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Fluid absorption follows Na absorption best 100 mg female viagra, which is co-transported with + chloride ion buy female viagra 50 mg visa, glucose, and aminoacids and through Na channels. Pathophysiologic classification Most diarrheal states are caused either by inadequate absorption of ions, solutes and water or by increased secretion of electrolytes that result in accumulation of water in the lumen. Based on this concept diarrhea can be classified as: A) Secretory diarrhea: Occurs when the secretion of fluid and electrolytes is increased or when the normal absorptive capacity of the bowel is decreased. It usually follows stimulation by mediators like enteric hormones, bacterial enterotoxins (E. These events can result in massive diarrhea, without evidence of cell injury, as shown by the ability + + + of the cell to absorb Na if coupled to nutrients (Na to glucose, Na to amino acids). That is why cholera and other forms of secretary diarrhea can be treated with oral solutions containing sodium and glucose. B) Osmotic diarrhea: 383 Internal Medicine It occurs due to the presence of poorly absorbed or nonabsorbable substance in the intestine which is osmotically active, resulting secondary accumulation of fluid and electrolytes. Such nonabsorbable substances include lactose in patients with lactase deficiency. Mucosal damage can interfere with absorption, induce secretion and affect motility, all of which contribute to diarrhea. Infectious Diarrhea Microbes cause diarrhea either directly by invasion of gut mucosa or indirectly through elaboration of different types of toxins: Secretory enterotoxins, cytotoxins and inflammatory mediators. I) Secretory toxin induced diarrhea Patients seldom have fever or major systemic symptoms. Examples: a) Vibrio cholerae produces enterotoxins which stimulate adenylate cyclase which results in massive intestinal secretion. Examples: a) Shigella dysenterae produces Shiga toxin which causes destructive colitis. Common causes include : Acute shigellosis Feaco-orally transmitted, as few as 10 - 100 bacteria are enough to cause diarrhea Initially multiplies in the small intestine causing secretary diarrhea. Acute Salmonellosis Transmitted by ingestion of contaminated meat, dairy or poultry products. This is in marked contrast to the 3 - 4 wks febrile illness caused by Salmonella typhi and paratyphi, which are not usually associated with diarrhea. Campylobacter jejuni It may be responsible for up to 10% of acute diarrhea world wide. Norwalk and Rota viruses Invade and damage villous epithelial cells Cause diarrhea by interfering with absorption through selective destruction of absorptive villous tip cells with sparing of secretary crypt cells. Cysts or trophozoites can be identified in the stool, and treatment should be given in both cases. They may cause voluminous life threatening diarrheal diseases in patients with acquired immunodeficiency syndrome. Evaluation of a patient with diarrhea Careful interview of patients with diarrhea contributes in etiologic diagnosis, evaluation of severity of illness, and in designing treatment and preventive measures. Thus, the history should include Duration of illness: if the diarrhea lasts for 2 - 4 wks, acute diarrheal diseases are said to exist. However, if it lasts for more than 4 wks, consider chronic diarrheal diseases and infectious causes are unlikely. Bloody diarrhea is usually inflammatory or ischemic in origin and caused by invasive organisms, ulcerative colitis, or neoplasms Volume of diarrhea Large volume diarrhea indicates small bowel or proximal colonic diseases Scanty, frequent stools associated with urgency suggest left colon or rectal diseases Any association with specific meal? If diarrhea is associated with intake of Fat it is due to fatty intolerance Sweet diet it is due to osmotic diarrhea Milk and milk products - it is due to lactase deficiency Is there history of drug intake? Laxatives Chemotherapeutic agents 7) Presence of underlying diseases (like diabetes mellitus) or systemic symptoms Physical examination: Assess severity of dehydration, Wight loss and other associated signs in patient with chronic diarrhea. Diagnosis: Laboratory tests: 1) Culture and sensitivity testing to detect a pathogenic bacterial strains. Proctosigmoidoscopy: to exclude of confirm the diagnosis of inflammatory bowel diseases. Rehydration In patients with massive diarrhea and vomiting with hypotension intravenous fluids like Ringers lactate or Normal saline should be given in adequate amount. Antimicrobial therapy Antibiotics: Most acute infectious diarrheal diseases do not require antibiotic therapy because majority of them are self limited and viral in nature. In immunocompromized patients continue maintenance dose of the same drug three times a week. Anemia Learning objectives: At the end of this topic the student we be able to:- 1. Evaluate cases of anemia with appropriate history, physical examination and proper laboratory studies 4. Anemia: General approach a) Definition Functional definition: A significant reduction in red cell mass and a corresponding decrease in the 02 carrying capacity of the blood. For instance; 389 Internal Medicine Hgb or Hematocrite could be falsely elevated ( plasma volume) e. Clinical approach to the Patients with anemia Anemia is a manifestation of an underlying pathological condition. Multifactorial : a combination of these History: Accurate history provides information crucial to the diagnosis of the underlying cause.

