Disorders of the Living Body

Treatment of Malaria in India

2010-10-10T23:36:00.001+05:30

1. Uncomplicated Malaria (sensitive to chloroquine)
P. vivax – chloroquine 25 mg/kg over 3 days + Primaquine 0.25 mg/kg OD for 14 days
P. falciparum - chloroquine 25 mg/kg over 3 days + Primaquine 45 mg single dose

2. Uncomplicated Malaria (chloroquine resistant)
Artemisinin Combination Therapy (ACT) i.e Artesunate 50 mg + Sulfadoxine 500 mg + Pyrimethamine 25 mg for 3 days

3. Severe Malaria
Artesunate- 2.4 mg/kg @ 0 hrs, 1.2 mg/kg @ 12 hrs, 24 hrs, then OD, IV/IM
Quinine- LD:20 mg/kg, MD:10 mg/kg, both in 5% Dextrose
Artemether- 3.2 mg/kg IM on day 1, then 1.6 mg/kg IM OD
ab Arteether- 150 mg daily i.m. for 3 days in adults only
Switch to oral anti-malarials as soon as condition improves

Hypersplenism

2010-02-08T17:42:00.001+05:30

Condition in which spleen removes circulating RBCs, granulocytes and platelets in excess quantity.

Diagnosis:

Pancytopenia
Normal or hypercellular bone marrow
Splenomegaly
Correction of cytopenias after splenectomy

Classification

Primary – when no aetiology for enlarged spleen is found.
Secondary –

Portal hypertension
Infiltrative disease, lymphoma, myelofibrosis
Hemolyitc anaemias, hematological disorders
Rheumatoid arthritis (Felty’s syndrome)
Tropical splenomegaly syndrome

Pathogenesis

When splenic size increases, there is increases pooling of blood in an environment with relatively reduced availability of nutrients but full of phagocytes.

This leads to exaggerated sequestration and destruction of cells leading to

Pancytopenia
Hemolysis
Increased plasma volume

Treatment

Therapy needed when cytopenias become severe and symptomatic

Treatment of underlying causes

Splenectomy if underlying cause cannot be corrected or treated

Type 1 Hypersensitivity

2009-06-26T00:21:00.000+05:30

Type 1 Hypersensitivity

Eczema
Hay Fever
Asthma ( atopy )
Theobald Smith phenomenon
Anaphylactic shock
Acute dermatitis
Urticaria
Prusnitz kustner reaction

Behcet's Syndrome

2009-05-10T17:58:00.000+05:30

It is a type of vasculitis

Symptoms:

Oral and genital ulcers
Uveitis
Optic atrophy

Pickwickian Syndrome:

2009-04-23T21:33:00.000+05:30

It is a symptom complex presenting with the following symptoms:

1.Obesity

2.Hypoventilation

3.Somnolence

4.Erythrocytosis

This comdition has been associated with sleep apnoea syndrome which has now been established as a separate entity.

Thoracic Aortic Aneurysm

2009-03-17T22:25:00.003+05:30

Description:

Aabnormal dilatation of blood vessel

Pathogenesis:

Intimal tears progress to longitudinal intraluminal tears forming a lumen in the media.

There is collection of basophilic mucoid material in media and elastic tissue.

Most important factors promoting continued propagation of dissection are hypertension and velocity of left ventricular ejection.

Complications:

Aortic rupture causing cardiac tamponade
Leakage may cause pericarditis
Dysphagia

Clinical Features:

hypertension on initial presentation
pericardial friction rub or AR murmur
aortic insufficiency
pulse deficit
focal neurologic deficits may be present

Treatment:

1.Medical management for uncomplicated distal dissection

sodium nitroprusside
beta blockers

2.Surgery for acute proximal aortic dissection

Operative repair to prevent rupture
Emergency surgical repair for dissection of ascending aorta
Cerebrospinal fluid drainage during and after surgery may reduce risk of neurological injury .

Idiopathic Intracranial Hypertension (IIH)

2009-02-17T08:50:00.001+05:30

Description
Also called pseudotumor cerebri, benign intracranial and serous meningitis, it is a condition in which there is raised intracranial pressure in absence of space-occupying lesion, often presenting as headache and can potentially cause permanent visual loss.

Symptoms
Constant generalized severe headache
Transient visual obscurations (shadows, dark patches, or black spots in one or both eyes.
Pulsatile tinnitus
Visual sparkles (photopsia)
Diplopia

Signs
Papilledema
Enlarged blind spot.
Usually does not affect visual acuity.

Treatment
Most important aim of treatment is halting or preventing visual loss.
Weight reduction if obese.
Serial lumbar punctures can relieve syndrome.

Neonatal Resuscitation

2008-12-04T22:03:00.003+05:30

Following is the algorithm in use for neonatal resuscitation:

Birth

•Clear of meconium?
•Breathing or crying?
•Good muscle tone?
•Colour pink?
•Term gestation?

Yes - Routine care [Provide warmth, Clear airway and dry]
No -

•Provide warmth
•Position, clear airway
•Dry, stimulate, reposition
•Give oxygen
Evaluate respirations, heart rate and colour.

If breathing, HR>100 and Pink, give supportive care.
If there is apnoea or HR<100

•Provide positive pressure ventilation

If ventilating, HR>100 and Pink, give supportive care.

If HR<60:

•Provide positive pressure ventilation

•Administer chest compressions

If after this HR>60, go back to previous step (provide PPV).
If HR<60, administer epinephrine.

Malignant Glaucoma

2008-11-22T21:47:00.002+05:30

Definition

Malignant glaucoma is characterised by a shallow anterior chamber associated with raise intraocular pressure and in the presence of a patent iridotomy. The condition usually follows intraocular surgery but has also been described following laser iridotomy and has even been associated with miotic therapy.

Mechanism

It is probably due to misdirection of the ciliary processes into or around the vitreous.

Anterior displacement of the lens iris diaphragm causes a shallow anterior chamber.

Diagnosis

Shallow anterior chamber with raised or normal IOP after a intraocular surgery.
Ultrasound biomicroscopy

Differential Diagnosis

Intumescent lens
Choroidal neoplasm
Central retinal vein occlusion
Secondary pupil block

Stapedectomy

2008-10-30T20:13:00.003+05:30

It is a surgical procedure in which the stapes is removed and replaced with a prosthesis, a piston usually made of teflon/stainless steel/gold. Its a mode of treatment for otosclerosis (otospongiosis). Another procedure, stapedotomy is done sometimes (a hole is punched into the footplate of stapes and the implant fixed there).

Indications

Conductive deafness due to fixation of stapes.
Air bone gap of at least 40 dB.
Presence of Carhart's notch in the audiogram of a patient with conductive deafness.
Good cochlear reserve as assessed by the presence of good speech discrimination.

Contraindications

Poor general condition of the patient.
Only hearing ear.
Poor cochlear reserve as shown by poor speech discrimination scores
Patient with tinnitus and vertigo
Presence of active otosclerotic foci (otospongiosis) as evidenced by a positive flemmingo sign.
Conductive deafness due to Ehlers-Danlos Syndrome (EDS)

Complications

Facial palsy
Vertigo in the immediate post op period
Vomiting
Perilymph gush
Floating foot plate
Tympanic membrane tear
Dead labyrinth
Perilymph fistula
Labyrinthitis
Granuloma (Reparative)

Chronic Pharyngitis

2008-10-19T22:10:00.003+05:30

Definition

It is a chronic inflammatory condition of the pharynx characterised by hypertrophy of the mucosa, seromucinous glands and sub epithilial lymphoid follicles.

2 types

Chronic catarrhal pharyngitis
Chronic hypertrophic (granular) pharyngitis

Aetiology

Prolonged/Repeated infections
Mouth breathing (due to any reason)
Chronic irritants (Eg. tobbacco chewing, ciggarettes etc)
Faulty voice production.
Environmental pollution.

Clinical Features

Symptoms

Pain in throat
Foriegn body sensation in throat
Tiredness of voice
Cough

Signs

Congestion of posterior pharyngeal wall, which may have red nodules. (Chronic hypertrophic/granular pharyngitis)
Hypertrophy of lateral pharyngeal bands.
Increased mucous secretions may cover the mucosa.

Treatment

Identification of cause and its correction.
Warm saline gargles.
Mandl's throat paint is useful in preventing secondary infections.
Cautery of lymphoid granules.

Glaucoma Surgeries

2008-10-07T22:24:00.001+05:30

Canaloplasty
Laser trabeculoplasty
Nd:YAG Laser peripheral iridotomy
Diode laser cycloablation
Trabeculectomy
Glaucoma drainage implants

Types of Cataract Surgeries

2008-09-26T23:26:00.001+05:30

Phacoemulsification
Extracapsular Cataract Extraction (ECCE)
Intra-capsular extraction

Glaucoma

2008-09-18T21:40:00.004+05:30

Definition:

A disease of the eye characterized by high (or normal) intraocular pressure within the eyeball, damaged optic disk, atrophy of the optic nerve, hardening of the eyeball, and partial defect in the field of vision or complete loss of vision.

Classification:

4 basic types.

1. Primary glaucoma

Primary Open Angle Glaucoma
Normotensive glaucoma
Primary Angle Closure Glaucoma
Other variants (ex. Pigmentary glaucoma, pseudoexfoliation glaucoma)

2. Developmental glaucoma

Primary congenital glaucoma
Infantile glaucoma
Glaucoma associated with hereditary of familial diseases.

