By R. Joey. Nicholls State University.

Approach to dysphagia Oropharyngeal dysphagia is also known as transfer dysphagia discount 60 mg xenical with amex. Often purchase xenical 120 mg free shipping, oropharyngeal dysphagia occurs in a patient with central nervous system pathology (eg safe 60 mg xenical. Esophageal dysphagia may be due to a mechanical reason causing partial obstruction of the esophagus purchase xenical 120 mg mastercard, or to dysmotility of the esophagus (Table 1). Patients with esophageal dysphagia describe a sense of food or liquid sticking in the retrosternal area. Causes of Esophageal Dysphagia Mechanical Lesions Extrinsic Lesions Motility Disorders - Reflux stricture - Cervical osteophyte - Achalasia - Esophageal cancer - Goitre - Scleroderma - Radiation induced stricture - Mediastinal mass - Reflux induced dysmotility - Post surgical anastomotic - Vascular structure (aberrant - Diffuse esophageal spasm stricture subclavian artery) - Hypertensive lower - Stricture post caustic esophageal sphincter ingestion - Nutcracker esophagus - Zenkers Diverticulum - Esophageal ring or web Certain historical points are important in evaluating esophageal dysphagia. A history of heartburn or regurgitation may point to a reflux stricture or reflux- induced esophageal dysmotility. The patient will often present to the emergency department and require endoscopic removal of the food bolus. A Zenkers diverticulum is an outpouching immediately above the upper esophageal sphincter. In addition to dysphagia, patients may experience halitosis and aspiration of food retained in the diverticulum. Management of oropharyngeal dysphagia involves treatment of the underlying disorder if possible and dietary modification together with the helpful guidance of a speech language pathologist. If a patient is suspected to have esophageal dysphagia, evaluation proceeds with either an endoscopy or barium swallow. Barium swallow has the advantage of being noninvasive, First Principles of Gastroenterology and Hepatology A. When a barium swallow and endoscopy fail to identify any pathology, esophageal manometry may be performed to demonstrate an esophageal motility disorder. Benign anastomotic strictures, radiation strictures and rings are similarly treated with periodic dilation. Esophageal malignancy is managed through a combination of surgery, radiation, chemotherapy and sometimes with the insertion of a palliative endoscopic stent. A small Zenkers diverticulum is generally followed, whereas larger and more symptomatic lesions may need surgery. Endoscopic management of a large Zenkers diverticulum is possible, but is not done in most centres in Canada. Achalasia can be managed with periodic Botulinum toxin injections to the lower esophageal sphincter, endoscopic balloon dilation or surgery (myotomy). Treatment of Scleroderma esophagus is mainly with high dose proton pump inhibitor. Other esophageal dysmotility disorders are sometimes managed with medication such as nitroglycerin or calcium channel blocker. Odynophagia is pain, and should be differentiated from the burning discomfort of heartburn. Differential diagnosis Odynophagia implies a break in the mucosa of the esophagus. The common infections that cause odynophagia are candida, herpes virus and cytomegalovirus. In an immunocompetent patient, an important cause of odynophagia is pill esophagitis. An ingested pill remains in the esophagus and dissolves there, leading to ulceration. This can be a result of not taking the pill with enough liquid, or lying down too soon after taking the pill. Pill esophagitis is a self-limited condition that resolves without specific therapy. Other less common entities that can cause odynophagia include esophageal cancer, radiation esophagitis, and severe reflux esophagitis. Description The term, dyspepsia refers to chronic or recurrent pain or discomfort centred in the upper abdomen. One such definition is one or more of postprandial fullness, early satiety or epigastric pain. Dyspepsia is a frequent symptom in the general population and, most persons do not seek medical attention. The most common cause is functional dyspepsia, also known as non ulcer dyspepsia. It may relate to gastric motor dysfunction, visceral hypersensitivity, psychosocial factors or in some cases it may be associated with gastritis due to an infection with Helicobacter pylori. History and Physical The approach to a patient with dyspepsia begins with a search for so called alarm symptoms. If present, the possibility of significant pathology increases, and investigation should take place in a timely fashion. Older age also increases the likelihood that dyspepsia is due to organic pathology. It has been suggested that in Canada, an age greater than 50 years be considered an alarm symptom. In a young patient with no alarm symptoms, it is very unlikely that dyspepsia will be due to malignancy. For example, the pain of biliary colic may be present in the epigastric area, but is often in the right upper quadrant as well. Irritable bowel may cause pain in the upper abdomen, but is associated with altered bowel pattern and relief of pain with defecation. As mentioned before, and to emphasize, be certain to take the appropriate history to exclude ischemic heart disease. Investigation and Management Investigation of dyspepsia generally entails bloodwork. Patients with alarm symptoms, over the age of 50 even if there are no alarm symptoms, and patients with persistent dyspepsia despite empiric trials of treatment should undergo endoscopy. In younger patients without alarm features, non-invasive testing for Helicobacter pylori (H. The