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Pain lasting more than six to 12 hours order 50 mg female viagra with mastercard, especially if accompanied by persistent vomiting or fever buy 100mg female viagra with mastercard, suggests another process such as cholecystitis or pancreatitis (Table 4). Diagnostic Imaging Detecting gallstones (as opposed to diagnosing clinically symptomatic gallstone disease) is by diagnostic imaging. Plain abdominal x-rays will only identify the 10-15% with high calcium content as radiopaque densities in the right upper quadrant. Ultrasonography is the most sensitive and specific method for detecting gallstones (appearing as echogenic objects that cast an acoustic shadow) or a thickened gallbladder wall (indicating inflammation). Also, if the gallbladder is fibrotic and shrunken, ultrasound may not visualize the gallbladder. Although most episodes of biliary colic resolve spontaneously, pain eventually recurs in 20-40% each year. Because of recurrent attacks of pain and these increased risks, cholecystectomy is indicated once biliary colic develops. The risk of any emergency procedure is greater then elective surgery, so this is why elective cholecystectomy is recommended. Open cholecystectomy The term open connotes the need for an incision to open the abdominal cavity for direct visualization in the course of removing the gallbladder. Open cholecystectomy is usually necessary in Mirizzis syndrome, an infrequent complication in which large gallstones compress First Principles of Gastroenterology and Hepatology A. In addition to the obvious cosmetic appeal, these smaller incisions result in less postoperative pain and shortened recovery time, allowing an early discharge from hospital (sometimes the same day as an outpatient) and return to work. The disadvantages include a somewhat higher complication rate, particularly from common duct injury and retained common duct stones, plus the potential for overuse. In 5% of cases the procedure must be converted to an open cholecystectomy because of technical problems. Laparoscopic cholecystectomy is now the standard for elective removal of the gallbladder in those with significant symptoms (e. Prophylactic cholecystectomy is not warranted in those with asymptomatic stones except for rare cases suspected of developing/ harboring carcinoma of the gallbladder (e. Chronic Calculous Cholecystitis Chronic inflammation of the gallbladder is the most common histological process, often manifest as mild fibrosis of the gallbladder wall with a round cell infiltration and an intact mucosa. Some degree of chronic inflammation inevitably accompanies gallstones, but the stones will have developed first. Even transient obstruction of the cystic duct can produce biliary colic and an element of inflammation that is chemical in origin. There is little correlation between the severity and frequency of such biliary episodes and the degree of inflammation or fibrosis. Chronic inflammation thus may follow the resolution of acute cholecystitis, evolve with recurrent episodes of biliary colic or develop insidiously. It is the presence of true biliary colic which drives the indication for cholecystectomy, not the possible presence of chronic cholecystitis. Clinical Features The clinical features are those of either biliary colic or a previous episode of acute cholecystitis that has resolved leaving the gallbladder chronically inflamed and scarred. The pain characteristically is a constant dull ache in the right upper quadrant or epigastrium, and sometimes also in the right shoulder or back. Flatulence, fatty food intolerance and dyspepsia occur, but are equally frequent in patients without gallstone disease. There may be local tenderness in the right upper quadrant of the abdomen but no peritoneal findings. If the gallbladder is fibrotic and shrunken, ultrasound visualization may be difficult. A nuclear medicine cholescintigraphy scan may be positive with the gallbladder failing to fill, but non-visualization is rather insensitive for chronic cholecystitis, because of frequent false positive and false negative tests. Medical management depends upon gallstone size, gallbladder function and any co-morbid conditions (e. Cholecystectomy provides definitive treatment, removing the stones and the gallbladder, and eliminating recurrences of true biliary pain. Obstruction of the cystic duct results in the gallbladder becoming distended with bile plus an inflammatory exudate or even pus. If resolution occurs, the mucosal surface heals and the wall becomes scarred, but the gallbladder may not function e. In a minority, acute cholecystitis can occur in the absence of obvious stones (acalculous cholecystitis). Although acalculous cholecystitis can occur in healthy individuals, it tends to affect elderly men who have co-existent vascular disease, debilitated individuals and even young children. Its location is usually the right upper quadrant or epigastrium, sometimes radiating to the back or the right shoulder. Pain in acute cholecystitis, unlike biliary colic, persists for more than six to 12 hours.

