David M. Levy FRCA

• Consultant Obstetric Anaesthetist, Anaesthetics Directorate,
• Nottingham University Hospitals, Queens Medical Centre
• Campus, Nottingham

Prevalence of subependymal giant cell tumors in patients with tuberous sclerosis and a review of the literature skin care yogyakarta decadron 0.5 mg otc. A neuropathology-based approach to epilepsy surgery in brain tumors and proposal for a new terminology use for long-term epilepsy-associated brain tumors acne guidelines buy decadron on line amex. Pathogenesis skin care malaysia buy discount decadron online, diagnosis and treatment of Rasmussen encephalitis: a European consensus statement acne 2nd trimester purchase genuine decadron. Epilepsy is clearly focal in onset in approximately two-thirds of pediatric cases and generalized in onset in one-quarter acne 6 months postpartum 8 mg decadron. Achievement of early remission however acne quiz cheap decadron 4mg with mastercard, does not always guarantee favorable long-term outcome, particularly in children with focal epilepsy. While structural abnormalities portend poorer outcome, the specific type is important, with higher rates of intractability in cases with cortical dysplasia, mesial temporal sclerosis and dual pathology, as opposed to encephalomalacia. While the primary goal of classification is to improve clinical epilepsy care, accurate classification is also important for epidemiological reasons. Using such a framework increases the likelihood of finding a precise diagnosis in a more cost-effective manner with fewer investigations for the patient. Reaching a precise diagnosis is essential to inform treatment recommendations and in the design of potential research trials evaluating new therapies. Medications which can be very effective for one type of epilepsy are ineffective, or may even exacerbate others. While sodium channel agents are often useful for focal epilepsies, they exacerbate Dravet syndrome and many types of genetic generalized epilepsies. Patients with focal cortical dysplasias are typically medically intractable, but have a high likelihood of seizure freedom with resective surgery. Those with autoimmune epilepsies respond favorably to immunomodulatory therapy, with better outcomes with more prompt onset of therapy. Many early-onset, severe epilepsies are highly correlated with cognitive decline,26 due in part to epileptic encephalopathy, and in certain cases prompt initiation of precision therapy may improve neurocognitive outcome. Examples include early initiation of vigabatrin in children with tuberous sclerosis. Finally, many pediatric epilepsies are self-limited and are typically outgrown by adolescence. Correlating specific phenotypes in a particular region or population may provide clues to underlying etiology, which may be potentially modifiable. Numerous studies have documented clusters of new-onset seizure disorders due to various infectious agents and toxins. It was made clear that syndromes did not always have common etiologies or outcomes. There could be a family history of benign epilepsy and the etiology was presumed to be genetic. Examples include benign childhood epilepsy with centrotemporal spikes and childhood epilepsy with occipital paroxysms. Symptomatic localization-related epilepsies include those with a known or suspected structural cause. Those with a presumed symptomatic cause, but with no structural abnormalities identified on neuroimaging, were classified as cryptogenic. The cause was presumed to be genetic and examples include childhood absence epilepsy, juvenile absence epilepsy, and juvenile myoclonic epilepsy. The symptomatic generalized epilepsies were typically characterized by multiple different generalized seizure types associated with bilateral discharges, but also asymmetric and focal discharges. There were also associated clinical and radiologic signs of diffuse encephalopathy. If no clear etiology was identified, these could also be classified as generalized cryptogenic epilepsy. In addition, minimal changes were made to the pre-existing list of epilepsy syndromes. Epileptic spasms were identified as a specific seizure type and included infantile spasms. The concepts of generalized and partial/ localization-related seizures were altered due to increased understanding of seizures occurring due to hyperexcitability and synchrony of neurons within networks, rather than specific areas of neocortex. Generalized seizures can appear to have focal features and be asymmetric, but the lateralization is inconsistent. The term "partial seizures" was felt to be imprecise, especially "simple partial" and "complex partial. It was recommended that seizures described as impairments in awareness/ consciousness be specifically recognized and the term "dyscognitive features" was used. Furthermore, etiology and comorbidities should be identified at each level, if possible. As part of the updated classification schema, the level of detail specified is up to the classifier (clinician, researcher, patient, family member, etc. Classification of unknown-onset seizures Motor Nonmotor Unclassified onset Epileptic spasms Behavioral arrest which information to include. The new classification aims to enhance communication between those who provide routine care for patients with epilepsy and those less familiar with this disorder, and to reflect our current and increasing understanding of the epilepsies. Generalized-onset seizures can be further classified into motor or nonmotor onset. The level of awareness is not included as it is assumed that awareness is impaired in the majority of generalized-onset seizures. Seizures of focal onset can be further subclassified based on additional features seen at seizure initiation (see box). A seizure in a patient who retains awareness of self and environment during the entire event would be classified as a focal seizure with retained awareness (or focal aware seizure). Awareness is an important