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By E. Ilja. East Tennessee State University. 2019.

A combination of antiviral agents is necessary: pegalated interferon plus ribavirin purchase cheap viagra soft line erectile dysfunction vitamins. Chronic hepatitis C requires surveillance for progression to cirrhosis buy 100 mg viagra soft visa causes of erectile dysfunction in 60s, liver failure and the development of hepatocellular hepatoma cheap 100mg viagra soft amex erectile dysfunction juicing. Super-infection tends to result in a more severe hepatitis than hepatitis B alone; further, 80% go on to chronic infection. Co-infection with both B and D viruses causes chronic hepatitis D infection in less than 5% of persons. Hepatitis D infection has the highest morbidity and mortality rate of all the hepatitis infections. The presentation is that of acute hepatitis or a flare of hepatitis, and the disease can rapidly evolve into cirrhosis, liver failure or hepatocellular carcinoma. Domestic animals are a common reservoir for the hepatitis E virus; some surveys indicate infection rates exceeding 95% among domestic pigs in endemic countries. It is not clear if acquisition of an acute infection will provide lifelong immunity. It is not clear if the immune globulin from developing countries would be more effective. Travelers to endemic countries should be advised not to consume any uncooked food or untreated water. Safe practices, such as hand washing prior to eating and no swimming in First Principles of Gastroenterology and Hepatology A. An experimental vaccine based on recombinant viral proteins has been developed and tested in a population of military personnel working in a developing country. Unclear is if the vaccine offers long-term protection or is cost-effective for this generally mild disease. About 90-95% of the North American population is seropositive, most after subclinical infection. Mild hepatitis is a common presentation, but jaundice, hepatomegaly and severe hepatitis are rare presentations. Herpes simplex and yellow fever) account for less than 1% of all acute viral hepatitis in North America. Complications of Acute Viral Hepatitis Most patients with viral hepatitis recover completely. The most important complication is the development of chronicity, which may follow hepatitis B, C and D. This complicates acute hepatitis B infrequently in adults but occurs in acute hepatitis C in over 70% of cases. Chronic hepatitis is suspect if symptoms and/or elevated serum aminotransferase levels persist beyond six months. Fulminant Liver Failure Fulminant liver failure is the development of acute liver cell injury proceeding to liver failure and hepatic encephalopathy within 8 weeks in a patient without any known previous liver disease. Clinically, the patient deteriorates with development of deep jaundice, confusion and drowsiness. At this stage, the mortality rate exceeds 50% unless a liver transplant can be performed rapidly. Death may occur from infection, hypoglycemia, increased intracranial pressure with cerebral edema, or renal failure. Massive hepatic necrosis leads to a shrunken liver in which the architecture collapses histologically. Usually a liver biopsy is not required; the procedure is associated with considerable bleeding risk unless done by the transjugular route. Cholestasis Occasionally, acute viral hepatitis exhibits a cholestatic phase, in which the patient becomes intensely pruritic and jaundiced. Relapsing (Biphasic) Hepatitis Clinically, these patients begin improving, only to have a recurrence of the signs and symptoms of their hepatitis. Hepatitis C is characterized by repeated and wide fluctuations in liver aminotransferase values, but a true biphasic clinical course is uncommon. This is due to circulating immune complexes of viral proteins and antibody, with complement activation. Extrahepatic manifestations in acute hepatitis A are uncommon, but include arthritis, vasculitis, thrombocytopenia and aplastic anemia. In both hepatitis B and C, about 5-10% of cases initially develop a serum-sickness-like syndrome characterized by skin rash, angioedema and arthritis. Other immunologic manifestations include pericarditis, aplastic anemia or neurologic abnormalities such as Guillain- Barre syndrome. The extraintestinal manifestations associated with chronic hepatitis will be discussed in the next chapter. Summary Acute viral hepatitis is usually a self-limited disease and in most cases requires supportive care only. For the few patients who develop fulminant liver failure, liver transplantation will be the only treatment option. Introduction The term chronic hepatitis means active, ongoing inflammation of the liver that persists for more than six months, being detected by biochemical and histologic means. Typically, biochemical tests are used to identify and follow patients with chronic hepatitis. Liver biopsies serve to define more precisely the nature of the chronic hepatitis, and to provide useful information regarding the extent of damage and prognosis. Histologically, chronic hepatitis is characterized by infiltration of the portal tracts by inflammatory cells. These cells are predominantly mononuclear, and include lymphocytes, monocytes and plasma cells. Liver biopsy is the gold standard to evaluate the grade (degree of inflammation) and stage (degree of fibrosis/cirrhosis) of chronic viral hepatitis. Histologic or inflammatory activity (A score) is determined by an algorithm incorporating the amount of portal and lobular inflammation and necrosis into a score from A0- A3. Primary biliary cirrhosis and primary sclerosing cholangitis may occasionally mimic chronic hepatitis, but are not usually classified as such. Table 2 summarizes an approach to help determine the etiology of chronic hepatitis. A careful assessment of risk factors is helpful in determining the cause of chronic hepatitis (Table 2). The rate of transmission via needle stick injury varies with the type of virus exposure, bore size of the needle, and whether the needle is hollow or not (Table 3). In most cases, selected laboratory tests will provide confirmation of the diagnosis. This portal tract contains a chronic inflammatory infiltrate that is confined to the portal triad and does not extend past the limiting plate (arrowheads). Inflammatory cells are shown infiltrating and destroying the periportal hepatocytes (arrow) and disrupting the limiting plate (interface necrosis) (arrowheads).