3. Secondary glaucoma

Inflammatory glaucoma
Phacogenic glaucoma
Glaucoma secondary to intraocular hemorrhage
Traumatic glaucoma
Neovascular glaucoma
Drug-induced glaucoma
Glaucoma of miscellaneous origin

4. Absolute glaucoma

Stages of Labour

2008-09-14T18:53:00.002+05:30

Usually 3 stages are described

Stage 1

It starts with the onset of labour pains and ends with the full dilatation of the cervix.

This stage lasts for 12 hrs in primigravidae and 6 hours in multiparae.

Stage 2

It is furhter divided into 2 phases.

Propulsive phase - starts from cervix dilatation upto the descent of the presenting part into the pelvic floor.
Expulsive phase - It ends with the delivery of the baby.

This stage lasts for 2 hrs in primigravidae and 30 mins in multiparae.

Stage 3

This involves the expulsion of the placenta and all the membranes.

This stage lasts for about 15 mins.

Stage 4

This stage of observation lasts for about 1 hour after stage 3. During this stage, the general condition of the patient and the behaviour of the uterus are to be carefully watched.

Atrophic Rhinitis

2008-09-07T22:48:00.003+05:30

Definition:

It is a chronic inflammation of nose characterized by atrophy of the nasal mucosa.

Typically seen in females nearing puberty.

Aetiology:

Hereditary
Racial (more in whites)
Endocrinal disturbances (oestrogen)
Nutritional deficiency.
Infections
Auto-immune

Pathology:

Squamous metaplasia in the mucosa, atrophy of seromucinous glands, venous blood sinusoids and neve elements, obliterative endarteritis. Turbinates undergo resorption. Paranasal sinuses are small due to arrested development.

Clinical features:

Anosmia
Degenerative changes
Nasal obstruction
Epistaxis
Greenish/greyish black dry crusts
Typically, the posterior wall of the nasopharynx can be visualised.
Nose may show saddle deformity

Treatment:

No definitive treatment is available for this condition. The following measures are tried to provide releif to the patient.

Medical

Nasal irrigation and removal of crusts (alkaline solution)
25% glucose in glycerine
Local antibiotics
Oestradiol spray
Placental extract
Potassium iodide (oral)

Surgical

Young's / Modified Young's operation - it involves the complete or partial closure of both the nostrils, to be opened after 6 months. This allows the turbinates and the mucosa to grow.
Narrowing the nasal cavities - this is done by injection of teflon paste or insertion of fat/cartilage/bone/teflon strips under the mucoperiostium.

Chronic Simple Rhinitis

2008-09-07T15:42:00.002+05:30

Aetiology and Risk factors:

Persistant rhinitis (due to tonsillitis, adenoids or sinusitis)
Chronic exposure to irritants (smoke, dust etc.)
Nasal obstruction
Vasomotor rhinitis
Endocrinal/metabolic factors (Hypothyroidism etc.)

Pathology:

This disease is considered an early stage of hypertrophic rhinitis.

Clinical features:

Nasal obstruction
Post nasal discharge
Headache
Oedema of turbinates

Treatment:

Medical

Treat cause
Nasal irrigation with alkaline solution
Nasal decongestants
Antibiotics

Deviated Nasal Septum (DNS)

2008-09-07T08:54:00.002+05:30

Etiology:

Trauma : usually in childhood, may even be during delivery.
Developmental
Hereditary
Racial predisposition

Types:

Anterior dislocation.
C-shaped
S-shaped
Spur
Septal thickening.

Clinical Features:

Nasal obstruction (more if high deviation)
Headache
Sinusitis
Epistaxis
Anosmia (partial of complete)
External deformity.
Middle ear infection.

Treatment:

Surgical treatment is adviced if nasal obstruction is complete, total anosmia is present and in cosmetic indications.

2 types

SMR (Sub-mucosal Resection) operation: Not done anymore because of the numerous complications involved and now with the availability of better options.
Septoplasty: (treatment of choice) The mucoperichondrial flap of one side is elevated after giving a modified Killian's incision. The defect in the cartilage &/or bone is removed. This surgery can be combined with a rhinoplasy if necessary.

Advantages of Septoplasty:

Conservative operation.
Can be done in children.
Can be combined with rhinoplasty.
Revision possible in case of recurrance/unsatisfactory results.
Less complications.

Umbilical Hernia

2008-09-06T23:11:00.003+05:30

Types:

Complete or incomplete (depending on whether sac extends through defect or not.)
Irreducible (incarcerated)
Sliding (wall of hernia sac not completely formed by peritoneum)
Richter's hernia (1 side of bowel wall trapped)

Causes:

Definite familial incidence.
Prematurity
Incomplete development of: lateral umbilical ligaments (obliterated umbilical arteries), urachus, round ligament (umbilical vein), subumbilical extension of transversalis fascia (Richet umbilical fascia).
Increased intra-abdominal pressure.

This condition is rarely symptomatic.

Treatment:

Surgery is the treatment of choice.

Indications:

Incarceration
Symptoms clearly referable to hernia.
Large sac

2 types of surgeries may be performed

Simple transverse repair of fascial defect.
Mesh or plug repair.

Diffuse Malignant Mesothelioma

2008-09-05T20:38:00.002+05:30

Pathogenesis:
The disease spreads over surfaces of viscera and body cavities.
Clinical Features:

Chest pain
Dypsnea
Occasionally abdominal pain, nausea, vomiting and weight loss.

Prognosis is very bad, mostly fatal and shows poor response to treatment.

This disease can only be prevented by avoiding exposure to asbestos.

Types of Leg Amputations

2008-08-31T21:33:00.000+05:30

Amputation of digits
Partial foot amputation (Chopart, Lisfranc)
Ankle disarticulation (Syme, Pyrogoff)
Below-knee amputation (transtibial)
Knee-bearing amputation (knee disarticulation)
Above knee amputation (transfemoral)
Van-ness rotation/rotationplasty (Foot being turned around and reattached to allow the ankle joint to be used as a knee.)
Hip disarticulation
Hemipelvectomy

Eisenmenger's Syndrome

2008-08-31T21:13:00.003+05:30

Description:

It is predominantly right-to-left shunt or reversal of left-to-right shunt, which usually resuts from severe pulmonary vascular obstruction.

Complications:
1. Stroke
2. Hemoptysis
3. Hyperviscosity
4. Hemostatic abnormalities.
5. Thrombocytopenia
6. Prolonged bleeding, prothrombin or partial thromboplastin times.
7. Vitamin K-dependent clotting factors deficiencies.
8. Abnormal fibrinolysis.
9. Cholelithiasis
10. Hypertrophic osteoarthropathy
11. Hyperuricemia and goutrenal dysfunction.
12. Sudden death.

Clinical Features:
Symptoms : dyspnea on exertion, chest pain, syncope, hemoptysis, angina.
Signs : cyanosis (constant or exercise), ascites, pedal edema, clubbing.

Investigations:
1. Blood tests :
a) 100% O2 does not correct arterial desaturation.
b) polycythemia (Hb > 20 g/dl common)
2. Imaging studies : echocardiography, Doppler, hemogram, catheterization
ECG shows right ventricular hypertrophy changes.

Treatment:
Surgery is indicated if medical treatment does not improve the oxygen saturation levels.
Phlebotomy may be necessary.

Acute otitis media

2008-08-30T21:42:00.004+05:30

Causes:
1. Viruses - most commonly rhinovirus, RSV and coronavirus.
2. Bacteria - Streptococcus pneumoniae, Moraxella (Branhamella) catarrhalis, H. influenzae and Streptococcus pyogenes (rare).

Pathogenesis:
Eustachian tube is port of entry for middle-ear pathogens from nasopharynx, but also is primary route of clearing middle ear secretions. This causes inflammatory edema of nasopharynx. Following this exudative and transudative fluid collect in middle ear, which allows for overgrowth of nasopharyngeal bacteria in middle ear. This suppuration may lead to spontaneous rupture, usually anterior-inferior quadrant following which discharge is seen, which is initially serosanguineous and later becomes mucopurulent.

Complications:
1. Hearing loss
2. Mastoiditis
3. Meningitis

Clinical Features:
1. Redness with bulging of tympanic membrane.
2. Mobility may be impaired.

Treatment:
A: Medical
1. Analgesics (ibuprofen and acetaminophen)
2. Antibiotics (amoxicillin is drug of choice)
3. Decongestants and/or Antihistamines (not in children)

B: Surgical
1. Tympanostomy tubes reduce recurrences of otitis media when middle ear effusion present.
2. Myringotomy to drain the pus.
3. Adenoidectomy is not very effective.

Astigmatism

2008-08-28T21:46:00.003+05:30

Definition:
It is the condition in which an optical system has different foci for rays that propagate in two perpendicular planes. If an optical system with astigmatism is used to form an image of a cross, the vertical and horizontal lines will be in sharp focus at two different distances.