feature to note as it has anatomic and pathophysiologic implications (seizure onset/spread) as well as lifestyle and social implications for patient counseling. If awareness is not known then motor or nonmotor onset findings can be used for naming and awareness excluded. For focal seizures with multiple signs and symptoms, classification is based on the most prominent initial feature at seizure onset. Often there may be several features associated with the focal seizure that aid in seizure description, but are not necessary for classification. Additional "free text" descriptors are encouraged to provide more information regarding seizure anatomic basis, behavioral characteristics, and etiology (Table 4. The term unknown onset should only be used until further information is apparent for continued classification. In these instances, classification should be held until additional corroborating information is available such as additional history, video-electroencephalogram data, or neuroimaging findings. The terminology used in the classification can be abridged so that when the next term used to describe the seizure supersedes the prior term, the prior term would be assumed. For example, a focal motor clonic seizure can also be described as a focal clonic seizure, as the term motor is inherent in that descriptor. Epilepsy classification guides patient care, including choice of antiseizure medications, prediction of medical comorbidities, and prognostication. Generalized epilepsy, focal epilepsy, combined generalized and focal epilepsy, and unknown epilepsy are the categories included in this classification tier. The specific category may be determined on clinical grounds with electroencephalographic information providing supporting evidence. Sudden brief muscle contraction (<100 ms) Sudden loss of muscle tone without preceding tonic or myoclonic component Hyperkinetic Agitated thrashing or leg pedaling movements. Examples include chewing, picking, hand fumbling Autonomic Seizure causing impairment in autonomic nervous system (cardiovascular, gastrointestinal, vasomotor, thermoregulation) Behavioral A pause in activity arrest Cognitive Seizure that affects higher cognitive functions (language, memory, spatial planning, praxis). Previous term was psychic seizure Emotional Seizure with predominant emotional component. Additionally can be applied to manifestations of dacrystic (crying) or gelastic (laughter) seizures Generalized Motor onset Myoclonic jerk followed by atonic seizure with loss of tone. Unknown epilepsy type is an additional category when there is not enough information for further classification. Many epilepsy syndromes have clear implications for etiology, treatment, and prognosis. Increasingly, drug trials in pediatric epilepsy are focusing on efficacy in defined syndromes. However, higher rates of learning disability, executive dysfunction and attention disorders, as well as poorer long-term psychosocial outcomes may be seen. While epilepsy syndromes are much more commonly identified in children than in adults, a clear epilepsy syndrome can only be defined in just over one-quarter of children. In certain cases, etiology may fall into two or more categories, such as the patient with tuberous sclerosis complex who has a structural etiology related to a genetic cause. There can be considerable heterogeneity in the phenotypic presentation of different etiologies. Given the advances in molecular techniques, there are more potential causative mutations being identified in patients with epilepsy. It is important to understand that gene mutations can be associated with a variety of electroclinical epileptic syndromes and electroclinical syndromes can be associated with different genetic mutations. These imaging abnormalities can be acquired, such as stroke or infection, or genetic, such as tuberous sclerosis complex. It is important to identify structural causes so that surgical resection can be considered carefully if medical treatments fail. Seizures are a core symptom of the disorder and the metabolic epilepsy results directly from this disorder. Metabolic disorders can be due to a genetic cause, such as glucose transporter deficiency, but can also be acquired, as in cerebral folate deficiency. Identification of a metabolic etiology is essential because some metabolic disorders have specific effective therapies and early implementation thereof may improve developmental and seizure outcomes. The seizures should be directly due to a known infection with which seizures are commonly associated, such as meningitis, encephalitis, and neurocysticercosis. This can also include congenital infections, including Zika virus and cytomegalovirus. This does not refer to acute seizures occurring in the setting of the infection, but rather the subsequent epilepsy with unprovoked seizures that occurs after the infection. The seizures must directly result from an immune disorder for which seizures are a core symptom. These can affect both children and adults and must not be forgotten in children with acute onset seizures and encephalopathy. In adults, there is often an underlying neoplasm, such as an ovarian teratoma in women. In children, the presenting symptoms are typically orofacial dyskinesias and an encephalopathy with seizures. They are also due to underlying etiology, age of epilepsy onset, epilepsy syndrome, seizure location, and possibly epileptiform abnormalities. To use this term would fail to bring attention to the learning disabilities, depression, anxiety, psychosocial concerns, and other issues that children experience. Inherent to this concept is that amelioration of epileptiform activity has the potential to improve the developmental consequences of the disorder. There are clear cases in which obvious cognitive decline parallels onset of frequent seizures and interictal discharges, and where resolution of the epileptiform abnormalities correlates with improved development.