rationale is that if the patient has an ulcer, treating the infection will eliminate the problem of recurrent ulcers. In young patients without alarm features, another option is an empiric trial of acid suppressive (proton pump inhibitor) or prokinetic (domperidone) therapy. Some patients may respond to simple reassurance, dietary manipulation, treatment of H. Vomiting should be differentiated from regurgitation, which is an effortless process. Retching is differentiated from vomiting in that no gastric contents are expelled. Vomiting has developed as a defence mechanism, allowing the individual to expel ingested toxins or poisons. The neural pathways that mediate nausea are the same as those that mediate vomiting. During nausea, there is gastric relaxation and frequent reflux of proximal duodenal contents into the stomach. Excitation of these areas leads to activation of the vomiting centre in the medulla. The chemoreceptor trigger zone exists on the floor of the fourth ventricle on the blood side of the blood-brain barrier. Neurotransmitters, peptides, drugs and toxins may activate the chemoreceptor trigger zone which in turn activates the vomiting centre. Shaffer 8 Activation of the vomiting centre leads to forceful abdominal wall contraction, contraction of the pylorus, and relaxation of the lower esophageal sphincter. History and Differential diagnosis The differential diagnosis of nausea and vomiting is wide. As alluded to above, nausea and vomiting may be triggered by numerous pathologies arising in many different systems. Associated gastrointestinal symptoms such as abdominal pain or diarrhea should be sought. Associated non gastrointestinal symptoms such as headache, chest pain or vertigo are important.

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Catheter-associated (or nosocomial) infections and The vast majority of acute symptomatic infections involve young women purchase 120 mg xenical fast delivery. Ascent of bacteria from the bladder may follow and is probably the pathway for most renal parenchymal infections discount xenical 60 mg on-line. Whether bladder infection ensues depends on interacting effects of the pathogenicity of the strain order 120mg xenical otc, the inoculum size purchase 120 mg xenical with visa, and the local and systemic host defense mechanisms. Gender and Sexual Activity: The female urethra appears to be particularly prone to colonization with colonic gram-negative bacilli because of its proximity to the anus, its short length (about 4 cm), and its termination beneath the labia. Pregnancy: Is clearly associated with altered uretheral smooth muscle function and higher incidence of asymptomatic bacteriuria and 20 to 30% of pregnant women with asymptomatic bacteriuria subsequently develop pyelonephritis. Symptomatic upper urinary tract infections, in particular, are unusually common during pregnancy. Vesicoureteral reflux: Defined as reflux of urine from the bladder cavity up into the ureters and sometimes into the renal pelvis. Obstruction: Any impediment to the free flow of urine caused tumor, stricture, stone, or prostatic hypertrophy results in hydronephrosis. Part of the risk is mediated through neurogenic bladder disturbance, and partly due to other immune disorders in diabetes. Immune deficiency: congenital, acquired or drug induced immunodeficiencies are associated with increased susceptibility to infection. Clinical presentation Cystitis: Patients with cystitis usually report dysuria, frequency, urgency, and suprapubic pain. Urethritis: Approximately 30% of women with acute dysuria, frequency, and pyuria have midstream urine cultures that show either no growth or insignificant bacterial growth. In this situation, a distinction should be made between women infected with sexually transmitted pathogens, such as C. Culture of the urine: is a definitive means for diagnosis A clean catch, mid stream urine specimen should be collected 5 The growth of more than 10 colonies /ml in the presence of symptoms signifies infection that needs treatment 3. Except in acute uncomplicated cystitis in women, a quantitative urine culture, rapid diagnostic test should be performed to confirm infection before treatment is begun. Factors predisposing to infection, such as obstruction and calculi, should be identified and corrected if possible. Bladder bacteriuria (cystitis) can usually be eliminated with nearly any antimicrobial agent to which the infecting strain is sensitive. Severe illness with high fevers, pain, and marked debility Empiric antibiotic choices o The initial antibiotic therapy is selected on the basis of urinalysis and an understanding of epidemiology and bacteriology of the infection. Prognosis In patients with uncomplicated cystitis or pyelonephritis, treatment ordinarily results in complete resolution of symptoms. When repeated episodes of cystitis occur, they are nearly always reinfections, not relapses. Repeated upper tract infections often represent relapse rather than reinfection, and a vigorous search for renal calculi or an underlying urologic abnormality should be undertaken. If neither is found, 6 weeks of chemotherapy may be useful in eradicating an unresolved focus of infection. Asymptomatic bacteriuria in these groups as well as in adults without urologic disease or obstruction predisposes to increased numbers of episodes of symptomatic infection but does not result in renal impairment in most instances. Approach to a patient with gastrointestinal disorder Learning objectives: at the end of this unit the student will be able to 1. Describe the difference between exudates and transudates and their clinical use 