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Ultrasound can identify the subepithelial tissue discount viagra soft 100mg free shipping erectile dysfunction caused by guilt, the internal sphincter best buy for viagra soft erectile dysfunction treatment blog, the intersphincteric space purchase generic viagra soft on-line erectile dysfunction doctor delhi, the longitudinal muscle as well as the external sphincter. Ultrasound is also quite useful in the follow-up of the post surgical correction of fecal incontinence. Optimally, an endoluminal coil is ideal for demonstrating subtle changes in the sphincters, and provides the required spatial resolution. Fecal Incontinence Understanding fecal incontinence requires knowledge of the normal function of the anorectum. This creates an anatomical sling of muscle that pulls the anorectal junction forward when it tightens, thus closing the upper anal canal and creating the anorectal angle that is vital to the maintenance of fecal continence. Some patients with fecal incontinence will describe their problem as diarrhea, rather than loss of control of bowel function. All patients with a complaint of diarrhea should be asked if they have lost control of stool (ie. If they have fecal incontinence, or accidents), as this may indicate where the problem actually lies. Once fecal incontinence has been noted, it is then necessary to identify the frequency of the incontinence, whether both liquid and solid stool have been leaked, and whether the individual has an urge to defecate before the leakage occurs. Drug therapy in irritable bowel syndrome Symptom Drug Dosage Abdominal pain o Anticholinergics Hyoscyamine 0. Shaffer 327 Most patients presenting with fecal incontinence have idiopathic fecal Incontinence. Fecal incontinence may occur as the result of childbirth, surgical trauma, or other causes. With childbirth, many women suffer occult sphincter injury to the anal sphincters, both the internal anal sphincter and the external anal sphincters, and child birth may also cause damage to the pudenal nerves. The injury is often not recognized at the time of childbirth, so the sphincter weakness and fecal incontinence only becomes symptomatic years later, presumably with atrophy of the muscles with aging. Similar injury occurs with the urinary sphincters, and many women with idiopathic incontinence resulting from childbirth injuries present years later with both urinary and fecal incontinence. If an episiotomy is done to prevent tearing into the sphincters, or if there was a posterior occiput presentation of the babys head at delivery, there is an increased risk of anal sphincter injury. The finding of perineal descent can be noted on examination of the perineum when the patient is asked to strain. This perineal dissent is associated with weakness of the pelvic floor muscles, as well as disruption of the normal anatomy. Perineal descent may be associated with a rectocele or, in female patients, with a uterine prolapse. Rectal prolapse can also accompany weakness of the pelvic floor muscles and give rise to fecal incontinence. Therapy of fecal incontinence has improved over the past decade, primarily because of the introduction of biofeedback training. Increasing dietary fiber to help reduce the amount of liquid stool may help some patients, but if this increases stool frequency, the patient be better on a low fiber diet to help constipate the stool and reduce the chance of stool incontinence. Loperamide has been shown to increase the resting tone of the anal sphincters (especially the resting tone of the internal anal sphincter) and is a useful adjunct, especially if the stool frequency is increased. Cholestyramine may be useful when the patient has diarrhea or loose stool(s) since cholestyramine can make stool more solid (constipating effect). Shaffer 328 Surgery is of greatest benefit in those patients who appear to have a mechanical problem, such as rectal prolapse or disruption of the anal sphincter. Surgery to correct perineal descent is often less helpful, since the muscle weakness that gives rise to the descent is not satisfactorily reversed by any of the surgical procedures currently used, and attempts to suspend the pelvic floor muscles cannot strengthen these muscles. Patients should refrain from excess straining if they have significant perineal descent, because this will serve only to worsen the pelvic floor muscle weakness. Constipation In the approach to a patient with constipation, it is first necessary to define what the patient means by the term. Many definitions exist, but the best clinical definition is that over 95% of the North American population has a stool frequency from three times a day to three times a week: therefore, patients who have a bowel frequency less than three times a week would be defined as being constipated. Many patients will describe their stool as constipated, meaning that the stool is hard or in pellets (scybalous), while other