By V. Denpok. Northwood University.
Bile and pancreatic secretions can also cause such oesophagitis if they are exposed to the lower oesophagus generic 200 mcg cytotec amex. The severity of the condition mainly depends on the type and concentration of the secre tions refluxed into the oesophagus and their contact time with the oesophageal mucosa buy 200mcg cytotec mastercard. The peculiarity of such pain is that it is related to posture and the pain increases on lying down or by stooping or by wearing surgical belt or tight corsets on the abdomen order cytotec 200 mcg amex. This type of pain is considered to come from oesophageal spasm rather than mu cosal irritation. Sometimes the patient may complain of a chronic sensa tion of a foreign body lodged in the throat. This seems to be due to reflux into the upper oesophagus causing irritation and spasm of cricopharyngeal sphincter. This is due to muscle spasm and motor disorder due to irritation of the oesophageal mucosa. Direct injury to the oesophageal mucosa may cause oedema, inflammation, spasm, fibrosis and even stricture in advanced cases. It must be remembered that an ulcer developing in oesophagus containing gastric epithelium i. Whether this is the cause or effect of reflux oesophagitis is still a controversy. One must remember respiratory symptoms may be mere association with this disease rather than being definitely caused by reflux oesophagitis. The whole of the oesophagus and stomach are to be examined first to exclude any disorder in the upper oesophagus or any abnormalities of the stomach including delayed gastric emptying. It must be remembered that the radiologists must see spontaneous free gastro-oesophageal reflux during the course of barium swallow examination. Unfortunately only half of the patients who ultimately are proved to have this disorder reveals reflux during barium swallow examination. Oesophagitis is graded from 0 to 4 according to the severity of changes observed through oesophagoscope. Presence of columnar epithelium more than 3 cm above the gastro-oesophageal junction suggests the diagnosis of Barrett’s oesophagus. This is due to metaplasia and is known to be precursor of adeno carcinoma of the distal oesophagus. It re quires skill to introduce rigid oesophagoscope and is not unsafe in the hands of experts, though there is significant risk of perfo ration. This instrument is probably better for examination of the lower pharynx and the cricopharyngeal area, as the view with flexible endoscope is rather poor in this area. Dilatation of oe sophageal stricture was undertaken with this rigid instrument and the classic Chevalier Jackson Bougie for many years, but now with flexible oesophagoscope the dilators passed over guidewires are much safer. First of all it does not require any general anaesthesia and can be performed as an out-patient method. The quality of magni fied image is far superior and the instrument is quite safe to pass through the oesophagus. It provides detailed images of the layers of the oesophageal wall and also gives Fig 43. Taking biopsies is quite easy with this instrument and it oesophagus due to oesophagitis following gastro-oesophageal reflux. Medical treatment includes : (i) The patients are instructed to sleep with the head end of the bed elevated on 6 inches blocks. This has been a major advance in the treatment of this condition and oesophagitis heals in majority of cases. Some suspicion has been raised whether it increases incidence of adenocarcinoma of the lower oesophagus and cardia due to long use of these drugs. The drugs which should be avoided in this condition are : Muscle relaxants, Anticholinergic drugs and Tranquillizers. When indications for surgical treatment are clear, the operation performed^s an anti-reflux operation. This operation is aimed at restoration of the intra-abdomi nal segment of oesophagus and mainte nance of the distal oesophagus as a tube like structure. A thorough exploration is done to exclude presence of gallbladder disease, peptic ulcer, pancreatic pathology and diverticular disease. The oesophageal hiatus is now explored and the size of the hernia, if at all present, is assessed. The triangular ligament of the left lobe of the liver is divided and it is retracted to the right. Traction on the stomach is made to reduce the hernia and to facilitate division of phreno-oesophageal ligaments which constitute the sac of the hernia. If only too much adhesion of the oesophagus is antici pated, a thoracic approach is worthwhile. If there is a good gap in the oe sophageal hiatus, this should be repaired anterior or posteriorly with non-absorbable material. Now the fundus of the stomach is exposed and upper short gastric vessels are divided. The fundus of the stomach is brought posteriorly around the oesophagus and sutured. Sutures are placed through the anterior fun dus, the wall of the oesophagus and the fundus brought posteriorly and sutured. It must be remembered that the fundus should be anchored to the intra-abdominal oesophagus securely, lest it should slip down on to the body of the stomach and cause obstruction to the stomach. This technique involves full 360° plica tion of stomach around the oesophagus and causes a higher intraluminal pressure in the abdominal oesophagus which is the sole objective of anti-reflux operation and in this respect this operation seems to be the most effective of all anti-reflux procedures. The only complication is that it may be a too tight repair and thus causes oesophageal obstruction. Postoperative barium swallow examination should be done to exclude such complication. The oesophagus is mobilised above upto the aortic arch to allow a sufficient long intra abdominal oesophagus. The fundus of the stomach is fixed firmly around 2/3rds of the circumference of the oesophagus along its lower 3 to 5 cm. Post-operative barium swallow should demonstrate a 4 cm segment of intra-abdominal oesophagus. As it is not a total fundoplication recurrence rate is more in long-term follow up. The oesophagus is mobilised extensively through the hiatus, but the phreno-oe- sophageal membranes are kept intact. The opening of the hiatus is narrowed by inserting sutures anterior to the oesopha gus, so that only one finger can Fig. Now the stomach is wrapped around the entrance of the oesopha gus into stomach by placing sutures on both anterior and posterior aspects of the gastro-oesophageal junction. These sutures are also passed through the median arcuate ligament for posterior gastropexy. Manometric pressure readings before, during and after this procedure indicate a rise in sphincter pressure to a level of 40 to 50 mmHg.
