgroup is at greater risk of complications. Multiple diverticulum openings several diverticulae are shown, with the are shown, with the lumen at the upper half of colonic lumen at the top of the image. There is a larger opening to the left that can be confused with the lumen of the colon. The muscle in the sigmoid colon is hypertrophied with multiple diverticulum openings and the lumen towards the right of the image. The pain from colonic ischemia is often not as severe as in other cases of acute intestinal ischemia. The majority of cases of colonic ischemia are self-limited, associated with ischemia of the left colon and/or transverse colon where the watershed area of the colonic vasculature supply to the colon is. Most cases have mucosal ischemia with the muscular wall of the colon relatively less prone to ischemia. Colonic ischemia may be associated with previous aortic surgery, usually because the inferior mesenteric artery that supplies much of the left colon arterial supply is sacrificed during these operations. Colonic ischemia is also associated with underlying diseases that may decrease colonic mesenteric blood supply due to low-flow states, as in hypotension related to surgery or other conditions that can lower blood pressure, or medications including drugs such as cocaine First Principles of Gastroenterology and Hepatology A. Certain diseases are more commonly associated with colonic ischemia; diabetes, vasculitis, rheumatoid arthritis and amyloidosis. In younger individuals, colonic ischemia is often associated with extreme exertion as a long distance running (marathon running or triathalon competitions).

Treatment of chronic gastritis: is aimed at controlling the sequellae 5mg deltasone visa, not the inflammatory process discount deltasone 40 mg with mastercard. This is probably due to the likelihood of gastric ulcers being silent and presenting only after complications. The end results are dependent upon the interplay between bacterial and host factors. Non-steroidal anti inflammatory drugs These are among the commonly used over-the-counter and prescription drugs. Miscellaneous factors Cigarette smoking - Higher incidence of peptic ulcer disease and complications in smokers, with delayed ulcer healing. Pathophysiology of Ulcer Diseases Peptic ulcers develop as a result of an imbalance between protective mucosal defensive factors and aggressive factors Defensive factors include 345 Internal Medicine Prostaglandins, Mucus Bicarbonates Mucosal blood flow Aggressive factors Pepsin Hydrochloric acid. Whereas acid-peptic injury is necessary for ulcer to develop, acid secretion is normal in almost all patients with gastric ulcers and increased in approximately a third of patients with duodenal ulcers. Clinical presentations Manifestations are dependent on ulcer location and patient age. Duodenal ulcer Pain tends to be consistent, usually absent when patient wakes up but appears in midmorning, and relieved by food but recurs again 2 - 3 hours after a meal. Relation of pain to Pain is relieved by food Pain aggravated by food/antacids or antacids ingestion of food Relation of pain to The pain The pain comes within food timing characteristically 30 minutes of ingestion comes 90 minutes to 3 of food hr after ingestion of food (hunger pain) Nausea and Not common Common vomiting Weight loss Uncommon Common because of fear to eat Perforation more common Less common Bleeding Less common more common Change in the character of pain may herald development of complications: Duodenal ulcer pain that becomes constant, is no longer relieved by food or antacids, or radiates to the back or to either upper quadrant, may signal penetration of the ulcer to the pancreas. But if the pyloric canal scarred, do endoscopic pyloric balloon dilatation or surgical relief of obstruction. Advantages a) Direct visualization and photographic documentation of the ulcer is possible. Acid Neutralizing/Inhibitory Drugs A) Antacids Are the most frequently used drugs before the advent of antihistamines (H2 - blockers). They are now rarely, if ever, used as the primary therapeutic agent, however are often used by patients for symptomatic relief of dyspepsia. C) Proton pump inhibitors + They inhibit the H -pump, which is important for synthesis of hydrochloric acid. D) Dietary advice There is no specific diet recommended for patients with peptic ulcer disease. Surgical treatment is indicated for: Perforation: immediate surgery is recommended for acute perforation. For the types of surgical procedures and their complications, please refer Surgical textbooks. Stress Related mucosal Damage Mucosal ischemia caused by decreased blood flow (from shock, Catecholamine release) impairs mucosal resistance to acid back diffusion. Hyperemia of the mucosa evolves & erosions and then frank ulceration in the stomach and duodenum that go on to bleeding. Clinical features May be absent Epigastric pain Hemorrhage (hematemesis, melena) Diagnosis History of drug ingestion Endoscopy Treatment: Removal of offending agent. Malabsorption syndromes Learning Objectives: at the end of this chapter the student will be able to 1. Refer the patient to hospitals for better diagnosis and treatment Definition: Syndromes resulting from impaired absorption of one or more dietary nutrients from the small bowel. Resection of 50 % of small intestine is well tolerated, if the remaining bowel is normal. Bacterial overgrowth may occur secondary to radiation stricture, lymphatic obstruction may occur due to edema or fibrosis c) Diabetes mellitus: alter gut motility from diabetic neuropathy, bacterial overgrowth and exocrine pancreatic insufficiency may lead to malabsorption. Phenytoin causes a selective folic acid malabsorption Clinical features Signs and symptoms Symptoms of malabsorption are caused either by the effects of osmotically active substances within the gastrointestinal tract or the resulting nutritional deficiencies. General symptoms: Steatorrhea: passage of abnormal stools, which are greasy soft, bulky, and foul smelling and may float in the toilet because of their increased gas content : a film of greasy or oil droplets may be seen on the surface of the water. This is often associated with abdominal distension, bloating, or discomfort and flatulence resulting from increased intestinal bulk and gas production Weight loss: which may be severe and involve marked muscle wasting. Diagnostic workup Symptoms and signs may point to the diagnostic impression of malabsorption. Five grams of D- Xylose is given orally to the fasting patient, and urine is collected for the next 5 hours. Plain abdominal x-ray may show pancreatic calcification as a sign of chronic pancreatitis. Pancreatic diseases Learning objectives: at the end of this unit the student will be able to 1. Acute Pancreatitis Etiology: 1) Biliary tract disease especially stones 2) Alcoholism 3) Drugs (furosemide, valproic acid, azathioprine, sulfasalazine) 4) Infection (e. Surgery is indicated for Trauma Uncontrolled biliary sepsis Inability to distinguish acute pancreatitis from other causes of acute abdomen To drain a pseudocyst that is expanding rapidly, secondarily infected, or associated with bleeding or impending rupture. Diagnosis: Laboratory tests are frequently normal, but inflammation markers may be minimally elevated.