Many factors can afect a mans ability to get and sends a stimulus Te brain plays an important part in getting an keep an erection purchase female viagra 100 mg on line. For an erection to happen discount female viagra 50mg without a prescription, the brain must combination of physical and psychological factors, are happen three or be aroused by sensations (real or imagined), such as often present at one time. When the brain receives a sign of another serious, but sometimes undiagnosed this stimulus, messages are sent down the spinal cord health problem. Sometimes there is no clear reason for to nerves leaving the lower part of the spinal cord. Erections can also happen from sensations around the penis such as touch or a full bladder, which send Is erectile dysfunction just part of getting old? Early morning erections, often linked penis are less responsive, interfering with getting and to having a full bladder, happen through keeping good erections. It may take much longer before a second erection happens compared to when the man was younger, and usually the erection is not as frm. Often poor erections can be the Psychiatric disorders frst sign of blood vessel problems and indicate a Interference with Spinal cord trauma higher risk of future heart attacks and stroke. Understanding what is normal Parkinsons disease in older age can prevent frustration and concern. Older men may notice a treatment for Sometimes men have erectile problems when they erectile dysfunction are taking medicines for other medical conditions. By working with sexual function, all of which could be because of lower testosterone) has the doctor, most men can fnd treatments that not only testosterone levels. However, these changes are often been diagnosed by improve their general health and well-being, but also because of ageing alone, and testosterone does not a doctor help the erectile problem. Can low testosterone levels cause Can prostate problems cause erectile dysfunction? Neither prostate cancer nor benign prostate disease Low testosterone levels can lead to problems with directly causes erectile problems. Tere is however getting and keeping an erection, but it is not a a link between lower urinary tract symptoms common cause of erectile problems. Even then, replacement It is the treatment of prostate diseases that often causes with testosterone will not always help the erectile erectile dysfunction. Men with low interest in sex (low operation, where the prostate gland is completely libido) should have their testosterone measured, as removed because of cancer, there may be damage to testosterone treatment may improve their sexual the nerves that control erections. Other hormonal problems, such as high around the prostate have to be removed because the prolactin and thyroid disease may afect erectile cancer has spread and this causes erectile dysfunction. Other prostate cancer treatment, such as radiotherapy, Tere are often reports in the media that testosterone can also cause erectile dysfunction. Even if a physical problem is the Tere is a strong connection between thoughts and Depression is a common and often unrecognised major cause of the emotions and erectile dysfunction. As a result, any other Depression directly causes erectile dysfunction and low factors that distract the brain or interrupt these sexual interest, and treatments used for depression may messages can have a major efect on erectile function. Concerns about sexual Erectile dysfunction can also lead to depression which performance or physical appearance can also may be reversed by treating the erectile dysfunction. What are the less common causes of Psychological and physical factors together can erectile dysfunction? If getting and keeping an A less common cause of erectile dysfunction is erection is difcult during sexual intercourse with a Peyronies disease, which is the build-up of thick partner, but not at any other time, then the problem fbrous scar tissue (plaque) in the penis. It sometimes develops after happening, the cause of the problem is more likely to surgery to the penis for other problems, and sometimes be physical. Making sure that the situation and setting for sexual Sometimes trauma to the pelvic area can cause activity are right for both partners is very important for bruising or more severe damage to the nerves or successful and satisfying sexual relations. Sometimes blood vessels, which may cause short-lived erectile talking to a counsellor can help reduce anxiety and any problems. Long-distance and competitive bike riding other concerns about sexual performance. For some dysfunction can be prevented by good general health, that may be short term. Te sooner you see a doctor, the sooner you can receive treatment for any other serious medical problems you may have. By getting a diagnosis and controlling the erectile problems early, the damage done to the tissues of your body (including the penis) may be reduced. Te local doctor is the best frst point of contact if he should have you have erectile problems. Often the local doctor At frst, the doctor will need to talk to you to fnd a face to face can treat erectile problems without the need to refer out more about the problem. Local doctors are able to prescribe for you to see the doctor with your partner, if his local doctor, whether or not he medicines to treat erectile dysfunction. It is important possible; outcomes can be more successful if you wants to have sex to talk openly to a doctor about any problems with both understand the problem and agree from the sexual functioning but this may be difcult for both beginning how to treat the erectile dysfunction. Most doctors are trained to After taking a history of sexual function and general deal with these problems, but if the doctor is not medical factors, the doctor will do a physical comfortable or confdent in this area of medicine, examination that may include checking the penis they may refer you to a colleague in their practice or and testes.