Types:
A: Based on axis of the principal meridians
1. Regular
- With the rule
- Against the rule
- Oblique
- Bioblique
2. Irregular

B. Based on focus of the principal meridians
1. Simple
- Myopic
- Hypermetropic
2. Compund
- Myopic
- Hypermetropic
3. Mixed

Symptoms:
1. Blurring of vision
2. Squinting
3. Asthenopic symptoms
4. Headache

Treatment:
Astigmatism may be corrected with eyeglasses, contact lenses, or refractive surgery.
Spherical lenses correction along with a cylindrical lens for correction of the residual error is used.

Myopia

2008-08-27T19:56:00.002+05:30

Definition:
It is that dioptric condition of the eye in which parallel rays of light are brought to focus at a point in front of the retina, in an eye with accomodation at rest.

Classification (based on etiology):
1. Axial myopia
2. Refractive myopia

Curvature myopia
Index myopia

Treatment:

Eyeglasses
Contact Lenses
Refractive Surgery

Cataract - Diagnosis

2008-08-24T19:58:00.001+05:30

Slit-lamp biomicroscopy : To detect location and density of opacity within lens.
Potential visual acuity with removal of cataract can be estimated with potential acuity meter (PAM) or laser interferometer.
B-scan ultrasound can be used to detect retinal detachment or tumors if severe cataract prevents retinal examination.
Glare testing and contrast sensitivity testing can quantitatively estimate functional impact of cataract on vision.

Cataract (contd..)

2008-08-24T19:46:00.002+05:30

Risk Factors:

Inhaled steroids
Tobacco use
Exposure of UV-B light
Allopurinol
Trabeculectomy
Diabetes
Psychotropic medications (antipsychotics, antidepressants, lithium, anticonvulsants, benzodiazepines)
Alcohol consumption
Obesity
Medications for hypertension, and angina

Cataract - Classification (contd..)

2008-08-24T08:11:00.002+05:30

Classification based on location of the opacity:
1. Anterior cortical cataract
2. Anterior polar cataract
3. Anterior subcapsular cataract
4. Posterior cortical cataract
5. Posterior polar cataract
6. Posterior subcapsular cataract (PSC)
7. Nuclear cataract
Grading:

Grey
Yellow
Amber
Brown/Black

Cataract - Classification

2008-08-23T21:19:00.002+05:30

Etiological Classification
1. Age-related cataract

Immature Senile Cataract (IMSC)
Cataract (MSC)
Senile Cataract (HMSC)

2. Congenital cataract

Sutural cataract
Lamellar cataract
Zonular cataract
Total cataract

3. Secondary cataract

Drug-induced cataract (e.g. Corticosteroids)

4. Traumatic cataract

Blunt trauma
Penetrating trauma

Cataract

2008-08-21T22:16:00.002+05:30

Definition:

A cataract is a clouding that develops in the crystalline lens of the eye or in its envelope, varying in degree from slight to complete opacity and obstructing the passage of light.

Pterygium

2008-08-19T21:54:00.002+05:30

Definition:
Pterygium is a raised, wedge-shaped growth of the conjunctiva. It is most common among those who live in tropical climates or spend a lot of time in the sun.

Pathology:
Pterygium in the conjunctiva is characterized by elastotic degeneration of collagen and fibrovascular proliferation. It has an advancing portion called the head of the pterygium, which is connected to the main body of the pterygium by the neck. Sometimes a line of iron deposition can be seen adjacent to the head of the pterygium called Stocker's line. The location of the line can give an indication of the pattern of growth.
Anatomically, the pterygium is comprised of several segments:

Fuchs' Patches (minute gray blemishes that disperse near the pterygium head).
Stocker's Line (a brownish line composed of iron deposits).
Hood (fibrous nonvascular portion of the pterygium).
Head (apex of the pterygium, typically raised and highly vascular).
Body (fleshy elevated portion congested with tortuous vessels).
Superior Edge (upper edge of the triangular or wing shaped portion of the pterygium).
Inferior Edge (lower edge of the triangular or wing shaped portion of the ptyerygium).

Symptoms:
Symptoms of pterygium include

Persistent redness
Inflammation
Foreign body sensation
Dry and itchy eyes.
In advanced cases the pterygium can affect vision as it invades the cornea with the potential of induced astigmatism and corneal scarring.

Treatment:
The majority of pterygia are inactive and can be treated with topical drops. Decongestant eye drops to make the eye appear less red and artificial tear drops to make the eye more comfortable when the pterygium flares up, can be used. If these are sufficient to maintain comfort and cosmesis then surgery is not indicated.
If this fails:

The 90 Sr plaque is a concave metal disc about 1-1.5cm in diameter which is hollow and filled with an insoluble strontium salt. The side placed on the eye is a very thin and delicate silver film that will contain the strontium but allow the beta particles to escape. The dose of radiation to the conjunctiva is controlled by the time that the plaque is left in contact with the surface. The integrity of the plaque surfaces is paramount to prevent exposure to patients and so is wipe tested to see if radioactive matter is escaping.
Conjunctival auto-grafting is a surgical technique that is effective and safe procedure for pterygium removal. When the pterygium is removed, the conjunctiva is also extracted, which is replaced from another peice of conjunctiva from the same patient.

Hordeolum

2008-08-17T22:15:00.003+05:30

Definition:
A common staphyloccal infection of the lid glands, essentially an abscess, with pus formation.

Classification:
Two types

Internal hordeolum - relatively large, affecting the meibomian glands. May point towards the skin or towards the conjunctivae.
External hordeolum - also known as a stye. It is smaller and more superficial. It is an infection of the glands of Moll or Zeiss and it always points toward the skin side of the lid margin.

Clinical features:
The patient complains of redness, swelling, and pain in the eyelid and swelling which is:

At the base of an eyelash (external hordeolum)
Deep within the lid (internal hordeolum)

Treatment:

Both types of hordeola are treated with warm compresses for 10-15 minutes 3-4 times a day. If the condition does not improve within 48 hours, incision and drainage of the pus is indicated. Antibacterial ophthalmic ointment is also helpful.

Chalazion

2008-08-13T21:08:00.003+05:30

Description:

A chalazion, also known as a meibomian gland lipogranuloma, is a cyst in the eyelid that is caused by inflammation of a blocked meibomian gland, usually on the upper eyelid.

Signs and symptoms:

Swelling on the eyelid
Eyelid tenderness
Sensitivity to light
Increased tearing
Heaviness of the eyelid

Treatment:

The primary treatment is application of warm compresses for 10 to 20 minutes at least 4 times a day. This may soften the hardened oils blocking the duct and promote drainage and healing.
Topical antibiotic eye drops or ointment.
Corticosteroid injections
Surgery under local anesthesia.

Complications:

A large chalazion can cause astigmatism due to pressure on the cornea.
Hypopigmentation may occur with corticosteroid injection.
Sebaceous cell carcinoma (recurring chalazion).

Legg-Calvé-Perthes Syndrome (Perthes Disease)

2008-08-11T21:30:00.002+05:30

Definition:
Legg-Calvé-Perthes syndrome is a degenerative disease of the hip joint, where a loss of bone mass leads to some degree of collapse of the hip joint, that is, to deformity of the ball of the femur and the surface of the hip socket. The disease is typically found in young children and small dogs, and it can lead to osteoarthritis in adults. Perthes can also sometimes continue into adulthood.
It is the idiopathic avascular osteonecrosis of the capital femoral epiphysis of the femoral head. It is caused by an interruption to the blood supply of the head of the femur close to the hip joint. It is equivalent to adult avascular necrosis.

Cause:
The direct cause is a reduction in blood flow to the joint, though what causes this is unknown. It is thought that the artery of the ligamentum teres femoris closes too early, not allowing time for the medial circumflex femoral artery to take over.[citation needed]Genetics does not appear to be a determining factor, though it may be involved. When the disease is genetic in origin, it typically runs along the male line. Some evidence suggests that parental smoking may be a factor, though this is not yet proven, or more recently that a deficiency of some blood factors used to disperse blood clots may lead to blockages in the vessels supplying the joint, but that, too, has not been proven.

Symptoms:
Symptoms are hip or groin pain, exacerbated by hip/leg movement. There is a reduced range of motion at the hip joint and a painful or antalgic gait. There may be atrophy of thigh muscles from disuse and an inequality of leg length. In some cases, some activity can cause severe irritation or inflammation of the damaged area including standing, walking, running, kneeling, or stooping repeatedly for an extended period of time.
Signs:
The first signs are complaints of soreness from the child, particularly when tired. The pain is usually in the hip, referred to the knee. It is predominantly a disease of boys (4:1 ratio). Whereas Perthes is generally diagnosed between 5 and 12 years of age. Typically the disease is only seen in one hip.

Treatment:
The goal of treatment is to avoid severe degenerative arthritis. Orthopedic assessment is crucial. Younger children have a better prognosis than older children. Currently, there are studies conducted on bisphosphonates for treatment of Perthes. Analgesic medication may be given as necessary.

Rheumatic Fever

2008-07-31T21:43:00.003+05:30

Definition:
Rheumatic fever is a multisystem inflammatory disease that occurs as a sequel to
pharyngeal infection with the bacterium, Group A Streptococcus pyogenes. Major
features are arthritis and carditis.

Clinical Features:
These are varied. They include fever, pain (with or without swelling) in one or more
joints, endocarditis, pericarditis, myocarditis, pleurisy, subcutaneous nodules, a
characteristic skin lesion (erythema marginatum) and an even more characteristic
disturbance of central nervous system function, Sydenham’s chorea. Carditis is
more frequent in the youngest age groups, and the majority of rheumatic fever
attacks occurring in adults are manifested primarily by arthritis.