Although some conditions lead to increased gas production skin care 35 year old buy decadron 4mg otc, many individuals with bloating exhibit normal gut gas volumes skin care and pregnancy purchase decadron with mastercard. Relief of symptoms with defecation or passage of flatus is consistent with a functional disorder skin care at 30 purchase decadron with american express, as is the absence of symptoms that awaken the patient from sleep acne jacket order decadron overnight delivery. Conversely skin care diet order online decadron, symptoms of fever acne nodules buy generic decadron from india, weight loss, nocturnal diarrhea, steatorrhea, or rectal bleeding increase the likelihood of organic disease. Medical conditions that predispose to bacterial overgrowth and use of medications that delay gut transit should be elicited. Anxiety disorders and other psychiatric conditions predispose to aerophagia and functional bowel disorders. Physical examination the physical examination is usually normal in patients with complaints of excess gas; however, patients with functional disease may exhibit anxiety, hyperventilation, and air swallowing. Abdominal distension should be assessed and differentiated from exaggerated lumbar lordosis or ascites. Physical findings suggesting organic disease include sclerodactyly (scleroderma), peripheral or autonomic neuropathy (dysmotility syndromes), or cachexia, jaundice, and palpable masses (malignant intestinal obstruction). Abdominal auscultation can assess for absent bowel sounds with ileus or myopathic dysmotility, highpitched bowel sounds with intestinal obstruction, or a succussion splash with gastric obstruction or gastroparesis. Abdominal percussion and palpation may reveal tympany and distension in mechanical obstruction or intestinal dysmotility. In selected patients, calcium and phosphate levels, renal function, liver chemistry values, and thyroid function tests may be indicated. Patients with diarrhea should undergo stool examination for enteric pathogens including bacteria or parasites such as Giardia or Entamoeba histolytica. Serum tissue transglutaminase and deaminated gliadin antibodies can screen for celiac disease. Rarely, antinuclear and scleroderma antibodies to screen for collagen vascular disease or antinuclear neuronal antibodies (antiHu) for paraneoplastic visceral neuropathy may be indicated. Upper endoscopy can be considered to assess for an inflammatory or neoplastic process, and obtain small bowel biopsies to diagnosis celiac disease. Functional studies Gastric emptying scintigraphy or manometry of the esophagus, stomach, and small intestine can be performed when an underlying motility disorder is considered. Radioopaque markers may be detected using plain abdominal radiographs to document colonic transit. Monosaccharide or disaccharide malabsorption increases hydrogen and methane gas production by intestinal bacteria that can be detected by breath testing. Expired breath samples are obtained before and after ingesting an aqueous solution of the suspected malabsorbed sugar. For example, an increase in breath hydrogen of greater than 20 ppm or methane greater than 10 ppm within 120 minutes of 25 g lactose ingestion distinguishes biopsyproven, lactasedeficient persons from lactasesufficient persons with a sensitivity of 90%. Patients can be tested for fructose or sorbitol malabsorption using hydrogen breath testing, but the normal values of these tests are not well established. Carbohydrate maldigestion Malabsorption of small amounts of carbohydrates, demonstrated by increased breath hydrogen excretion, may produce eructation, bloating, abdominal pain, and flatulence. Lactase deficiency is the most common form of carbohydrate intolerance, affecting approximately 20% of the population in the United States. Fructose is naturally found in honey and fruits and is used as a sweetener in many commercial soft drinks. Sorbitol is also present in fruits and is used as a sweetener in dietetic candies and chewing gum. Other poorly 72 Approach to Patients with Gastrointestinal Symptoms or Signs Table 7. The autosomal recessive hereditary syndrome sucraseisomaltase deficiency typically presents in infancy with malabsorption of sucrose. Of the complex carbohydrates, only rice and glutenfree wheat are completely absorbed in healthy individuals, whereas up to 20% of the carbohydrates from whole wheat, oat, potato, and cornflour are maldigested and can contribute to gas generation. Fiber intake correlates with flatus production in some individuals, although other studies suggest that fiber only increases the sensation of bloating