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Much more commonly order female viagra 100 mg free shipping, both arterial gas hypotension signify a very severe attack and vigorous levels are abnormal female viagra 100mg with mastercard. Investigation Acute Arterial blood gases provide the most useful guide to the severity of the attack and to the success of treat-. It should apnoea, drug overdosage, stroke) also be performed if there is a failure to respond to. Thesepatientsareparticularlylikelytodevelop patients in whom the diagnosis is suspected. Oxygen is given continuously until the acute situation (including infection and heart failure) has recovered. For chronic respira- tory failure controlled oxygen can be given continu- Acute on chronic respiratory ously at homewithimprovement in symptomsand an increase in life expectancy (Trials Box 11. Clinical presentation Indications for respiratory support and mechanical ventilation. Haemophilus inuen- zae, Legionella species, Chlamydia psittaci and Staph- ylococcus aureus account for most of the remainder. Thisrare condition occursfollowingexposure to aller- gens such as certain foods, e. Clinical features Investigations range from mild with ushing of the face, pruritus Investigationsareperformedtoestablishthediagnosis andblotchywheals,toseverewithasthma,respiratory and assess severity. Blood count white cell count>15109/l suggests challenge is given if there is hypotension. Hydrocor- bacterial infection; white cell count>20109/l or tisone takes several hours to act. Haemoglobin rst injection of adrenaline (epinephrine)) in a dose of 200mg slowly intravenously or intramuscularly, for haemolysis. Gram staining and culture of sputum but cough is should be identied and avoided. Most patients will unproductive in one-third of patients, and negative wish to carry self-adminstration preassembled pens results are common, particularly if antibiotics have containing adrenaline (epinephrine) for intramuscu- been given. Pleural uid, if present, should be aspirated for by C1 esterase deciency (autosomal dominant). It responds to danazol prophylaxis Management and fresh frozen plasma (or if available plasma de- rived C1 inhibitor) to correct the deciency during. In uncomplicated pneu- Pneumonia monia,treatmentisusuallystartedwithoralamoxicillin or a macrolide (erythromycin or clarithromycin). In Community-acquired pneumonia affects approxi- severe pneumonia intravenous therapy is given, often mately 510/1000 adults per year. One in 1000 re- usingacombinationofamacrolide(erythromycin)and quires hospitalisation, and mortality in these patients a second- or third-generation cephalosporin (cefurox- is around 10%. The choice of antibiotics should takeaccountoflocalguidelines,whichwilltakeaccount Clinical presentation of other factors, including the incidence of Clostridium difcile enteritis. The likely causa- Pneumococcal pneumonia is the most common bacte- tive agent cannot be predicted from clinical ndings. Hepatitis, encephalitis, renal failure and hae- and those with pre-existing lung disease. Treatment is with tetracycline or presents acutely with fever, pleuritic pain and rust- erythromycin. It causes both lobar and broncho- Viral pneumonia in children is commonly due to pneumonia. A polysaccharide pneu- is a respiratory virus which produces syncytium for- mococcal vaccine is available for those at high risk. Infection may be shouldbegivenatleast2weeksbeforesplenectomyand indistinguishable from acute bacterial bronchitis or before chemotherapy. It may complicate Acute viral pneumonia in adults is less common inuenzal pneumonia, and this makes it relatively butoccursduringepidemicsofinuenza. It also occurs ache and myalgia are followed after a few days by dry in patients with underlying disease, which prevents a cough and chest pain. The viruses sequent bronchiectasis are relatively common ofmeasles,chickenpoxandherpeszostermaydirectly complications. The diagnosis is conrmed by a rise in Legionnaires disease was rst described in a group specic antibody titre. The caus- Aspiration pneumonia comes in two main varie- ative Gram-negative bacillus ourishes in the cooling ties, differentiated from each other by the type of uid waters of air conditioners and may colonise hot-water aspirated and the circumstances in which it occurs. It begins as an inuenza-like Aspiration of gastric contents may produce a severe illness with fever, malaise and myalgia, and proceeds chemical pneumonitis with considerable pulmonary with cough (little sputum), dyspnoea and sometimes oedema and bronchospasm (Mendelson syndrome). The acute respiratory distress and shock can be very Diarrhoeaandvomitingarecommonandrenalfailure rapidlyfatalandverydifculttotreat. Examination shows consolidation that in states of reduced consciousness such as general usually affects both lung bases. X-ray changes may anaesthesia, drunks and when gastric lavage (for drug persist for more than 2 months after the acute illness. Erythromycin or ciprooxacin are the antibiotics of Aspiration of bacteria from the oropharynx may choice, but the mortality remains high.