6. List the different radiological and endoscopic investigations and their clinical use Patients with gastrointestinal disorders may present with a variety of symptoms that are specific to the gastrointestinal tract and/or general systemic symptoms. Common symptoms include: Abdominal pain, abdominal distension Dyspepsia Diarrhea or constipation Gastrointestinal bleeding Jaundice Change in weight and change in appetite Nausea vomiting Change in stool color During history taking, detailed analysis of the above symptoms should be done, and history of medications should also be elicited. Technique Empty the urinary bladder Patient lying flat or slightly probed up Give local anesthetics if available Site of aspiration is the right iliac fossa, a little outside the midpoint of a line joining the umbilicus to anterior superior iliac spine. The fluid is analyzed biochemically, bacteriologically, cytologically and physically. Different terminologies are used to describe barium studies of the different parts of the gastrointestinal tract: o For esophagus - Barium swallow. Ultrasound is a noninvasive procedure that may be help full in diagnosing the following diseases: o Cirrhosis o Metastasis o Fluid filled lesions cysts, abscess o Cholelithiasis 3. Biopsy can be done in two forms Open biopsy is done during laparatomy and allows to take adequate tissue samples 340 Internal Medicine Needle biopsy is done percutaneously 4. Gastritis and peptic ulcer diseases Objectives: at the end of this unit the student will be able to:- 1. Chronic gastritis Defined as a histological demonstration of lymphocytic and plasma cell infiltration of gastric mucosa. Chronic gastritis is classified into two: Type A gastritis (chronic fundal gastritis) The inflammation is limited to gastric fundus and body with antral sparing. However, the inflammation may progress to involve the gastric fundus and body causing pangastritis usually after 15 - 20 years. Treatment of chronic gastritis: is aimed at controlling the sequellae, not the inflammatory process. 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.

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Without insulin xenical 120mg with mastercard, glucose builds up in the blood purchase 120 mg xenical fast delivery, and the bodys cells are starved of energy proven 120mg xenical. You can browse online cheap 60mg xenical fast delivery, download documents in pDf, and order materials through the mail. National Institute of Mental Health science Writing, press & Dissemination Branch 6001 executive Boulevard room 8184, msc 9663 Bethesda, mD 20892-9663 phone: 301-443-4513 or 1-866-615-nimH (6464) toll-free ttY: 301-443-8431 or 1-866-415-8051 toll-free faX: 301-443-4279 e-mail: nimhinfo@nih. Reprints this publication is in the public domain and may be reproduced or copied without permission from nimH. Department of HealtH anD Human services national institutes of Health national institute of mental Health niH publication no. The children were diagnosed in overweight girls aged 10 per cent of people with diabetes have 10 vast majority of them have Type 1 diabetes. In Scotland there are as many children living with in 2012, children of Asian origin were 8. If this were the case in all four counterparts and children of Black origin were 5. The The at-risk population would still be greater chances of developing it may depend on a mix than this, even if their level of risk was not as of genes, lifestyle and environmental factors. Type 1 diabetes develops when the the main modifable risk factors of Type 2 diabetes insulin-producing cells in the pancreas have been are increased waist circumference and being destroyed. This may be triggered by a viral or Health Survey in England, 22 per cent of men other infection. Using these two risk factors alone, body is not making enough insulin, or the insulin based on the adult population, 5. Some of the risk factors are provided in more Recently published information, based on data detail below. Type 2 diabetes There is a complex interplay of genetic and environmental factors in Type 2 diabetes. People with diabetes in the family are two to six times more likely to have diabetes than people without diabetes in the family17. It accounts for 8085 per cent of should add up to at least 150 minutes (2 hours) levels of obesity, physical inactivity, unhealthy diet, the overall risk of developing Type 2 diabetes of moderate intensity activity in bouts of 10 minutes smoking and poor blood pressure control. All these and underlies the current global spread of the or more one way to approach this is to do 30 factors are inextricably linked to the risk of diabetes condition19. This is an increase of spread across the week or combinations of related to deprivation. The Health Survey for England 2011 found that suggests that 26 per cent of boys and 29 per cent Adults should also undertake physical activity men in the lowest quintile of equivalised household of girls are also overweight or obese. For people in the 21 All adults should minimise the amount of time spent cent of children aged between 2 and 15. There was a suggests that people in the most deprived quintile marked increase in the proportion of adults that are 1. The variation in cent in 2011 for men and from 16 per cent to 26 deprivation and diabetes is only seen in those per cent for women22. Deprivation has no effect on developing Type 1 diabetes, which is unsurprising In 2011, in England around three in ten boys as it is not lifestyle related. However, new diagnostic criteria, which introduces an additional fasting plasma glucose measurement for gestational diabetes28, could