Patients Localised bowel pathology may result in focal area of have signicant systemic upset deltasone 10mg lowest price. These are conrmed twists on itself usually around a brous peritoneal band on barium studies and require resection purchase deltasone 10mg on line. Investigations Pathophysiology A barium enema can be used to show oedema or mu- The ischaemia results from venous infarction due to cosal sloughing. Mesenteric angiography will external pressure resulting in venous congestion and demonstrate the stenosis or occlusion. Management The condition generally is self-limiting within a few days Clinical features/management with uncomplicated cases managed conservatively. If blood ow is not restored, a progression to in- farction and necrosis necessitates bowel resection. Chronic intestinal ischaemia Denition Slow progressive ischaemia of the gut due to atheroma Ischaemic colitis generally occurring in the elderly. Denition Ischaemia of the colon due to interruption of its blood Aetiology supply. Risk factors: r Fixed: Age, sex, positive family history, familial hyper- Aetiology In most cases the underlying cause is thrombosis of the lipidaemia. Pathophysiology In around half the ischaemia is transient with damage Pathophysiology connedtothemucosaandsubmucosa. Thesplenicex- Progressive atheroma occludes the lumen of the vessels ure is most often affected due to the territories of the causing reduced blood ow. If the blood supply is not depends on the position and degree of occlusion and the restored, ischaemia progresses to gangrenous ischaemic presence of collateral blood supply. Clinical features Patients describe pain occurring after food, weight loss, Clinical features malabsorption and signs of vascular disease. The patient presents with lower abdominal pain, nausea, vomiting and bloody diarrhoea. There is lower abdom- Investigations inal tenderness and guarding in the lower abdomen. Microscopy Management There is ischaemic loss of mucosa, ulceration and later Surgical revascularisation depends on the results of an- healing with oedema and inammatory inltrate. Denition Complete necrosis and gangrene of the midgut resulting Aetiology from cessation of blood ow in the superior mesenteric r Squamous carcinoma accounts for more than 90% of artery. These usually occur in the middle third of the oesophagus although the lower third may also be af- Clinical features fected. Aetiological factors include high alcohol con- There may be a preceding history of non-specic symp- sumption, smoking and chewing betel nuts. Signs of acute intestinal failure include ab- affects the lower third of the oesophagus particularly dominal tenderness, guarding, loss of bowel sounds and the gastrooesophageal junction possibly following ep- rigidity, due to perforation. Calcication within the abdominal aorta may be evident r Familial forms have been noted. Gas lled, thickened, dilated bowel loops and free gas within the peritoneal cavity due to Pathophysiology perforation may also be seen. Following adequate resuscitation laparotomy and resec- tion(whichmaybemassive)arerequired. Patients may present with progressive dysphagia, but of- Asecond look laparotomy can be performed 24 hours tenpresent late with weight loss, anaemia and malaise. If Barium swallow demonstrates an apple core defect or the patient survives they have considerable malabsorp- stricture without proximal dilatation. In the absence of metastases endoscopic ultrasound is useful to assess operability. Management r Wherever possible surgical resection is the primary Age treatment with those occurring in the lower third Rare below the age of 40 years. Neoadjuvant Denition chemotherapy with cisplatin and 5-uorouracil (5- Malignant tumour of the stomach. Sex Prognosis 2M > 1F Surgical resection carries an operative mortality of up to 20%. Benign gastric tumours Aetiology Denition Pre-malignant conditions include chronic atrophic gas- Benign tumours and polyps of the stomach. These can tritiswithintestinalmetaplasiaandadenomatouspolyps be divided into epithelial and mesenchymal derived tu- of the stomach. Hyperplastic polyps are common overgrowths of gas- r Dietary carcinogens possibly including nitrates and tric mucosa often resulting from the healing of an alcohol. Pathophysiology They have a signicant risk of malignant change most Gastric adenocarcinomas are derived from mucus se- likely in large polyps. Tumours may be of three types: Mesenchymal derived benign tumours: r Ulcerating (most common) with appearance similar r Leiomyomas appear as mucosal or intramural nod- to benign ulcers but with raised edges and no normal ules. Most benign tumours are asymptomatic and found on r Inltrating when brous tissue causes a rm non- endoscopy or barium meal. Rarely bleeding or obstruc- distendable or linitis plastica (leather bottle) stomach. Spread may be direct invasion to the liver and pancreas, Management transcoelomic spread resulting in a malignant ascites Allsuspiciouspolypsrequireexaminationbyendoscopic and ovarian Krukenberg tumour, lymphatic spread to excision biopsy, multiple polyps may require gastric re- regional and distant lymph nodes (Virkows node) and section.