without increasing gas production. The Patient with Gas and Bloating 73 Motor disorders of the gut such as diabetic diarrhea are associated with overgrowth because of an impaired ability to clear organisms from the gut. Dysmotility syndromes Conditions that alter gut motor function produce prominent gas and bloating. Bloating is reported by patients with gastroparesis and by those with fat intolerance and rapid gastric emptying. Surgical fundoplication to treat gastroesophageal reflux disease is associated with an inability to belch or vomit secondary to an unyielding wrap of gastric tissue around the distal esophagus. Intestinal pseudoobstruction leads to gaseous symptoms because of delayed small bowel transit of gas and development of bacterial overgrowth. Functional bowel disorders Irritable bowel syndrome and functional dyspepsia may have symptoms of gas and bloating. The pathogenesis is likely multifactorial, and although some studies illustrate increased gas production and objective abdominal distension in irritable bowel syndrome, others do not. Abnormal gut motor and sensory function contribute to the symptoms of gas and bloating. Miscellaneous causes Aerophagia during gum chewing, smoking, or oral irritation produces significant gas symptoms, especially eructation. Patients who have undergone laryngectomy experience eructation from swallowing air for esophageal speech. Patients with intestinal obstructions may infrequently present only with symptoms of gas and bloating. Small bowel malabsorptive conditions including celiac disease may produce gaseous manifestations that may predominate or be part of a larger constellation of symptoms. Individuals with peptic ulcer, gastroesophageal reflux, or biliary colic may belch to relieve their other symptoms. Gaseous complaints may be reported as consequences of endocrinopathies such as hypothyroidism. Medical the underlying disorder responsible for symptoms of excess gas should be specifically managed whenever possible. Lactase deficiency is controlled by excluding lactose from the diet or by supplementing the diet with exogenous lactase. Acidsuppressive medications may reduce eructation associated with gastroesophageal reflux disease. For complaints of excess gas for which no organic disorder is defined after appropriate diagnostic testing, attempts are made to decrease intestinal gas and to regulate bowel function. Aerophagia may be controlled by cessation of gum chewing and smoking and improving oral hygiene. The chronic belcher may be aided by selfobservation in a mirror to demonstrate aerophagia. In particular, fructans in breakfast cereal, pasta, and bread are implicated in gas and bloating. Flatulence is best managed by education of the foods that increase gas production such as beans, cabbage, lentils, Brussel sprouts, nuts, and legumes. Bismuth subsalicylate (524 mg four times daily) has been shown to decrease bloating. However, the evidence supporting activated charcoal in reducing symptoms of bloating and gas is variable. However, complications from organic disease usually are manifestations of the underlying disease rather than of the gas itself. There have been rare case reports of explosions resulting from ignition by tobacco smoking of feculent gas expelled during eructation in patients with gastrointestinal obstruction and proximal bacterial overgrowth. Similarly, colonic explosions with perforation have been reported in patients undergoing colonoscopy with intracolonic cautery. In general, these vanishingly rare complications result from inadequate bowel cleansing or the use of mannitol or sorbitol purging solutions, both of which generate hydrogen gas. Case studies Case 1 A 32yearold woman complains of excessive belching, in excess of 30 times per day. She has no medical problems including diabetes or thyroid disease and denies medication use. The patient is queried further and her symptoms had increased when she tried to stop smoking by using nicotine gum, although she continues to smoke. She is counseled about aerophagia and over time is able to stop smoking and discontinue the gum, which results in substantial reduction in her symptoms. Aerophagia is commonly exacerbated by smoking or gum chewing but can be primary and is generally a learned behavior. Patients are often unaware of aerophagia, so the use of a mirror to provide objective evidence of episodes of air swallowing can be useful. Case 2 A 48yearold man with a 30year history of type 1 diabetes complains of excessive gas and flatulence, with cramping abdominal pain and loose stools. He states that there had been a progressive increase in