Arthritis usually affects larger joints, particularly wrists, elbows, knees and ankles.
Hips are less often affected, small joints of hands and feet rarely, and spine almost
never. Characteristically, fleeting arthritis occurs but more commonly, only arthralgia alone occurs. Untreated, the joint pains settle within 1-4 weeks. The
arthritis of rheumatic fever does not lead to permanent damage to the joints
affected.
Carditis is the most important clinical manifestation of rheumatic fever, being the
one with permanent effects. Endocarditis is detected clinically by new or changing murmurs, and pericarditis by a friction rub. Heart failure is the most serious presentation,
occurring in younger patients.
Chorea is now rare. The latent period is 1 to 6 months. It features jerky, purposeless
movements, exaggerated by tension but disappearing in sleep. It occurs
predominantly in females.
Other less common manifestations include erythema marginatum, an evanescent
macular eruption and subcutaneous nodules, which may
appear as painless lumps in people with long-standing carditis.

Recurrence:

An attack of rheumatic fever greatly increases the chances that a subsequent
streptococcal throat infection will be followed by another attack of rheumatic
fever. The risk of recurrence is greater in children, in patients with pre-existing
rheumatic heart disease, and in those experiencing symptomatic throat infection.
The risk declines with advancing age, but nevertheless rheumatic patients remain at
increased risk well into adult life.

Diagnosis:

Revised Jones' criteria - evidence of preceding strep infection (positive throat culture or rapid streptococcal antigen test, increased or rising anti-strep Ab, recent scarlet fever) plus 2 major or 1 major and 2 minor criteria.

Major criteria

Polyarthritis
Carditis
Chorea
Subcutaneous nodules
Erythema marginata

Minor criteria

History of acute rheumatic fever
Rheumatic heart disease
Fever
Arthralgias
Increased WBC, increased ESR, increased C-reactive protein
Prolonged PR interval on ECG

Complications:

The major complication of rheumatic fever is valvular disease of the heart giving rise to pansystolic blowing mitral murmur, less commonly diastolic aortic murmur at left sternal border.

Treatment:

Treat streptococcal infection with antibiotics : penicillin G 600,000-1.2 million units as 1 injection or PO for 10 days
Erythromycin if allergic to penicillin
Anti-inflammatory treatment - aspirin is treatment of choice for ARF
Sedating drugs for severe chorea - phenobarbital, chlorpromazine, haloperidol

Developmental Dysplasia of the Hip (DDH)

2008-07-26T20:45:00.006+05:30

Causes:

Intrauterine malpositioning.
Genetic factors
Maternal hormones.
Post-natal postural influence (hence rare in India)

Complications:

Recurrence of dislocation
Incomplete reduction
Avascular necrosis of femoral head
Residual deformity of hip joint
Late onset of premature osteoarthritis

Clinical Features:

Clunks are sensations felt when femoral head dislocates with Barlow maneuver or relocates with Ortolani maneuver

Diagnosis:

X-ray findings

Shenton's line should be continuous.
Acetabular index more vertical (closer to 90).

Treatment:

Depends on age.

1. Newborn - 3 months

Pavlick harness
manipulative reduction
hip spica cast

2. 3-6 months

Pavlick harness
Manipulative reduction
Hip spica cast
Ooccasionally open reduction necessary.

3. 6-12 months

pre-reduction traction, open or closed reduction, hip spica cast

Osteogenesis Imperfecta

2008-07-25T22:20:00.002+05:30

Description:

Also called Brittle bone disease it is a congenital connective tissue disorder.

Clinical features:

Fragility of bone
Osteopenia
Variable degrees of short stature
Progressive skeletal deformities
HEENT - blue sclerae (translucent thin connective tissue over choroid)
50% hearing loss (maturity-onset deafness)
Dentinogenesis imperfecta

Osteopetrosis

2008-07-24T21:22:00.002+05:30

Definition:
Osteopetrosis also known as marble bone disease and Albers-Schonberg disease is an extremely rare inherited disorder whereby the bones harden, becoming denser, in contrast to the more prevalent osteomalacia, in which the bones soften.

Variants:

Autosomal recessive (malignant type)
Autosomal dominant (benign type)
Carbonic anhydrase II deficiency (Type 3 Renal tubular acidosis)

Pathogenesis:

Pathologic alteration of osteoclastic bone resorption leads to thickening of cortical and lamellar bone.

Clinical Features:

Brittle bones
May have blindness, deafness and cranial nerve involvement if skull base involvement
Osteopetrosis tarda
Fractures related to brittle osteopetrotic bones or osteomyelitis
Osteopetrosis congenita
Failure to thrive
Growth retardation
Sshort stature
Intracranial calcifications
Sensorineural hearing loss
Psychomotor retardation

Lab Investigations:

X-rays

Blood tests: anemia, elevated acid phosphatase level in some cases.
Imaging studies: markedly increased density of skeleton, osteopetrosis tarda often detected as incidental finding, typical dense deformed sclerotic bones.

Differential Diagnosis:

Hypervitaminosis D
Hypoparathyroidism
Paget's disease
Diffuse bone metastasis of breast or prostate cancer .
Intoxication with fluoride, lead or beryllium.
Hematological disorders such as myelofibrosis, sickle cell disease and leukemia.

Complications:

Multiple fractures
Anemia (decreased marrow space)
Hepatosplenomegaly
Hypersplenism

Treatment:

1. Surgery

Surgery useful if significant alterations of facial profile, recurrent fractures with subsequent deformity or severe related degenerative joint disease.
Bone marrow transplant is only curative treatment for osteopetrosis congenita.
Placental blood transplant (umbilical cord blood) as useful source of allogeneic hematopoietic stem cells for bone marrow reconstitution.

2. Medical

Interferon gamma-1b
1,25-dihydroxyvitamin D

Prognosis:

Good for osteopetrosis tarda, poor for other types.
Osteopetrosis congenita usually results in death by 2 years from severe anemia, bleeding or infection.

Chronic Sinusitis

2008-07-21T19:15:00.002+05:30

Clinical features:
HEENT examination elicits tenderness and edema. Mild mucopurulent rhinorrhoea, nasal obstruction and facial pain/frontal headache, with or without upper toothache.
Diagnosis:
2 major criteria or 1 major and 2 minor criteria
Major criteria

Purulent nasal discharge
Purulent pharyngeal drainage
Cough

Minor criteria

Periorbital edema
Headache
Facial pain
Tooth pain
Earache
Sore throat
Foul breath
Increased wheeze
Fever

Treatment:

Medical

Corticosteroids
Administering nasal steroids with head inverted may be more effective in cases of sinusitis refractory to traditionally applied nasal steroids.
Antibiotics may provide short-term relief but not long-term benefit.
Saline nasal irrigation
Intranasal hypertonic saline washes

Surgery

Surgical drainage if medical treatment fails
Functional Endoscopic Sinus Surgery (FESS)
Adenoidectomy is an alternative

Complications:

Suppurative CNS complications
Pott's puffy tumor
Frontal bone osteomyelitis and subperiosteal abscess.

Mooren's Ulcer (Chronic Serpiginous Ulcer)

2008-07-20T19:59:00.002+05:30

Definition:
Mooren's ulcer is strictly a peripheral ulcerative keratitis (PUK) with no associated scleritis.

Clinical Features:

It commences as one or more grey infiltrates which break down to form small
spreading ulcers which eventually coalesce. The ulcer undermines the epithelium
and superficial lamellae at the advancing border, forming a characteristic
overhanging edge, the base becoming vascularized.
Erosion of the epithelium is accompanied by pain and watering of the eye.
Perforation is rare but intermittent progression over several months is usual until a
thin nebula forms over the whole cornea with diminution of sight.
In about 25% of cases both corneae are affected but not always simultaneously.

Exact aetiology is unknown. It is suspected to be a degenerative condition.

Treatment:

Topical steroids
Conjunctival resection
Systemic immunosuppressives
Additional surgical procedure
Rehabilitation

Abdominal Aortic Aneurysm (AAA)

2008-07-20T08:35:00.002+05:30

An unruptured AAA

Causes:
95% cases due to atherosclerosis in United States. Mycotic abdominal aortic aneurysm is caused by bacterial infection, most commonly Salmonella

Pathogenesis:
Intimal dissection causes aortic dilatation and creation of false lumen, into which blood collects.

Risk factors:

Smoking
Clinical vascular disease
Male
Old age
Hypertension
Hyperlipidemia
Family history of AAA

Signs and Symptoms:
Normal vital signs may be present initially with rupture, but patients can become severely hypotensive rapidly.
Abdomen usually presents as asymptomatic palpable pulsatile nontender mass, with bruits. Abdominal palpation is an important symptom.

Diagnosis:
Abdominal ultrasound or other imaging.

Treatment:

Surgery recommended for AAA > 5.5 cm or symptomatic AAA of any diameter.