lead to an increase in the number of pregnancies affected by gestational diabetes. For every 1kg increase over their pre-pregnancy weight, there is a 40 per cent increased odds of developing Type 2 diabetes33. There the legs, which is known as peripheral vascular per cent increased risk of angina, a 94. People with diabetes have cent increased risk of myocardial infarction as well as costs to the lives of people with diabetes. This means that about one ffth of medication where required to help control risk begin fve to six years before diagnosis and the hospital admissions for heart failure, heart attack factors like diabetes, high cholesterol, triglyceride 76 actual onset of diabetes may be ten years or and stroke are in people with diabetes. The kidneys are quarter of all patients having diabetes recorded the blood vessels supplying the retina the seeing the organs that flter and clean the blood and get as the primary cause of their kidney failure47 and part of the eye. They lower than for people without diabetes especially through to the retina and if left untreated can damage also release several hormones. For protection effciently and this can cause the kidneys to start for those with diabetes. The development of diabetic nephropathy 66 per cent of those without diabetes were alive 5 that it is best to have eyes screened with a digital usually takes at least 20 years46. About three in four people with diabetes will deaths in Type 1 diabetes and 11 per cent 48 Diabetes is the leading cause of preventable sight develop some stage of kidney disease during their of deaths in Type 2. This is most likely related to Type 2 diabetes (60 per cent) have some degree improved management and tighter control of 51 of retinopathy. People with diabetes have nearly 50 per cent increased risk of developing glaucoma, especially if they also have high blood pressure52, and up to a three fold increased risk of developing cataracts53 both of which can also lead to blindness. Reviewing the feet of have emotional or psychological support needs developing neuropathy, or prevent it becoming people with diabetes regularly and keeping blood resulting from living with diabetes or due to causes worse, is to control blood glucose levels36. Neuropathies (or nerve damage) may affect up control can prevent some of the complications 63 36 Coming to terms with diagnosis, the development to 50 per cent of patients with diabetes. In some cases this can type of neuropathy which reduces sensation in This is over 140 amputations a week amongst lead to depression, anxiety, eating disorders 55 the lower limbs and feet and contributes to the people with diabetes or 20 a day. Autonomic neuropathy can have severely More recent studies, using better methods and debilitating effects on various functions of the According to some studies, amputation carries with it meta-analyses, have shown lower estimates body. Gastroparesis delayed emptying of the a signifcantly elevated mortality at follow-up, ranging of prevalence. The chances of having diffculties diabetes (given the likely increase in diabetes to achieve or maintain an erection for sexual are greatly reduced through tight blood glucose affected pregnancies due to the rise in numbers intercourse, is one of the most common sexual 70 control before and during pregnancy. In reality, especially between 35 per cent and 90 per cent among men with the rise in Type 2 diabetes in younger women, 66 three times as likely to die in their frst months with diabetes. One 75 rate of abortions in women where congenital increased risk of dementia, but this is a highly study found that 27 per cent of women with Type 72 abnormalities are found. However, 69 Women with diabetes are fve times more likely this is still at a relatively early stage. This balance will be changing as more women develop Type 2 diabetes at a younger, child-bearing age. Another way of saying this is every 76 Globally, diabetes causes one death every 6 day 65 people die early from diabetes. For Type 1 diabetes, mortality is 131 192 million a week per cent greater than expected and for Type 2 27 million a day diabetes it is 32 per cent greater. The greatest increased risk of death is in younger ages and in 1 million an hour females76. In men, the difference between the 20 to 24 One in seven hospital beds is occupied by groups is 11 years, and 5 years in the 65 to 69 someone who has diabetes. People with diabetes 14 years between the 20 to 24 groups, and 81 77 are twice as likely to be admitted to hospital. Diabetes contributes 44 per cent of the combined In Type 2 diabetes, the average reduced life angina, myocardial infarction, heart failure and expectancy for someone diagnosed in their 50s 76 78 stroke hospital bed days. These fgures have not changed signifcantly There are big variations in the percentage of over the last three years. Diabetes Care 37(9), for diagnosed and undiagnosed for 2010 of 109,000 [unpublished]. Adding these up gives us the 2500-7 estimate of fve million people with diabetes in 2025 (4,957,468) Tillin, T. Statistics on Obesity, Physical Activity and Diet: England, 2013 Table of children diagnosed Type 1 at January 2014. Northern Ireland Childhood Register at 23 Department of Health (2011) Physical Activity Guidelines for adults (19-64 years): Factsheet 4 Queens University. The impact of potential new diagnostic criteria on the prevalence of gestational diabetes mellitus in Australia. Lancet 352 (9131); 837853 modifed International Association of Diabetes and Pregnancy Study Groups criteria: a population based cohort study.

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