intestinal gas over the past six months despite no change in his diet, good glucose control, and regular the Patient with Gas and Bloating 77 exercise. His physical examination confirms reduced proprioception, but the remainder of his examination is normal, including the abdomen. Laboratory tests reveal an elevated blood urea nitrogen and creatinine but a normal HbA1C and thyroid function. Glucose hydrogen breath testing reveals an abnormally elevated baseline level that increases significantly after carbohydrate ingestion. Ciprofloxacin 500 mg orally twice daily for seven days is prescribed, which rapidly improves symptoms. Diabetic "enteropathy" is a neuropathy that interferes with normal intestinal motility; it rarely occurs in the absence of peripheral neuropathy so physical findings (reduced proprioception) are key to the diagnosis. The glucose hydrogen breath test is classically used to evaluate for the presence of bacterial overgrowth; however, it is insensitive, and empirical therapy is often employed in lieu of diagnostic testing. Chronic pseudoobstruction is a functional abnormality of longer duration that simulates mechanical obstruction but has no anatomical cause and may exhibit clinical manifestations similar to ileus. Toxic megacolon is a special form of ileus in which severe transmural inflammation produces colonic atony, systemic toxemia, and a high risk of spontaneous perforation. Obstruction implies complete or partial blockage of the gut at one or more levels. Clinical presentation History Patients with ileus, obstruction, and pseudoobstruction have symptoms of abdominal pain, nausea, vomiting, abdominal distension, or obstipation. Acute ileus or gastric or duodenal obstruction may be associated with little abdominal pain, whereas distal intestinal or colonic obstructions generally cause greater discomfort. Upper and midabdominal pain are characteristic of obstruction proximal to the transverse colon, whereas left colonic obstruction is associated with lower abdominal discomfort. Distension may be pronounced with ileus and with distal obstruction but minimal with gastric obstruction. Copious vomiting of clear liquid characterizes gastric obstruction, whereas marked bilious emesis occurs with duodenal blockage. If mechanical obstruction is incomplete or if ileus is mild, pain and distension may be intermittent and aggravated by fiberrich, poorly digestible foods. Complete obstruction usually produces obstipation and the inability to expel flatus. Conversely, watery diarrhea is noted with partial obstruction and fecal impaction. Prior surgery can cause adhesions, and reports of abdominal wall bulging suggest a hernia. Histories of malignancy, radiation, inflammatory bowel disease, ulcer disease, gallstones, diverticular disease, pancreatitis, motility disorders, and foreign body ingestion suggest specific causes. Physical examination A patient with obstruction usually appears to be in great distress, whereas a patient with ileus may be more comfortable despite pronounced abdominal distension. Auscultation usually reveals hypoactive or absent bowel sounds with ileus, whereas obstruction produces louder, highpitched, hyperactive bowel sounds that may have a musical or tinkling quality. Shaking of the abdomen while listening through a stethoscope may reveal a succussion splash, which is associated with gastric obstruction or gastroparesis. Hepatosplenomegaly, lymphadenopathy, and masses raise concern for malignancy, although tender masses may be present in inflammatory diseases. Tympany accompanies both ileus and obstruction, whereas shifting dullness and a fluid wave characterize ascites. Rectal examination may detect occult fecal blood with inflammatory, neoplastic, infectious, or ischemic disease. Digital rectal and pelvic examinations may also detect subtle masses not found on abdominal palpation or may reveal obturator or sciatic hernias. Repeated abdominal examinations are essential to assess for development of complications such as perforation. If fever, hypotension, or signs of sepsis or peritonitis develop or if bowel sounds disappear, the viscus may be ischemic and operative intervention may be urgently indicated. Key practice points the physical examination can usually differentiate between ileus and obstruction. Ileus will present with absent or rare bowel sounds, whereas the physical examination in obstruction will reveal hyperactive, highpitched (tinkling) bowel sounds. Additional testing Laboratory studies Blood tests may not identify the cause of mechanical obstruction; in contrast, laboratory studies often indicate the cause of ileus.