Surgery for AAA <>
Intervention not recommended for asymptomatic infrarenal or juxtrarenal AAA <>

Senile Dementia of Alzheimer Type

2008-07-18T22:05:00.002+05:30

Clinical Presentation:

Usually presents with memory deficit or personality changes
Recent memory loss that affects job performance, difficulty performing familiar tasks, problems with language, disorientation of time and place, poor or decreased judgment, problems with abstract thinking, misplaced things, changes in mood or behavior, changes in personality, loss of initiative.
May present as new-onset auditory hallucinations in elderly

Histology:

Prognosis:
Median survival is 4-6 years after initial diagnosis of Alzheimer disease

Carpal Tunnel Syndrome

2008-07-17T20:17:00.002+05:30

Definition:
Carpal tunnel syndrome (CTS) is a compression neuropathy caused by constriction
of the median nerve where it passes beneath the flexor retinaculum of the wrist. It is
a common condition. The crude incidence rate in the UK of about one per thousand
person-years in hospital-diagnosed patients and twice that in primary care.

Clinical Features:

Tingling (paraesthesia), numbness, or discomfort in the thumb, index and
middle fingers. Distressing tingling is often prominent by night, and the patient
may need to exercise the fingers or shake the hand in attempt to gain relief.

Weakness and/or clumsiness of the hand, particularly in carrying out fine
movements such as those concerned in writing, typing, sewing and other tasks
necessitating pinch grip.

There is often forearm or elbow pain, aching in nature, poorly localised and
exacerbated by activity. Some patients have shoulder pain. In advanced cases
of median nerve entrapment, there is impaired sensation and thenar atrophy.

Aetiology:

Carpal tunnel syndrome usually presents as an isolated phenomenon but it is often
associated with other conditions especially where there is fluid retention or
inflammation. These include, diabetes mellitus (where it may be due to diabetic
mono-neuropathy rather than compression), the prolonged use of oral
contraceptives, pregnancy, Colles' or scaphoid fractures, other direct trauma, electric
shock, tenosynovitis, rheumatoid disease, osteoarthritis and gout. Obesity and short
stature are independent risk factors.

Colles' Fracture

2008-07-15T21:19:00.005+05:30

Causes

The fracture is most commonly caused by people falling backward onto a hard surface and breaking their fall with extended outstretched hands.

Displacements

Proximal impaction
Dorsal displacement
Dorsal tilt
Ulnar tilt

Treatment

Treatment of depends on the severity of the fracture. An undisplaced fracture may be treated with a cast alone.The cast is applied with the distal fragment in palmar flexion and ulnar deviation. A fracture with mild angulation and displacement may require closed reduction. Significant angulation and deformity may require an open reduction and internal fixation or external fixation.

Radiograph showing a typical Colle's Fracture

Myositis Ossificans

2008-07-14T19:10:00.003+05:30

Types:

Nonhereditary Myositis Ossificans

Myositis Ossificans Progressiva

Clinical Features:

Myositis ossificans usually presents with pain, tenderness, focal swelling, and joint muscle reduction, in the aftermath of a painful muscle contusion which resolved more slowly than expected, if at all.
The condition rarely is asymptomatic, and may sometimes be diagnosed from radiographs obtained for unrelated problems.
Most (i.e. 80%) ossifications arise in the thigh or arm, and are caused by a premature return to activity after an injury. Other sites include intercostal spaces, erector spinae, pectoralis muscles, glutei, and the chest. Hazy densities are sometimes noted ca. one month after injury, while the denser opacities eventually seen may not be apparent until two months have passed

Treatment:

Treatment is initially conservative, as some patients' calcifications will spontaneously be reabsorbed, and others will have minimal symptoms. In occasional cases, surgical debridement of the abnormal tissue is required, although success of such therapy is limited.

Radiograph of both feet

More Updates Soon

2008-07-07T22:35:00.002+05:30

Dear readers,
I apologise for the absence updates on this blog.
I shall be contributing more frequently from now on.
Thanks.

Paget's disease of Bone

2008-01-21T21:00:00.000+05:30

Paget's disease, otherwise known as osteitis deformans, is a chronic disorder that typically results in enlarged and deformed bones. It is named after Sir James Paget, the British surgeon who first described this disease. The excessive breakdown and formation of bone tissue that occurs with Paget's disease can cause bone to weaken, resulting in bone pain, arthritis, deformities, and fractures. Paget's disease may be caused by a slow virus infection (i.e., paramyxoviruses such as measles and respiratory syncytial virus), present for many years before symptoms appear. There is also a hereditary factor since the disease may appear in more than one family member.
Paget's disease is rarely diagnosed in people less than 40 years of age. Men are more commonly affected than women. Prevalence of Paget's disease ranges from 1.5 to 8 percent depending on age and country of residence. Prevalence of familial Paget's disease ranges from 10 to 40 percent in different parts of the world. Because early diagnosis and treatment is important, after age 40, siblings and children of someone with Paget's disease may wish to have an alkaline phosphatase blood test every 2 or 3 years. If the alkaline phosphatase level is above normal, other tests such as a bone-specific alkaline phosphatase test, bone scan, or x-ray can be performed.

Source : Wikipedia

Acute Myocardial Infarction

2008-01-01T23:20:00.001+05:30

Acute myocardial infarction (AMI or MI), more commonly known as a heart attack, is a medical condition that occurs when the blood supply to a part of the heart is interrupted, most commonly due to rupture of a vulnerable plaque. The resulting ischemia or oxygen shortage causes damage and potential death of heart tissue. It is a medical emergency, and the leading cause of death for both men and women all over the world.

Important risk factors are a previous history of vascular disease such as atherosclerotic coronary heart disease and/or angina, a previous heart attack or stroke, any previous episodes of abnormal heart rhythms or syncope, older age—especially men over 40 and women over 50, smoking, excessive alcohol consumption, the abuse of certain drugs, high triglyceride levels, high LDL ("Low-density lipoprotein") and low HDL ("High density lipoprotein"), diabetes, high blood pressure, obesity, and chronically high levels of stress in certain persons.

The term myocardial infarction is derived from myocardium (the heart muscle) and infarction (tissue death due to oxygen starvation). The phrase "heart attack" is sometimes used incorrectly to describe sudden cardiac death, which may or may not be the result of acute myocardial infarction.

Classical symptoms of acute myocardial infarction include chest pain (typically radiating to the left arm), shortness of breath, nausea, vomiting, palpitations, sweating, and anxiety. Patients frequently feel suddenly ill. Women often experience different symptoms from men. The most common symptoms of MI in women include shortness of breath, weakness, and fatigue. Approximately one third of all myocardial infarctions are silent, without chest pain or other symptoms.

Immediate treatment for suspected acute myocardial infarction includes oxygen, aspirin, glyceryl trinitrate and pain relief, usually morphine sulfate. The patient will receive a number of diagnostic tests, such as an electrocardiogram (ECG, EKG), a chest X-ray and blood tests to detect elevated creatine kinase or troponin levels (these are chemical markers released by damaged tissues, especially the myocardium). Further treatment may include either medications to break down blood clots that block the blood flow to the heart, or mechanically restoring the flow by dilatation or bypass surgery of the blocked coronary artery. Coronary care unit admission allows rapid and safe treatment of complications such as abnormal heart rhythms.

Mesothelioma Update

2007-12-15T22:15:00.000+05:30

Malignant mesothelioma is a rare cancer that occurs in the thin layer of tissue that covers the majority of your internal organs (mesothelium). Doctors divide mesothelioma into different categories based on what part of the mesothelium is affected by cancer. Mesothelioma that occurs in the tissue that surrounds the lung (pleura) is called pleural mesothelioma and is the most common form. Mesothelioma that occurs in the tissue in your abdomen (peritoneum) is called peritoneal mesothelioma and accounts for 10 percent to 20 percent of all mesotheliomas. In rare cases, mesothelioma can also occur in the lining around the heart (pericardium) and in the lining around the testicles (tunica vaginalis).

Osteomyelitis

2007-12-14T22:34:00.000+05:30

Osteomyelitis is an infection of bone or bone marrow, usually caused by pyogenic bacteria or mycobacteria. It can be usefully subclassifed on the basis of the causative organism, the route, duration and anatomic location of the infection.

Deep Vein Thrombosis (DVT)

2007-12-12T08:30:00.000+05:30

Deep-vein thrombosis (also known as deep-venous thrombosis or DVT and colloquially as economy class syndrome) is the formation of a blood clot ("thrombus") in a deep vein. It commonly affects the leg veins, such as the femoral vein or the popliteal vein or the deep veins of the pelvis. Occasionally the veins of the arm are affected (known as Paget-Schrötter disease). Thrombophlebitis is the more general class of pathologies of this kind. There is a significant risk of the thrombus embolizing and traveling to the lungs causing a pulmonary embolism.

Disseminated Intravascular Coagulation

2007-12-09T18:52:00.000+05:30

Disseminated intravascular coagulation (DIC), also called consumptive coagulopathy, is a pathological process in the body where the blood starts to coagulate throughout the whole body. This depletes the body of its platelets and coagulation factors, and there is a paradoxically increased risk of hemorrhage. It occurs in critically ill patients, especially those with Gram-negative sepsis (particularly meningococcal sepsis) and acute promyelocytic leukemia.