patients may have a stool frequency that falls within the normal range yet feel that their bowels have not completely emptied. In Western culture the most frequent cause of constipation is an inadequate intake of dietary fiber. The concept of fiber has become quite confusing to many persons, with the increased emphasis on oat fiber for elevated cholesterol treatment. Cereal grain fibers that have more insoluble fiber (as opposed to soluble oat bran fiber) are best to increase stool frequency. The insoluble fiber should be added gradually over 8 to 12 weeks up to a maximum daily dose of about 30 g. Many patients who are constipated continue to pass dry, hard stool, despite an increase in dietary fiber, because they do not increase the water content of their diet. This possibility of organic disease should always be considered in a patient with the new onset of constipation after the age of 40 years (when the incidence of colon cancer rises). Not infrequently, patients with an underactive thyroid will present with the primary symptom of constipation. Hypercalcemia rarely reaches levels that produce constipation, but should always be considered, since this electrolyte disturbance can be a life-threatening disorder. Constipation in this setting is always resistant to therapy until the hypercalcemia is treated. This is due to the functional obstruction from spasm caused by the inflammation First Principles of Gastroenterology and Hepatology A. The colon more proximally continues to produce formed stool, which cannot pass easily through the inflamed rectum. Proctitis will usually be associated with excess mucus production, with or without blood in the stool, and proctosigmoidoscopy will diagnose this entity. Another cause of constipation is diabetes mellitus, which results in impaired colonic motility due to dietary factors, as well as autonomic neuropathy of the enteric nervous system, seen with long-standing diabetes mellitus. Patients with diabetes may also develop diarrhea, which again has been linked to the autonomic neuropathy. This is presumed to be secondary to reduced colonic activity due to a low fiber intake. Severe cardiopulmonary diseases of whatever cause that limit activity can also result in constipation. Neurologic disorders that cause the patient to have a reduced ability to ambulate can have constipation as a feature. Some patients with diseases of the nervous system may have impaired awareness of rectal distention to signal a need to defecate, and nerve dysfunction (both peripheral and central) may impair normal colonic propulsion.

In normal individuals this area is resonant on percussion and remains resonant on inspiration purchase genuine viagra soft online xarelto erectile dysfunction. In patients with mild splenic enlargement this area will be resonant on percussion and become dull on maximal inspiration order viagra soft 100mg amex erectile dysfunction treatment in islamabad. This method has a sensitivity and specificity of approximately 80% for detection of splenic enlargement and is helpful for detection of a minimally enlarged spleen that may not be palpable buy cheap viagra soft 100 mg erectile dysfunction treatment in unani. Palpation of the spleen should begin in the right lower quadrant and proceed toward the left upper quadrant in order to follow the path of splenic enlargement. Palpation should initially be carried out in the supine position with a bimanual technique using the left hand to gently lift the lowermost portion of the left rib cage anteriorly. The fingertips of the right hand are used to palpate gently for the spleen tip on inspiration. The hand is moved from the right lower quadrant, advancing toward the left upper quadrant. If the spleen is not palpated in the supine position, the patient should be moved into the right lateral decubitus position and again with bimanual technique the spleen tip should be sought using the fingertips of the right hand on inspiration. This technique has a sensitivity of about 70% and specificity of 90% for splenic enlargement. Examination for Suspected Ascites The presence of ascites, free fluid within the abdominal cavity, is always due to an underlying pathological process (see section 16). It is easy to identify large-volume ascites clinically, but the sensitivity of the examination techniques falls with lower volumes of fluid. Ultrasound, which can detect as little as 100 mL of free fluid, is the gold standard against which the clinical diagnostic maneuvers are compared. An approach involves inspection for bulging flanks, palpation for the presence or absence of fluid waves, and percussion to demonstrate shifting dullness. Bulging flanks are suggestive of ascites since fluid sinks with gravity, while gas filled bowel loops float to the top. To demonstrate a fluid wave it is necessary to enlist the aid of the patient or another individual. With the patient in the supine position, the examiner places one palm on the patients