Lesions also occur throughout the gastrointestinal tract and may produce occult bleeding acne research cheap decadron 4 mg without prescription. Diagnostic investigation Upper and lower gastrointestinal endoscopy can diagnose hemangiomas acne practice buy discount decadron. Capillary lesions appear as punctate red nodules skin care doctors trusted 8mg decadron, whereas cavernous lesions are violetblue acne shoes order decadron with amex, sessile skin care 35 proven decadron 0.5 mg, polypoid lesions skin care hospitals in hyderabad buy 1mg decadron with visa. The color, submucosal location, and compressibility distinguish the latter from colonic adenomas. Angiography and capsule 454 Specific Gastrointestinal Diseases endoscopy are useful for detecting hemangiomas in the small intestine. The characteristic pooling of contrast in the venous phase is a typical finding in angiographic images of large cavernous lesions but may be absent in images of small lesions. Management In disorders with multiple gastrointestinal hemangiomas, conservative therapy with iron supplementation is recommended initially. Small capillary hemangiomas may be amenable to endoscopic obliteration by coagulation, band ligation, sclerotherapy or polypectomy. Persistent hemorrhage or obstruction at a defined site requires surgical resection. Miscellaneous vascular lesions Angiosarcomas, epithelioid hemangioendotheliomas, and hemangiopericytomas are malignant neoplasms that originate from the cellular components of blood vessels. Kaposi sarcoma is another vascular neoplasm that frequently disseminates to the gastrointestinal tract. This represents one of the most common causes of gastrointestinal bleeding in patients with acquired immunodeficiency syndrome. Gastrointestinal bleeding also occurs in patients with pseudoxanthoma elasticum, as a result of an abnormal vascular structure. This disorder of elastin synthesis typically presents with bleeding from arterioles in the gastric fundus. Patients characteristically have skin hyperextensibility, articular hypermobility and tissue fragility. Diagnosis is by clinical presentation, family pedigree analysis, and identifying genetic or biochemical defects. There is an increased risk of intramural intestinal hematomas, colonic diverticular hemorrhage, and intestinal perforation. Gastrointestinal Vascular Lesions 455 Case studies Case 1 A 62yearold man presents with melena, hematemesis, and hypotension. He has no prior history of bleeding and has no risk factors for liver disease or portal hypertension. After resuscitation with saline and blood products, an upper endoscopy is performed that reveals large clots in the stomach but no evidence of varices, ulcers, or masses. He is transferred from the intensive care unit to the medical ward, where his vital signs and hemoglobin remain stable for two days; however, he has recurrence of hypotension and melena that require additional blood products and fluid. His endoscopy is repeated and after thorough lavage of his gastric contents, an actively spurting vessel is noted in the gastric fundus without surrounding ulceration. Epinephrine is injected around the bleeding site, which slows the rate of hemorrhage, allowing placement of three hemoclips that successfully stop the bleeding. The surrounding tissue is tattooed and the patient has no further episodes of rebleeding during the hospitalization. Discussion the diagnosis of a Dieulafoy lesion can be evasive because in the absence of active bleeding or a visible vessel indicating a fibrin clot, there is no endoscopic evidence of the source of hemorrhage. For this reason, after successful endoscopic treatment using injection of epinephrine for initial hemostasis followed by either hemostatic clipping, electrocautery, or band ligation, it is important to tattoo the area surrounding the lesion so that endoscopic therapy may be targeted to a specific location in the case of recurrent hemorrhage. Case 2 A 53yearold man presents to your clinic with iron deficiency anemia and intermittent melena. He has never been hospitalized but has received multiple blood transfusions and is on iron supplementation for anemia of at least three years duration. He has a history of chronic hepatitis C for which he has undergone successful eradication. He has undergone an upper endoscopy that did not reveal ulcerations, masses, or varices, and the endoscopist did not specify a bleeding lesion. His vital signs and physical examination are normal, and he has no stigmata of chronic liver disease. The colonoscopy is normal to the terminal ileum; however, the 456 Specific Gastrointestinal Diseases upper endoscopy is notable for erythematous longitudinal antral folds that converge toward the pylorus. Three months later you see him in clinic followup and his hemoglobin and ferritin are normal and he denies further episodes of melena. The most common presentation is iron deficiency anemia, but occasional patients will have overt bleeding. The term watermelon stomach describes the erythematous linear streaks that line the gastric body and antrum. Obesity is defined as the presence of excessive body fat due to excess caloric intake relative to energy expenditure. The possibility of an eating disorder should be investigated because patients with eating disorders should have interventions directed at treatment of the eating disorder before any treatment for obesity is considered. Waist circumference should also be measured because it is associated with risk of medical complications. Diagnostic investigation Laboratory studies Laboratory studies include evaluation to screen for known complications of obesity including a fasting lipid panel, comprehensive metabolic panel, fasting glucose, hemoglobin A1C, and liver function tests. Management Obesity has been demonstrated to