If the patient has a steppage gait purchase cytotec 100 mcg with mastercard, the workup of peripheral neuropathy should be done cheap 100 mcg cytotec otc, as noted on page 378 discount cytotec 200 mcg visa. Involvement of the upper extremities should suggest Raynaud’s disease, scleroderma, and other collagen diseases. The complete absence of a peripheral pulse, particularly if it is sudden onset, should suggest an arterial embolism. If there are other signs of systemic disease, collagen disease, macroglobulinemia, and cryoglobulinemia should be suspected. A sudden onset of the gangrene should make one suspect clostridia infections or arterial embolism. If there are diminished pulses, especially if the onset is acute, angiography will be useful. The Sia water test and serum immunoelectrophoresis will be useful in diagnosing macroglobulinemia and cryoglobulinemia. Patients with Klinefelter’s syndrome, supermale, superfemale, sexual precocity, and virilism have abnormal secondary sex characteristics and a tall stature. Patients with a family history of tall stature often have constitutional tall stature and not pituitary gigantism. A chromosome study should be done to identify Klinefelter’s syndrome, supermale, and superfemale. A serum testosterone, dihydrotestosterone, and dehydroepiandrosterone sulfate will be helpful in diagnosing sexual precocity and virilism caused by tumors and hyperplasia of the adrenal gland. Echocardiography and urinary hydroxyproline will help identify Marfan’s syndrome, whereas a urine for homocysteine will help diagnose homocystinuria. Presence of a rash, whether it is macular or vesicular, especially if it is in a dermatomal distribution, would suggest herpes zoster. Occasionally, herpes zoster occurs without a rash and should still be considered in the differential diagnosis. The findings of long tract signs would indicate compression, degeneration, or inflammation of the spinal cord, and conditions such as multiple sclerosis, acute transverse myelitis, spinal cord tumor, herniated disk, and pernicious anemia should be considered. If there are no long tract signs and no rash, one should consider early spinal cord tumor or herniated disk, intercostal neuralgia, fractured ribs, and sometimes a compression fracture of the vertebra. However, one should remember that herpes zoster may be associated with an underlying neoplasm, particularly Hodgkin’s disease. If these are normal and the diagnosis remains in doubt, one should consult a neurologist. Thus, the latter will give false positives for lactose, fructose, galactose, and salicylates. If the blood sugar is elevated or a glucose tolerance test is positive, one should suspect diabetes mellitus. If these tests are normal, one should suspect renal glycosuria, pregnancy, or renal tubular acidosis. If there are clinical features of an endocrine disorder, the various tests for these disorders should be ordered. Digitalis, phenothiazine, amphetamine, marijuana, and many other drugs may cause gynecomastia. Klinefelter’s syndrome, male pseudohermaphroditism, and testicular feminization syndrome may cause gynecomastia. If there is a bronze skin, one should consider hemochromatosis, as this may be associated with gynecomastia. Cushing’s syndrome, Addison’s disease, and hyperthyroidism may cause gynecomastia. Myotonic dystrophy, paraplegias of various types, and Friedreich’s ataxia are among the many neurologic disorders that may be associated with gynecomastia. Liver function studies, liver biopsy, and serum iron and iron- binding capacity will help rule out hemochromatosis and cirrhosis of the liver. Further, evidence of Klinefelter’s syndrome is obtained by a buccal smear (Barr bodies). Such a history may suggest that the cause is onions, garlic, alcohol, tobacco, paraldehyde, mercury, or other substances. A garlic odor to the breath is common to many poisonings (arsenic, organophosphates, etc. Abnormalities that may be found on examination of the mouth, nose, and throat include gingivitis, carious teeth, pyorrhea, stomatitis, sinusitis, pharyngitis, and tonsillitis. The presence of a chronic productive cough should suggest bronchiectasis, lung abscess, gangrene of the lungs, tuberculosis, and other lung infections. The history of esophageal regurgitation should suggest reflux esophagitis, peptic ulcer, partial intestinal obstruction, and esophageal diverticula. Cultures of any suspicious area of inflammation in the mouth, nose, and throat should be done. A 24-hour sputum collection may help differentiate bronchiectasis and lung abscesses. This would suggest an organic cause such as organic brain syndrome, epilepsy, brain tumor, etc. If the hallucinations occur in episodes with normal behavior in between, one should consider epilepsy