As a result generic deltasone 20mg on-line, cell masses grow and expand order deltasone 5mg fast delivery, afecting surrounding normal tissues (such as in the brain), and can also spread to other locations in the body (metastasis). Te average number of cells formed in any individual during an average lifetime is 1016 (10 million cells being replaced every second! It would therefore be logical to assume that human populations anywhere in the world would show similar frequencies of cancer. However, cancer incidence rates (number of individuals diagnosed) vary dramatically across countries. Evidently, some factors seem to intervene to dramatically increase cancer incidences in some populations. Te obvious inference is that contributory factors that cause cancer are either hereditary or environmental. It means that either certain populations carry a large number of cancer-susceptibility genes or that the environment in which populations live largely contribute to the cancer incidence rates. While genes are distributed unequally across populations, they do not explain the diferences in cancer incidence rates in the world. Incidences of stomach cancer are 68 times higher among Japanese compared to Americans. However, children of migrant Japanese settled in America show incidence rates of stomach cancer comparable to that of the American population. Terefore, the risk of developing cancer seems largely environmental, accounting for more than 90% of all cancers caused. In the late 18th century, Sir Percival Pott reported that scrotal cancer in chimney sweeps was linked to poor hygiene and accumulation of cancer-causing agents from soot. Te Danish Chimney sweepers Guild recommended daily baths and was the most likely reason for the dramatic reduction in scrotal cancer incidence rates in Europe. In 1950, compelling epidemiological evidence showed that heavy cigarette smokers ran a 20-fold higher risk of developing lung cancer compared to non-smokers. Excessive alcohol use has been linked to liver and mouth/throat cancers in both males and females. Smoking and tobacco use signifcantly increases the risk of lung cancers equally in males and females, and there is also a slightly higher risk of mouth/throat cancers. Incidences of skin cancers (melanomas) are on the rise, especially in Australia, due to exposure to high levels of ultraviolet radiation in the suns rays and popularity of tanning salons. However the risk of developing some of these cancers can be reduced by changing lifestyles and vaccines (like Gardasil which reduces the risk of cervical carcinomas). Initiation and progression of cancer is also due to exposure to cancer-causing agents (carcinogens, mutagens). Tese are present in food and water, in the air, and in chemicals and sunlight that people are exposed to. Since epithelial cells cover the skin, line the respiratory and alimentary tracts, and metabolize ingested carcinogens, it is not surprising that over 90% of cancers originate from epithelia (carcinomas). In less than 10% of cases, a genetic predisposition increases the risk of cancer developing a lot earlier (E. Sixty percent of new cancer cases and two thirds of cancer deaths occur in persons > 65 years. By 2020, wind could provide one-tenth of our planets Brain power electricity needs. These can be reduced dramatically thanks to our systems for on-line condition monitoring and automatic lubrication. We help make it more economical to create cleaner, cheaper energy out of thin air. By sharing our experience, expertise, and creativity, industries can boost performance beyond expectations. Te exponential rise in many cancers with age fts with an increased susceptibility to the late stages of carcinogenesis by environmental exposures. Lifetime exposure to estrogen may lead to breast or uterine cancer; exposure to testosterone leads to prostate cancer. Te decline in cellular immunity may also lead to certain types of cancer that are highly immunogenic (e. Tere are several benefts to identifying and classifying cancers using histological sections and staining methodology 1) Diagnosis: Microscopic observation helps determine whether the tumour tissue is benign (harmless) or malignant (potentially fatal). Gross cellular morphology and tissue specifc markers are used to classify cancerous cells. Patients with simple hyperplasia in the uterine epithelium have <1% chance of developing cancer compared 82% risk in patients with atypical hyperplasia. The mesothelium is a layer of cells which cover various organs in the body protecting them and allowing organs to move against each other as the lungs expand and contract or the heart beats. However the complexity of this disease is not as simple at the cellular and molecular level.