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Complications If surgery is delayed beyond 1218 hours the blood sup- Disorders of the male genital ply is compromised and infarction occurs requiring sur- system gical orchidectomy buy female viagra 50mg free shipping. Investigations Torsion of the testis Diagnosis is clinical and surgery should not be delayed generic female viagra 50mg with visa. Age Most occur in young children and peri-pubertally, less Management common over 25 years. The scrotum is explored, the twist is reversed and if the testis is viable both testes are xed in position as the Sex condition is a bilateral defect. Aetiology Torsion occurs if the testis is insufciently xed by its Hydrocele lower pole to the tunica vaginalis by the gubernaculum testis, so allowing it to twist. Pathophysiology Twisting of the testis on the spermatic cord leads to ve- Incidence/prevalence nous/haemorrhagic infarction. Aetiology Most hydroceles are idiopathic but may occur secondary Incidence/prevalence to trauma, infection or neoplasm. Pathophysiology Fluid accumulates between the two layers (parietal and Aetiology/pathophysiology visceral) of the tunica vaginalis. It is thought to occur Thesearetheequivalentofvaricoseveins,duetothevalve due to imbalance of secretion/reabsorption of peritoneal leaets becoming incompetent, blood ows back down uid from these layers. Varicoceles occur more commonly on by the persistence of the processus vaginalis and can be the left side due to the perpendicular drainage of the left associated with herniation of abdominal contents into spermatic vein into the renal vein, which is compressed the sac. Usually the hydrocele covers the testis, tile, but many also have normal sperm counts. Testicular atrophy is thought to swelling, a normal spermatic cord should be palpable occur due to the slightly raised temperature triggering (this differentiates a hydrocele from an inguinal hernia). A simple hydrocele transilluminates well, but if there is blood (a haematocele) or it is chronic and the wall is Clinical features thickened, it does not. Patients may complain of a dragging sensation or aching pain in the scrotum, particularly on standing. On palpation there is a soft If there is any doubt an ultrasound scan conrms the swelling like a bag of worms along the spermatic cord, diagnosisandisusefultoexcludeanunderlyingtesticular which is compressible and disappears on lying at. Management Management Surgery is indicated in boys and young males with asym- 1 Anysecondary cause should be identied and treated. Aspiration should not be attempted as there is a tile men with a varicocele, surgery has not been shown risk of infection and bleeding. Ligation of the spermatic 3 If the hydrocele uid becomes infected or contains vein can be either by open or laparoscopic surgery. In blood, incision and drainage of pus are necessary, and older males who no longer wish to have more children, examination of the scrotal contents to exclude an un- treatment with scrotal support and analgesia may be derlying tumour may be performed at that time. Aetiology/pathophysiology Clinical features Normally the foreskin does not retract at birth and it Aswelling in the scrotum located above and behind the may be months to years before it becomes retractile. In testes, thus some patients attend saying they have devel- congenital phimosis, the orice is too small from birth oped a third testis. Surgery to remove the cyst(s) risks damaging the sper- Clinical features matic pathway, such that bilateral operations can cause r Ayoung child with congenital phymosis may have dif- sterility, and more conservative removal often leads to culty with micturition, with ballooning of the pre- recurrence. Denition Inability to achieve or sustain a sufciently rigid erection Complications r in order to have sexual intercourse. Occasional episodes Recurrent balanitis may occur due to secretions col- of impotence are considered normal, but if erectile dys- lecting under a poorly retractile foreskin. Balanitis function precludes more than 75% of attempted inter- causes pain and a purulent discharge. Also called male If apoorly retracting foreskin remains retracted after sexual dysfunction. Incidence/prevalence r Phimosis increases the rate of penile cancer by at least This has been underestimated in the past, due to the 10-fold. With Management greater understanding, increased availability of treat- Symptomatic phimosis is treated by elective circum- ment and more widespread discussion of the problem, cision. Circumcision is not required in asymptomatic 40% of men aged 40 are recognised to have some degree young children, unless for religious reasons. In cases of of sexual dysfunction, increasing by approximately 10% acute paraphimosis, the band is excised under general with each decade. Aetiology The cause is pyschogenic in 25% of cases, drugs (25%) and endocrine abnormalities (25%). The other 25% are Epididymal cysts caused by diabetes, neurological and urological/pelvic Denition disease. Epididymalcystsareuidlledswellingsconnectedwith Psychogenic causes can be divided into following: the epididymis that occur in males.

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