be associated with progressive excess mortality. Complications the primary complication from obesity is the metabolic syndrome, which is the constellation of insulin resistance, visceral adiposity, hypertension, and dyslipidemia. This subsequently results in a two to three times increased risk of Medical, Surgical, and Endoscopic Treatment of Obesity 459 cardiovascular disease. In addition, obesity leads to significant osteoarthritis and increased the risk of developing obstructive sleep apnea. Initial treatment should begin with diet, exercise, and behavioral therapy, with the goal of achieving a 10% weight reduction over a 6 months period. Combination of decreased caloric intake with increased energy expenditure with the goal of a loss of 500 kcal/day should result in a loss of 1 pound/week. Pharmacologic agents that are currently approved for the treatment of obesity in the United States include orlistat, lorcaserin, phentermine, and phentermine/ topiramate (Table 43. The goal of bariatric surgery is to obtain a sustained excess weight loss of >50% and resolution of comorbid conditions from obesity. Studies have demonstrated reduction in both morbidity and mortality with bariatric surgery. Bariatric surgeries have two potential mechanisms of action: restrictive and malabsorptive. This surgery results in the greatest excess weight loss with the lowest rate of weight regain and results in resolution of comorbidities. Intragastric balloons have been developed and are currently available for placement in the United States. Intragastric balloons are endoscopically delivered devices that can be filled with saline to occupy the intragastric space. These devices are intended only for temporary placement (up to six months) and result in weight loss by decreasing food intake and reducing gastric emptying. Adverse events including ulcer bleeding, bowel obstruction, and perforation have been reported. Treatment with the intragastric balloon in conjunction with lifestyle directed therapy can result in durable weight loss with improvement in comorbidities. Endoscopic sleeve gastroplasty is another method that is currently being developed and investigated. Endoscopic sleeve gastroplasty is a procedure that is in evolution with the ongoing development of new endoscopic suturing devices. Preliminary studies of endoscopic sleeve gastroplasty compared to laparoscopic sleeve gastrectomy have demonstrated less weight loss for patients undergoing endoscopic sleeve gastroplasty; however, endoscopic sleeve gastroplasty had fewer adverse events. On further questioning, he notes episodes of food "sticking" that have occurred one to two times per year for the past three to four years. Endoscopic findings are notable for multiple esophageal rings and longitudinal furrows. What histologic findings would be expected on biopsies taken from the proximal and distal esophagus Upper endoscopy shows a 3 cm hiatal hernia but no esophagitis or Barrett esophagus. She does not have a history of liver disease and denies intake of nonsteroidal antiinflammatory agents or aspirin. Which of the following is not an appropriate upfront step in her evaluation and management His initial blood 466 Questions and Answers pressure in 120/85 with a pulse of 76. He has a history of wellcontrolled hypertension and a 30 packyear history of smoking. He appears as a thin older man with normal affect and without localizing signs on physical exam. She also reports symptoms of nausea, vomiting, abdominal distension, and constipation. She denies weight loss, melena, hematochezia, or other alarm features, and she has no family history of inflammatory bowel disease or celiac disease. Her laboratory tests including hemoglobin, iron, albumin, B12, folate, and fatsoluble vitamin concentrations are normal. Nasogastric tube suctioning, discontinuation of narcotics and other potential exacerbating drugs, and correction of potential electrolyte disturbances b. The next day repeated plain abdominal radiographs reveal a cecum diameter of 13 cm. The patient describes abdominal distension and mild discomfort but has no peritoneal findings on examination. Her physical examination is notable for pitting edema of her lower extremities, but no abdominal masses or tenderness. Laboratory tests are notable for a normal complete blood count and electrolytes, but a low albumin (2. Stool tests are negative for red and white blood cells, and an enteric pathogen panel is negative. You perform a colonoscopy that is normal to the terminal ileum including random biopsies that reveal normal small intestinal and colonic biopsies. Her stool tests include the absence of red or white cells, negative bacterial culture and C. She and several friends ate at an Asian restaurant in the afternoon, and within six hours, two of the five diners had acute onset of nausea and vomiting, followed by watery diarrhea. Of the following, the least likely etiology for persistent hyperbilirubinemia is: a. Antimitochondrial antibody is positive in approximately 50% of patients with primary biliary cholangitis b. Coumadin should be held for two days, and low molecular weight heparin should be administered until the night before the scheduled procedure b. Coumadin should be held for five to seven days prior to the procedure, and low molecular weight heparin should be administered until the night before the scheduled procedure c. Endoscopic resection of visible lesions followed by ablation of flat Barrett mucosa. His physical exam is notable for orthostatic hypotension, reduced bowel sounds, and epigastric tenderness with guarding. His rectal examination reveals melena, but his nasogastric lavage consists of bilestained nonbloody fluid. Her physical examination is normal and her laboratory testing shows a normal complete blood count and liver tests.