or narcolepsy. Are the hallucinations associated with early stages of falling asleep or awakening? These types of hallucinations are called hypnagogic and are common in narcolepsy but may also be seen in normal people. Most physicians will want to refer the patient to a psychiatrist if these studies are negative. Psychometric testing will help identify schizophrenia and other psychiatric disorders. Masses that seem to be attached to the skull are osteomas, dermoid cysts, and sarcomas. Brain tumor tissue may occasionally protrude out beneath the scalp through a craniotomy defect. In the newborn, there may be edema of the scalp (called caput succedaneum) following a vertex delivery due to molding or a large hematoma over one or both parietal bones (called cephalhematoma) due to the trauma of delivery. There may be meningoceles or encephalomeningoceles due to imperfect closure of the skull (cranium bifidum). Vascular abnormalities of the skin may be found and include angiomas, arteriovenous fistulas, and telangiectasis. It is usually worse in the morning and occasionally is associated with nausea but no vomiting. Following the algorithm, you ask about a history of drugs, caffeine, or alcohol ingestion with negative results. There is no nuchal rigidity or focal neurologic signs, but funduscopic examination reveals papilledema and a visual field examination reveals an inferior nasal quadrantanopia and enlarged blind spot.
X-ray of a joint that has been involved in multiple gouty attacks will show erosive calcifications order cytotec paypal. With acute gouty arthritis generic 100 mcg cytotec visa, the goal is to decrease inflammation and thus prevent erosion and joint destruction; also in this stage it is very important to avoid fluctuations in serum uric acid level order generic cytotec on-line. However, if a patient has been taking allopurinol and an acute attack occurs, do not discontinue. This is usually required for life and initiated in those whose recurrent gouty attacks cannot be corrected by low-purine diet, alcohol limitation, avoiding diuretics, etc. Unlike acute gout, the uric acid level here may help the physician to follow the effect of hypouricemic treatment. Allopurinol can be used in overproducers, undersecretors, or patients with renal failure or kidney stones Febuxostat is used in those intolerant of allopurinol. Pegloticase dissolves uric acid: used in refractory disease Probenecid can be used in the undersecretors (>80% of adults) only. A 32-year-old man comes with a history of right ankle swelling that occurred the night before. On a routine visit the same patient has had 4 documented episodes of gout, despite limiting alcohol and diet. The presence of pseudogout in a patient age <50 should raise suspicions about one of these metabolic abnormalities. Possible acute presentation like gout, or possible asymptomatic and chronic form Knee is most commonly affected joint; other joints commonly affected are the wrist, shoulder, and ankle Definitive diagnosis requires the typical rectangular, rhomboid, positive birefringent crystals on synovial fluid evaluation. X-ray may reveal linear radiodense deposits in joint menisci or articular cartilage (chondrocalcinosis). Examination reveals decreased passive and active range of motion of the right shoulder joint, as well as erythema. The most common cause of infectious arthritis is gonorrhea, and gonococcal arthritis accounts for 70% of episodes in patients age <40. Women are at greater risk during menses and pregnancy, and women 2–3x more likely than men to develop disseminated arthritis. In older patients, Staphylococcus aureus is a common cause of infectious arthritis and occurs in patients with preexisting joint destruction from other rheumatic diseases. Acute bacterial infection may cause rapid cartilage destruction, and thus a patient presenting with monoarticular arthritis needs prompt diagnosis. Further, Staph or Strep must be cleaned out of the joint space by arthrocentesis or arthroscopy. Remember that most infected joints with gonococcal will not have positive cultures, and the Gram stain will be negative. The vasculitis syndromes are stratified according to the types of vessels involved. It typically affects the respiratory tract (sinuses, nose, trachea, and lungs) and kidneys, but can involve any organ system. The most common sign of Wegener granulomatosis is involvement of the upper respiratory tract, which occurs in nearly all patients. A common sign of the disease is chronic rhinitis that does not respond to usual treatment and that becomes increasingly worse. Despite lack of symptoms, lungs are affected in most people; if symptoms are present, they include cough, hemoptysis, and dyspnea. The only way to confirm the diagnosis