flank. This is to apply sufficient pressure to dampen any wave that may pass through adipose tissue in the anterior abdominal wall. The sensitivity of this technique is approximately 50% but it has a specificity of greater than 80%. To test for shifting dullness, percuss from resonance in the mid-abdomen to dullness in the flanks. The area of transition is then marked and the patient rolled to the opposite side. For example, if flank dullness is demonstrated on the left then the patient should be rolled onto the right side. One should allow approximately 30 seconds for the fluid to move between the mesentery and loops of bowel into the inferior portion of the abdomen. In three separate studies shifting dullness had a sensitivity that ranged from 6088% First Principles of Gastroenterology and Hepatology A. In one study involving six gastroenterologists and 50 hospitalized alcoholic patients, the overall agreement was 75% for the presence or absence of ascites and reached 95% among senior physicians (i. The absence of a fluid wave, shifting dullness or peripheral edema is also useful in ruling out the presence of ascites. Description A number of gastrointestinal disorders are associated with oral or cutaneous manifestations. When seen in association with dysphagia, the patient likely has esophageal candidiasis. Lesions sometimes follow the course of the intestinal disease, however not always. This disorder is characterized by vascular lesions including telangiectasias and arteriovenous malformations. This syndrome is an acronym for calcinosis, raynauds, esophageal dysfunction, sclerodactyly and telangiactasia. Calcinosis is a deposition of calcium in the soft tissue, often around the elbows. Raynauds is a discolouration of fingers due to vasospasm that often results from exposure to cold. Gardners syndrome is a form of Familial Adenomatous Polyposis, patients develop hundreds to thousands of colonic polyps at a young age. Peutz-Jeghers syndrome is characterized by hamartomatous polyps, mucocutaneous hyperpigmentation and an elevated risk of various cancers. In cirrhosis, palmar erythema, telangiactasia, and caput medusa (dilated periumbilical veins) may also be seen. Patients with hemochromatosis, a condition of iron overload, may develop a bronze discolouration of the skin. Xanthomas, deposits of yellowish, cholesterol rich material, develop on the trunk and face of patients with primary biliary cirrhosis. John McKaigney, University of Alberta Case 1 Scleroderma Case 2 - Peutz-Jeghers syndrome Case 3 - Crohn disease First Principles of Gastroenterology and Hepatology A. Shaffer 37 Case 4 - Osler-Weber-Rendu Case 5 - Black TongueBismuth Licorice, Fungal infection, Post antibiotic Case 6 - Canker Sores and Angular Cheilosis Case 7 Syphylis Case 8 Macroglossia First Principles of Gastroenterology and Hepatology A. Shaffer 38 Case 9 - BehetssyndromeOral and genital ulceration Case 10 - Anterior uveitis Case 11 Xanthelasmata Case 12 Dermatomyositis Case 13 - Acanthosis nigricans First Principles of Gastroenterology and Hepatology A. Shaffer 39 Case 14 - Spider angioma Case 15 - Blue rubber bleb nevus syndrome Case 16 - Leukocytoclastic vasculitis Case 17 - Dermatitis herpetiformis First Principles of Gastroenterology and Hepatology A. Shaffer 40 Case 18 - Cullens sign Case 19 - Grey Turners signFlank hemorrhage again in acute pancreatitis Case 20 - Erythema nodosum Case 21 - Pyoderma gangrenosus First Principles of Gastroenterology and Hepatology A. Shaffer 41 Case 22 - Ascitic abdomen with caput medusa Case 23 - Caput medusa type veins and umbilical hernia Case 24 - Skin pigmentation Case 25 Carotenemia hemochromatosis First Principles of Gastroenterology and Hepatology A. Shaffer 42 Case 26 - Palmar erythema Case 27 Dupuytrens Case 28 - White nails Case 29 - Beaus lines Case 30 - Nail pitting-psoriasis Case 31 - Psoriatic Nails First Principles of Gastroenterology and Hepatology A. Shaffer 43 Case 32 - Calcinosis crest syndrome Case 33 Scleroderma First Principles of Gastroenterology and Hepatology A. Introduction The esophagus is a hollow muscular organ whose primary function is to propel into the stomach the food or fluid bolus that it receives from the pharynx. Symptoms of esophageal disease are among the most commonly encountered in gastroenterology. The physician must be on the lookout, however, for the more serious disorders, which can present with a similar spectrum of symptoms. This chapter will focus on the pathophysiology, diagnosis and management of the more common esophageal disorders. In the proximal one-quarter to one-third of the esophagus, the muscle is striated. There is then a transition zone of variable length where there is a mixture of both smooth and striated muscle. Sensory innervation is also carried via the vagus and consists of bipolar nerves that have their cell bodies in the nodose ganglion and project from there to the brainstem.

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