The treatment of underlying cause is a must and should be initiated immediately. Anticoagulants are only given when indicated (development of thrombotic renal complications) as patients with DIC are prone to bleeding. Platelets may be transfused if counts are very low, and fresh frozen plasma may be administered.
DIC results in lower fibrinogen (as it has all been converted to fibrin), and this can be tested for in the hospital lab. A more specific test is for "fibrin split products" (FSPs) or "fibrin degradation products" (FDPs) which are produced when fibrin undergoes degradation when blood clots are dissolved by fibrinolysis.
In some situations, infusion with antithrombin may be necessary. A new development is drotrecogin alfa, a recombinant activated protein C product. Activated Protein C (APC) deactivates clotting factors V and VIII, and the presumed mechanism of action of drotrecogin is the cessation of the intravascular coagulation. Due to its high cost, it is only used strictly on indication in intensive care patients.
The prognosis for those with DIC, depending on its cause, is often grim, leading the initials to be known colloquially as "death is coming".

Source : Wikipedia

Bronchiectasis

2007-12-08T20:51:00.000+05:30

Inrtoduction:

Bronchiectasis is a disease that causes localized, irreversible dilatation of part of the bronchial tree. Involved bronchi are dilated, inflamed, and easily collapsible, resulting in airflow obstruction and impaired clearance of secretions. Bronchiectasis is associated with a wide range of disorders, but it usually results from necrotizing bacterial infections, such as infections caused by the Staphylococcus or Klebsiella species or Bordetella pertussis.

Pathogenesis:
Dilation of the bronchial walls results in airflow obstruction and impaired clearance of secretions because the dilated areas disrupt normal air pressure in the bronchial tubes, causing sputum to pool inside the dilated areas instead of being pushed upward. The pooled sputum provides an environment conducive to the growth of infectious pathogens, and these areas of the lungs are thus very vulnerable to infection. The more infections that the lungs experience, the more damaged the lung tissue and alveoli become. When this happens, the bronchial tubes become more inelastic and dilated, creating a self-perpetuating cycle of further damage to the lungs.

Causes:
There are both congenital and acquired causes of bronchiectasis. Kartagener syndrome, which affects the mobility of cilia in the lungs, aids in the development of the disease. Another common genetic cause is cystic fibrosis, in which a small number of patients develop severe localized bronchiectasis. Young's syndrome, which is clinically similar to cystic fibrosis, is thought to significantly contribute to the development of bronchiectasis. This is due to the occurrence of chronic, sinopulmonary infections. Patients with alpha 1-antitrypsin deficiency have been found to be particularly susceptible to bronchiectasis, for unknown reasons. Other less-common congenital causes include primary immunodeficiencies, due to the weakened or nonexistent immune system response to severe, recurrent infections that commonly affect the lung.

Treatment:
Treatment of bronchiectasis is aimed at controlling infections and bronchial secretions, relieving airway obstruction, and preventing complications. This includes the prolonged usage of antibiotics to prevent detrimental infections, as well as eliminating accumulated fluid with postural drainage and chest physiotherapy. Surgery may also be used to treat localized bronchiectasis, removing obstructions that could cause progression of the disease.
Inhaled steroid therapy that is consistently adhered to can reduce sputum production and decrease airway constriction over a period of time, and help prevent progression of bronchiectasis. One commonly used therapy is beclometasone dipropionate, which also used in asthma treatment. Use of inhalers such as albuterol (salbutamol), fluticasone (Flovent/Flixotide) and ipratropium (Atrovent) may help reduce likelihood of infection by clearing the airways and decreasing inflammation.

Mesothelioma

2007-12-06T22:21:00.000+05:30

Mesothelioma is a form of cancer that is almost always caused by previous exposure to asbestos. In this disease, malignant cells develop in the mesothelium, a protective lining that covers most of the body's internal organs. Its most common site is the pleura (outer lining of the lungs and chest cavity), but it may also occur in the peritoneum (the lining of the abdominal cavity) or the pericardium (a sac that surrounds the heart).

Most people who develop mesothelioma have worked on jobs where they inhaled asbestos particles, or have been exposed to asbestos dust and fibre in other ways, such as by washing the clothes of a family member who worked with asbestos, or by home renovation using asbestos cement products. Unlike lung cancer, there is no association between mesothelioma and smoking.

Source : Wikipedia

Bubonic Plague

2007-12-05T22:12:00.001+05:30

Source:Wikipedia

Meckel's diverticulum

2007-12-04T20:02:00.000+05:30

Introduction:
A Meckel's diverticulum, a true congenital diverticulum, is a small bulge in the small intestine present at birth. It is a vestigial remnant of the omphalomesenteric duct (also called the vitelline duct), and is the most frequent malformation of the gastrointestinal tract. It is present in approximately 2% of the population, with males more frequently experiencing symptoms.

Symptoms:
If symptoms do occur, they typically appear before the age of two.
The most common presenting symptom is painless rectal bleeding, followed by intestinal obstruction, volvulus and intussusception. Occasionally, Meckel's diverticulitis may present with all the features of acute appendicitis. Also, severe pain in the upper abdomen is experienced by the patient along with bloating of the stomach region. At times, the symptoms are so painful such that they may cause sleepless nights with extreme pain in the abdominal area.

Treatment:
Treatment is surgical, consisting of a resection of the affected portion of the bowel.

Whipple's disease

2007-12-04T19:56:00.000+05:30

Introduction:
Whipple's disease is a rare, systemic infectious disease caused by the bacterium Tropheryma whipplei. First described by George Hoyt Whipple in 1907 and commonly considered a gastrointestinal disorder, Whipple's disease primarily causes malabsorption but may affect any part of the body including the heart, lungs, brain, joints, and eyes. Weight loss, diarrhea, joint pain, and arthritis are common presenting symptoms, but the presentation can be highly variable.

This micrograph shows the typical findings of enlarged villus with abundant macrophages in the in small intestine.

Symptoms:

Arthritis or arthralgia
malabsorption
intestinal lipodystrophy (accumulation of fatty deposits in lymph nodes of the intestine)
lymphadenopathy
abdominal pain
diarrhea
fever
melanoderma
Neurological symptoms

Treatment:

Treatment is with penicillin, ampicillin, tetracycline or co-trimoxazole for 1 -2 years.

Crohn's Disease

2007-12-02T18:11:00.000+05:30

Introduction:
Crohn's disease (also known as regional enteritis) is a chronic, episodic, inflammatory condition of the gastrointestinal tract characterized by transmural inflammation (affecting the entire wall of the involved bowel) and skip lesions (areas of inflammation with areas of normal lining between). Crohn's disease is a type of inflammatory bowel disease (IBD) and can affect any part of the gastrointestinal tract from mouth to anus; as a result, the symptoms of Crohn's disease vary among afflicted individuals. The main gastrointestinal symptoms are abdominal pain, diarrhea (which may be bloody) or constipation, vomiting and weight loss. Crohn's disease can also cause complications outside of the gastrointestinal tract such as skin rashes, arthritis, and inflammation of the eye.

Symptoms:
Gastrointestinal symptoms:
Abdominal pain may be the initial symptom of Crohn's disease. The pain is commonly cramp-like and may be relieved by defecation. It is often accompanied by diarrhea, which may or may not be bloody, though constipation is not uncommon especially in those who have had surgery. The nature of the diarrhea in Crohn's disease depends on the part of the small intestine or colon that is involved. Ileitis typically results in large-volume watery feces. Colitis may result in a smaller volume of feces of higher frequency. Fecal consistency may range from solid to watery. In severe cases, an individual may have more than 20 bowel movements per day and may need to awaken at night to defecate. Visible bleeding in the feces is less common in Crohn's disease than in ulcerative colitis, but may be seen in the setting of Crohn's colitis. Bloody bowel movements are typically intermittent, and may be bright or dark red in colour. In the setting of severe Crohn's colitis, bleeding may be copious. Flatus and bloating may also add to the intestinal discomfort.

Systemic symptoms:
Crohn's disease, like many other chronic, inflammatory diseases, can cause a variety of systemic symptoms. Among children, growth failure is common. Many children are first diagnosed with Crohn's disease based on inability to maintain growth. As Crohn's disease may manifest at the time of the growth spurt in puberty, up to 30% of children with Crohn's disease may have retardation of growth. Fever may also be present, though fevers greater than 38.5 ˚C (101.3 ˚F) are uncommon unless there is a complication such as an abscess. Among older individuals, Crohn's disease may manifest as weight loss. This is usually related to decreased food intake, since individuals with intestinal symptoms from Crohn's disease often feel better when they do not eat and might lose their appetite. People with extensive small intestine disease may also have malabsorption of carbohydrates or lipids, which can further exacerbate weight loss.

Treatment:

Treatment is only needed for people exhibiting symptoms. The therapeutic approach to Crohn's disease is sequential: to treat acute disease and then to maintain remission. Treatment initially involves the use of medications to treat any infection and to reduce inflammation. This usually involves the use of aminosalicylate anti-inflammatory drugs and corticosteroids, and may include antibiotics.
Once remission is induced, the goal of treatment becomes maintaining remission and avoiding flares. Because of side-effects, the prolonged use of corticosteroids must be avoided. Although some people are able to maintain remission with aminosalicylates alone, many require immunosuppressive drugs.

Surgery may be required for complications such as obstructions, fistulas and/or abscesses, or if the disease does not respond to drugs within a reasonable time. For patients with an obstruction due to a stricture, two options for treatment are strictureplasty and resection of that portion of bowel. According to a retrospective review at the Cleveland Clinic, there is no statistical significance between strictureplasty alone versus strictureplasty and resection specifically in cases of duodenal involvement. In these cases, re-operation rates were 31% and 27%, respectively, indicating that strictureplasty is a safe and effective treatment for selected patients with duodenal involvement.