is with a biopsy of an involved organ (usually nasal septum), demonstrating the presence of vasculitis and granulomas. Standard treatment is combined glucocorticoid plus an immunosuppressive agent (cyclophosphamide). Peripheral neuropathies are very common: tingling, numbness, and/or pain in the hands, arms, feet, and legs, and mononeuritis (e. Diagnosis is made by biopsy of involved organs (most commonly taken from skin, symptomatic nerves, or muscle). Treatment is high doses of corticosteroids and immunosuppressive drugs (cyclophosphamide). The cardinal manifestations of Churg-Strauss are asthma, eosinophilia, and lung involvement. New- onset headache in any patient age >50 prompts consideration of this diagnosis, which if left untreated may result in permanent vision loss. Diagnosis is confirmed by biopsy of the temporal arteries, which will demonstrate the characteristic giant cells. She has never had migraine headaches and denies blurry vision, nausea, or vomiting. The inflammatory myopathies are inflammatory muscle diseases that present with progressive muscle weakness. Patients report difficulty with tasks that involve the proximal muscles: lifting objects, combing hair, getting up from a chair. Ocular muscles are never involved (this feature differentiates the inflammatory myopathies from myasthenia gravis and Eaton-Lambert syndrome). Dermatomyositis will also have skin involvement; the heliotrope rash is a purple-lilac discoloration of the face, eyelids, and sun-exposed areas of the body. These are the most sensitive tests to perform in patients suspected of an inflammatory myopathy. Autoantibodies (anti-Jo-1) occur in patients with inflammatory myopathies, supporting a possible autoimmune origin. Electromyography shows evidence of myopathic potentials characterized by short-duration, low-amplitude units. Clinical Recall A 55-year-old man comes to the outpatient clinic complaining of right toe pain for the past 8 hours. Both dysphagia and odynophagia will cause weight loss if symptoms persist for more than a few days. Evaluation includes select videofluoroscopy (modified barium swallow); the patient swallows food under fluoroscopy and the upper esophageal sphincter is evaluated as the initial swallow is made. Patients with this condition present with: Coughing with swallowing Choking Nasal regurgitation with fluids Aspiration while swallowing Patients with esophageal dysphagia report food “sticking” or discomfort in the retrosternal region. She has had this problem for almost a year, and it is most difficult for her to eat solids. Her symptoms have not worsened at all over this time period, and her weight has been stable. A very small number can be from Chagas disease, gastric carcinoma, or a disease that can infiltrate into the area such as lymphoma. Achalasia presents with progressive dysphagia to both solids and liquids simultaneously and can have regurgitation several hours after eating.
Treatment is prophylactic: Tetanus toxoid (Tdap) boosters every 10 years Immediate surgical care generic cytotec 100mcg without prescription, débride wound Antitoxin proven 100 mcg cytotec, tetanus immunoglobulin Penicillin 10–14 days Wound Management Patient Not Tetanus Prone Tetanus Prone Linear cheap 100mcg cytotec amex, 1 cm deep cut, without Blunt/missile, burn, frostbite, 1 cm deep; devitalized tissue, without devitalized tissue present + contaminants major contaminants, <6 hours (e. Invasive pulmonary 90% have 2 of these 3 risks: 1) neutropenia <500, 2) steroid use, and 3) cytotoxic drugs (e. Depends on the type of disease being caused; however, all can have an abnormal chest x-ray and Aspergillus in sputum. Allergic bronchopulmonary elevation of markers of allergy/asthma, such as eosinophil/IgE levels Positive skin testing Mycetoma: abnormal sputum culture/serum precipitins/x-ray Invasive: Sputum culture not sufficient; biopsy to show invasion necessary. Allergic: steroid taper and asthma medications, not antifungals Mycetoma: surgical removal Invasive: Voriconazole is superior to amphotericin; there are fewer failures seen with it (and caspofungin) as compared with amphotericin. Proteinuria may be caused by glomerular or tubular disease, although glomerular disease leads to greater amounts. Any positive urine dipstick for protein should be followed up by a quantitative study. Red cells can be found in the urine from any cause of disease in the urologic system. Etiologies are stones, cancer, bleeding disorders, trauma to urinary system, and treatment such as cyclophosphamide (which causes hemorrhagic cystitis or glomerular disease). Gram-negative bacteria reduce nitrate to nitrite, which is a marker of urinary infection. Glucose: Glucosuria most often reflects hyperglycemia, but may also be