Source : Wikipedia

Celiac Sprue

2007-12-01T23:51:00.000+05:30

Introduction:

It is a malabsorption syndrome related to immune reaction to gluten in diet, also called nontropical sprue, celiac disease and gluten sensitive enteropathy (GSE).

Causes:

Toxic effect of gluten/gliadin (gliadin is a glycoprotein component of gluten)
immune reaction (antibody to gluten/gliadin)
adenovirus type 12
may be autosomal dominant with incomplete penetrance

Physical Findings:

In infants - growth retardation, failure to thrive and irritability. Most patients are thin, emaciated.

Microscopic Findings:

This is a micrograph of a typical celiac disease intestine.

Diagnosis:
There are several tests that can be used to assist in diagnosis. The level of symptoms may determine the order of the tests, but all tests lose their usefulness if the patient is already taking a gluten-free diet. Intestinal damage begins to heal within weeks of gluten being removed from the diet, and antibody levels decline over months. For those who have already started on a gluten-free diet, it may be necessary to perform a re-challenge with 10 g of gluten (four slices of bread) per day over 2–6 weeks before repeating the investigations. Those who experience severe symptoms (e.g. diarrhoea) earlier can be regarded as sufficiently challenged and can be tested earlier.

Prognosis:
Patient do recover and villi regenerate.
Celiac disease associated with increased mortality among patients with malabsorption symptoms.

Early Gastric Carcinoma

2007-12-01T23:43:00.000+05:30

This is a gross specimen of an early gastric carcinoma (from Pathology Text).

It shows nodular mucosa, not very apparent from this surface view, but it is very much evident on cut section, showing involvement of mucosa and submucosa, but not the muscularis.

Hirschsprung's disease

2007-12-01T18:27:00.000+05:30

Description:

Also called congenital megacolon. Its a disease in which there is congenital absence of parasympathetic innervation of distal intestine.

Pathogenesis:

Physical Findings:

Abdominal distention, occasionally loops of stool-filled bowel palpable, increased rectal sphincter tone, no stool in rectal vault or ampulla, classically explosion of watery stool on removal of finger.

Lab Diagnosis:

Abdominal x-ray
Barium enema
Rectal suction biopsy
No ganglion cells in submucosal plexus confirms diagnosis

Treatment:

Cured by surgical excision of affected segment.

Acute Gastritis

2007-12-01T18:14:00.000+05:30

Description:
Focal damage to gastric mucosa. Also called acute erosive gastritis, gastric erosion, acute hemorrhagic gastritis, stress ulcers.

Causes:

Aspirin (NSAIDs)
Ethanol
Aalkali and acid
Ischemia
Steroids, cigarettes, pancreatic enzymes, bile acids
Severe stress such as sepsis, severe trauma and burns.

Physical Findings:

Often normal, GI bleeding, tachycardia, hypotension, pallor and upper abdominal tenderness.

Diagnosis:

Endoscopy shows congestion, friability, superficial ulceration, petechiae, black hemorrhagic areas are superficial erosions
Blood in gastric aspirate

Treatment:

Antacids, H2 blockers, sucralfate, omeprazoleprochlorperazine for treating uncomplicated nausea and vomiting.
For massive bleeding give vasopressin IV or intra-arteriorly to mesenteric artery; contraindicated in coronary artery disease; only temporary treatment.
Near-total gastrectomy if uncontrolled bleeding

Coming Up....

2007-11-29T23:16:00.001+05:30

I shall be dealing with the diseases of the gut in the next few posts.
These include the following :

Peptic Ulcer
Gastritis
Gastric Carcinoma
Hirschsprung's disease
Celiac sprue
Crohn's disease
Ulcerative colitis
Paralytic Ileus
Whipple disease
Meckel's diverticulum

Poliomyelitis in India

2007-11-29T23:12:00.000+05:30

A problem statement of Poliomyelitis in India.

This map shows the incidence of Wild Poliovirus in India.

Dengue Fever

2007-11-29T22:49:00.000+05:30

Causes:
Caused by dengue virus (Flaviviridae, Arbovirus). 4 serotypes of this virus have been reported.
Characteristics of dengue virus: Icosahedral, envelope, internal matrix protein, 1 glycoprotein spike, single-stranded RNA.
It lives only in humans.
Transmitted by mosquito bite (Aedes aegypti mosquito, also Aedes albopictus and Aedes polynesiensis mosquitoes), typically during daytime.

Pathogenesis:
Incubation period 5-8 days (range 3-15 days)
It usually manifests as dengue hemorrhagic fever.
Caused by cross-reacting antibody at second infection and/or virulent virus and leakage of plasma through endothelial gaps.

Risk factors:
Mosquito season, travel to tropics and urban epidemics.
Endemic in Africa, Central and South America, Caribbean and southeast Asia.

Malaria : The Risk

2007-11-29T22:42:00.000+05:30

Malaria incidence rates in different parts of the world.

Source : WHO World Malaria Report 2005

Tetanus

2007-11-29T19:19:00.000+05:30

Introduction:
Tetanus is a medical condition that is characterized by a prolonged contraction of skeletal muscle fibers. The primary symptoms are caused by tetanospasmin, a neurotoxin produced by the Gram-positive, obligate anaerobic bacterium Clostridium tetani. Infection generally occurs through wound contamination, and often involves a cut or deep puncture wound. As the infection progresses, muscle spasms in the jaw develop hence the common name, lockjaw. This is followed by difficulty swallowing and general muscle stiffness and spasms in other parts of the body. Infection can be prevented by proper immunization and by post-exposure prophylaxis.

Types:
Local tetanus: It is an uncommon form of the disease, in which patients have persistent contraction of muscles in the same anatomic area as the injury. The contractions may persist for many weeks before gradually subsiding. Local tetanus is generally milder; only about 1% of cases are fatal, but it may precede the onset of generalized tetanus.
Cephalic tetanus :It is a rare form of the disease, occasionally occurring with otitis media (ear infections) in which C. tetani is present in the flora of the middle ear, or following injuries to the head. There is involvement of the cranial nerves, especially in the facial area.
Generalized tetanus: It is the most common type of tetanus, representing about 80% of cases. The generalized form usually presents with a descending pattern. The first sign is trismus or lockjaw, followed by stiffness of the neck, difficulty in swallowing, and rigidity of pectoral and calf muscles. Other symptoms include elevated temperature, sweating, elevated blood pressure, and episodic rapid heart rate. Spasms may occur frequently and last for several minutes. Spasms continue for 3–4 weeks and complete recovery may take months.
Neonatal tetanus: It is a form of generalized tetanus that occurs in newborn infants. It occurs in infants who have not acquired passive immunity because the mother has never been immunized. It usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with a non-sterile instrument. Neonatal tetanus is common in many developing countries and is responsible for 14% (215,000) of all neonatal deaths, but is very rare in developed countries.

Prophylaxis:
In pregnant women, a two dose regimen is recommended i.e 1 vaccine in the 4th month and the next after 1 month.
In India, all newborns are vaccinated against this disease along with Diphtheria and Pertussis (DPT vaccine) in the 6th, 10th and 14th months, followed by boosters in the 18th month, 5th and 10th years.

Peptic Ulcer Disease

2007-11-29T18:19:00.000+05:30

Introduction:

2 types viz gastric and duodenal.

Gastric ulcers are now common than duodenal ulcers and in the small intestine, they are associated with Meckel's diverticulum.

Causes:

The major causes are H. pylori (duodenal + gastric) or NSAIDs (gastric), Zollinger-Ellison syndrome, CMV and HSV infection.

Pathogenesis:

H. pylori infection may be prerequisite for almost all duodenal ulcers in absence of NSAIDs or ZE and 80% non-NSAID-induced gastric ulcers, yet most H. pylori-infected individuals do not develop ulcersacid is necessary, reduced bicarbonate, increased acid.

Complications:

bleeding
perforation, especially duodenal
diabetes associated with increased 30-day mortality in patients with bleeding or perforated peptic ulcer
older age associated with increased 30-day mortality in patients with bleeding or perforated peptic ulcer
5% gastric outlet obstruction
posterior penetration (severe back pain), pancreatitis

Treatment:

clarithromycin 500 mg twice daily
amoxicillin 1 g twice daily
metronidazole 500 mg twice daily

Rabies

2007-11-28T21:52:00.000+05:30

Introduction:
Rabies (Latin: rabies, "madness, rage, fury") is a viral zoonotic disease that causes acute encephalitis (inflammation of the brain) in mammals. In non-vaccinated humans, rabies is almost invariably fatal after neurological symptoms have developed, but prompt post-exposure vaccination may prevent the virus from progressing.

Transmission and symptoms:
Any mammal may become infected with the rabies virus and develop symptoms, including humans. Most animals can be infected by the virus and can transmit the disease to humans. Infected bats, monkeys, raccoons, foxes, skunks, cattle, wolves, dogs or cats provide the greatest risk to humans. Rabies may also spread through exposure to infected domestic farm animals, groundhogs, weasels and other wild carnivores. Squirrels, rodents and rabbits are seldom infected.

The virus is usually present in the nerves and saliva of a symptomatic rabid animal. The route of infection is usually, but not necessarily, by a bite. In many cases the affected animal is exceptionally aggressive, may attack without provocation, and exhibits otherwise uncharacteristic behaviour. Transmission may also occur via an aerosol through mucous membranes; transmission in this form may have happened in people exploring caves populated by rabid bats. Transmission between humans is extremely rare, although it can happen through transplant surgery (see below for recent cases), or, even more rarely, through bites or kisses.

After a typical human infection by bite, the virus directly or indirectly enters the peripheral nervous system. It then travels along the nerves towards the central nervous system. During this phase, the virus cannot be easily detected within the host, and vaccination may still confer cell-mediated immunity to prevent symptomatic rabies. Once the virus reaches the brain, it rapidly causes encephalitis and symptoms appear. It may also inflame the spinal cord producing myelitis.

The period between infection and the first flu-like symptoms is normally two to twelve weeks, but can be as long as two years. Soon after, the symptoms expand to slight or partial paralysis, cerebral dysfunction, anxiety, insomnia, confusion, agitation, abnormal behavior, paranoia, hallucinations, progressing to delirium. The production of large quantities of saliva and tears coupled with an inability to speak or swallow are typical during the later stages of the disease; this can result in "hydrophobia", where the victim has difficulty swallowing, shows panic when presented with liquids to drink, and cannot quench his or her thirst. The disease itself was also once commonly known as hydrophobia, from these characteristic symptoms. Death almost invariably results two to ten days after the first symptoms. It is neurotrophic in nature.

Prevention:
Rabies can be prevented by vaccination, both in humans and other animals. Virtually every infection with rabies was a death sentence, until Louis Pasteur and Emile Roux developed the first rabies vaccination in 1885. This vaccine was first used on a human on July 6, 1885 – nine-year old boy Joseph Meister (1876–1940) had been mauled by a rabid dog.

Their vaccine consisted of a sample of the virus harvested from infected (and necessarily dead) rabbits, which was weakened by allowing it to dry for 5 to 10 days. Similar nerve tissue-derived vaccines are still used now in some countries, and while they are much cheaper than modern cell culture vaccines, they are not as effective and carry a certain risk of neurological complications.

The human diploid cell rabies vaccine (H.D.C.V.) was started in 1967. Human diploid cell rabies vaccines are made using the attenuated Pitman-Moore L503 strain of the virus. Human diploid cell rabies vaccines have been given to more than 1.5 million humans as of 2006. Newer and less expensive purified chicken embryo cell vaccine and purified Vero cell rabies vaccine are now available. The purified Vero cell rabies vaccine uses the attenuated Wistar strain of the rabies virus, and uses the Vero cell line as its host.

Some recent works have shown that during lethal rabies infection blood-brain barrier (BBB) does not open in order to allow anti-viral immune cells to enter the brain, the primary site of rabies virus replication. This aspect contributes to the pathogenicity of the virus and artificially increasing BBB permeability promotes viral clearance. Opening the BBB during rabies infection has been suggested as a possible novel approach to treat the disease.

Post-exposure prophylaxis:
Treatment after exposure, known as post-exposure prophylaxis or "P.E.P.", is highly successful in preventing the disease if administered promptly, within fourteen days after infection. The first step is immediately washing the wound with soap and water, which is very effective at reducing the number of viral particles. In the United States, patients receive one dose of immunoglobulin and five doses of rabies vaccine over a twenty-eight day period. One-half the dose of immunoglobulin is injected in the region of the bite, if possible, with the remainder injected intramuscularly away from the bite. This is much less painful compared with administering immunoglobulin through the abdominal wall with a large needle, which is how it was done in the past. The first dose of rabies vaccine is given as soon as possible after exposure, with additional doses on days three, seven, fourteen, and twenty-eight after the first. Patients that have previously received pre-exposure vaccination do not receive the immunoglobulin, only the post-exposure vaccinations. Since the widespread vaccination of domestic dogs and cats and the development of effective human vaccines and immunoglobulin treatments, the number of recorded deaths in the U.S. from rabies has dropped from one hundred or more annually in the early twentieth century, to 1–2 per year, mostly caused by bat bites, which may go unnoticed by the victim and hence untreated.

P.E.P. is effective in treating rabies because the virus must travel from the site of infection through the peripheral nervous system (nerves in the body) before infecting the central nervous system (brain and spinal cord) and glands to cause lethal damage. This travel along the nerves is usually slow enough that vaccine and immunoglobulin can be administered to protect the brain and glands from infection. The amount of time this travel requires is dependent on how far the infected area is from the brain: if the victim is bitten in the face, for example, the time between initial infection and infection of the brain is very short and P.E.P. may not be successful.

Pre-exposure prophylaxis:
Currently pre-exposure immunization has been used on domesticated and normal non-human populations. In many jurisdictions, domestic dogs, cats, and ferrets are required to be vaccinated. A pre-exposure vaccination is also available for humans, most commonly given to veterinarians and those traveling to regions where the disease is common, such as India. Most tourists do not need such a vaccination, just those doing substantial non-urban activities. However, should a vaccinated human be bitten by a carrier, failure to receive subsequent post-exposure treatment could be fatal, although post-exposure treatment for a vaccinated human is far less extensive than that which would normally be required by one with no pre-exposure vaccination.

In 1984 researchers at the Wistar Institute developed a recombinant vaccine called V-RG by inserting the glycoprotein gene from rabies into a vaccinia virus. The V-RG vaccine has since been commercialised by Merial under the trademark Raboral. It is harmless to humans and has been shown to be safe for various species of animals that might accidentally encounter it in the wild, including birds (gulls, hawks, and owls).

Mesothelioma

2007-11-27T23:29:00.000+05:30

Introduction:
Mesothelioma is a form of cancer that is almost always caused by previous exposure to asbestos. In this disease, malignant cells develop in the mesothelium, a protective lining that covers most of the body's internal organs. Its most common site is the pleura (outer lining of the lungs and chest cavity), but it may also occur in the peritoneum (the lining of the abdominal cavity) or the pericardium (a sac that surrounds the heart).

Signs and symptoms:
Pleural

Chest wall pain
Pleural effusion
Shortness of breath
Fatigue or anemia
Wheezing, hoarseness, or cough
Blood in the sputum (fluid) coughed up

Abdominal

Abdominal pain
Ascites
Mass in the abdomen
Weight loss

Pathophysiology:

The mesothelium consists of a single layer of flattened to cuboidal cells forming the epithelial lining of the serous cavities of the body including the peritoneal, pericardial and pleural cavities. Deposition of asbestos fibres in the parenchyma of the lung may result in the penetration of the visceral pleura from where the fibre can then be carried to the pleural surface, thus leading to the development of malignant mesothelial plaques. The processes leading to the development of peritoneal mesothelioma remain unresolved, although it has been proposed that asbestos fibres from the lung are transported to the abdomen and associated organs via the lymphatic system. Additionally, asbestos fibres may be deposited in the gut after ingestion of sputum contaminated with asbestos fibres.

Treatment:

Surgical approach: palliative decortication for pain control and to improve pulmonary function, surgical resection and intrapleural chemotherapy
Radiation therapy: post-operatively as a consolidative treatment.
Chemotherapy: Drugs of choice are cisplatin and pemetrexed, gemcitabine and cisplatin.

Prognosis:
Often fatal, poor response to treatment.

Screening:
Screening for asbestos-related disease not recommended for general population, but may be appropriate if history of significant asbestos exposureif history of significant exposure and exertional dyspnea, spirometry and chest x-ray recommended in addition to history and physicalif no evidence of abnormalities, consider high-resolution CT which may reveal pleural-based plaques, CT is more sensitive than chest x-ray for detecting lesions and mild fibrosispresence of plaques indicates significant asbestos exposureif patient has abnormal spirometry results, imaging abnormalities, or suspected asbestos-related conditions, consider full pulmonary function tests, including measurement of lung volumes and diffusion capacity.

Asbestosis

2007-11-27T23:10:00.000+05:30

Introduction:
Pneumoconiosis = restrictive interstitial lung disease.
Organs Involved are lung (bibasilar), respiratory bronchioles and alveolar ducts.
It is the third most common interstitial fibrotic lung disease.

Etiolopathogenesis :
Caused by light thin sharp asbestos fibers, which induce inflammation and fibrosis. History of asbestos exposure, even a very remote one, is considered and a potential risk factor.

Complications:
Higher incidence of bronchogenic carcinoma and mesothelioma are the main complications. Other complications include hyalinized fibrocalcific plaques, fibrinous pleuritis, peribronchial fibrosis, recurrent respiratory infections and pleural effusion.

Physical Findings:
Cardiac findings are late, after pulmonary hypertension sets in. It may end up in right heart failure.
Basilar inspiratory rales are the usual auscultatory findings.
Extremities may have clubbing.

Diagnosis:
Blood shows increased ESR, hypergammaglobulinemia.
Chest skiagram shows pleural thickening or calcification (lower lobe predominance)
Histopathology examination is done by bronchoscopy, open biopsy or video-assisted thorascopy. Asbestos bodies (ferruginous bodies):
These are complex of hemosiderin and glycoprotein within macrophage.
Diffuse interstitial cellular and fibrotic reaction is a constant finding.

Prognosis:
May progress without further exposure