caused by defective proximal tubular reabsorption, seen in Fanconi syndrome. By itself, the isolated finding of bacteria in the urine is of very limited significance. The most important exception is in pregnant women, whom you should screen for bacteria and treat. If eosinophils are suspected, they should be stained for with Hansel or Wright staining. Renal tubular epithelial cells appear in the urine during acute tubular necrosis, as dying tubular cells slough into the urine. Casts are collections of precipitated protein in the renal tubule, often capturing cells which are present there. These casts develop as an accumulation of the normal amount of tubular protein; they do not necessarily mean disease. Red cell Glomerulonephritis Broad, Chronic renal failure waxy Granular Also called “dirty” or “muddy”; are associated with acute tubular necrosis and represent accumulated epithelial cells White Pyelonephritis, interstitial nephritis cell Table 8-1. The ratio of albumin to creatinine is a good estimate of the albumin that would have been collected in a 24 hour collection, and is much easier to do. Therefore, serum creatinine values should always be compared to a given patient’s baseline. Hence, if the creatinine goes from 1 to 3 over a period of 2 days in a patient with renal injury, this is consistent with nonfunctioning kidneys. For example, in rhabdomyolysis or contrast-induced renal failure, it may develop over several hours, while in aminoglycoside toxicity it may take 1-2 weeks. The distinction cannot be made by a single serum creatinine test, but requires serial determinations. The term azotemia literally means the buildup of azole groups or nitrogen in the blood. Volume-depleted patients present with signs of orthostatic or frank hypotension and tachycardia. This demonstrates a reduction of effective arterial volume a physiologic term for perfusion of organs, determined by intravascular volume, blood pressure, and cardiac output. Since the underlying physiology is systemic vasodilation, treatment with vasoconstrictors may be useful. This beneficial effect is most likely secondary to the decrease in intra-glomerular hypertension. This may come by obstruction of any part of the renal collection system (renal pelvises to urethra). Prostate: hyperplasia and cancer Neurologic disease: Neurogenic bladder: patients have a history of obstructive symptoms followed by sudden onset of oliguria or anuria. This may be due to multiple sclerosis, spinal cord lesions, or peripheral neuropathy. Clinical Presentation: Patients may experience a distended bladder in prostatism or neurologic disorders. Urine output may diminish or cease, proceeded by incomplete voiding in prostate or bladder diseases. The urinalysis is variable, from normal (neurogenic bladder) to hematuria (stones, bladder cancer, clots). Prostate or bladder outflow disease may be detected by finding large volumes of urine in the bladder after passing a Foley urinary catheter (a large post-void residual volume). After urinating (voiding), there should be no more than 50 mL of urine left in the bladder. If this post-void residual is markedly elevated, it implies an obstruction to the flow of urine out of the bladder. Treatment is based on quickly relieving the cause of the obstruction: For bladder/prostate disease, do Foley catheter insertion. For ureteral/pelvic obstruction, do nephrostomy tube insertion (percutaneous or transurethral). Clinical Recall Which of the following lab values is most likely in patients with prerenal azotemia? Causes include ischemia and hypoperfusion of the kidney (shock, sepsis, heart failure) and tubular toxins (aminoglycosides, contrast dyes, amphotericin, myoglobin [rhabdomyolysis], cisplatin). Next comes a reduction/cessation of urine flow (oligo- or anuria) as the tubules necrose and the glomerular ultrafiltrate back- leaks into the blood instead of forming urine. With severe or prolonged injury, the tubular cells will necrose and slough off into the urine and become visible as renal tubular epithelial cells or granular/muddy brown/pigmented casts. The rising serum creatinine (over days) is accompanied by reduced urine output or anuria. Treatment focuses on correcting the underlying cause (no therapy can reverse the renal failure). Volume repletion with normal saline is often given to make sure there is no prerenal component and may reduce contrast-induced renal failure, but it does not reverse it once it occurs. Dialysis may be needed if uremic symptoms occur, and is stopped once the tubules recover. Rhabdomyolysis can be caused either by (a) sudden/severe crush injury, seizures, or severe exertion, or (b) hypokalemia, hypophosphatemia, or medications (e.
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