Even after wire passage and balloon dilatation acne drugs proven 1mg decadron, there is a significant residual thrombus that skin care clinique buy decadron with mastercard, after deployment of a stent skin care gift baskets order decadron 4 mg online, might result in distal embolisation and coronary slow flow with associated complications and impaired prognosis skin care lines decadron 4 mg with amex. Systematic manual thrombectomy has not been shown to consistently prevent or abolish this problem [3] acne vulgaris cause buy decadron 1mg amex. A meta-analysis was performed that suggested better angiographic outcomes although cardiovascular outcomes were not improved [12] acne and diet purchase decadron uk. However, randomised multi-centre trials with reproducible and consistent results are not easily designed and completed. A large meta-analysis that included all the randomised studies that evaluated deferred stenting was reported recently [13]. Less robust flow is not the subset being discussed, as the reason for the same has to be established prior to a decision. This interesting concept has been advocated by some dedicated interventionists but needs more detailed study before it is either adopted or rejected universally. Revascularisation in patients with cardiogenic shock 105 subendocardial scars in the non-infarct-related artery segments (probably fresh Type 4a myocardial infarction) and many had remote scars that were picked up at this time [22]. Thus, revascularisation of the non-infarct vessel definitely reduces ischaemia-driven revascularisation although the spontaneous event rate may be unclear. A physiology-driven strategy seems to be the current gold standard, but this strategy has its limitations as the vast majority of clinical events occur in nonobstructive lesions. The optimal timing currently seems to be during the index hospitalisation although clinical judgement is paramount. A wealth of information is likely to be available in the near future on this issue that will definitely impact decisions. A rapid and skilled analysis of the clinical situation and anatomy should prompt the treatment strategy. The interventionist has the daunting task of walking the tight rope between doing too little, leaving significant ischaemic myocardium, or too much, and with excessive procedure time and contrast burden negatively impacting outcomes. Liistro F, Grotti S, Angioli P, Falsini G, Ducci K, Baldassarre S, Sabini A, Brandini R, Capati E, Bolognese L. Impact of thrombus aspiration on myocardial tissue reperfusion and left ventricular functional recovery and remodeling after primary angioplasty. End points included all-cause death, repeat revascularisation and rehospitalisation for recurrent heart failure. Repeat revascularisation and rehospitalisation for heart failure were higher in the culprit-only group (32. Comparison of hospital mortality with intra-aortic balloon counterpulsation insertion before versus after primary percutaneous coronary intervention for cardiogenic shock complicating acute myocardial infarction. Delay in reperfusion has a major impact on 1-year mortality as shown by de Luca et al. Hence, thrombolysis remains the dominant reperfusion strategy in India and it is important to have clarity of approach after thrombolysis in order to optimise the results [3]. The efficacy of thrombolysis is variable and varies with the type of lytic agent used. Also, 5% to 10% of patients will suffer coronary artery re-occlusions after an initial successful thrombolysis. This is because the plaque/thrombosis ratio at the site of the coronary occlusion is on average 80% plaque to 20% thrombotic material [4] and it is often plaque expansion that contributes more than acute thrombosis to the acute coronary occlusion. Both studies, though, included small numbers of patients and thus were underpowered for clinical end points. The primary end-point outcomes were driven mainly by reduction in reinfarction or recurrent ischaemia. Another meta-analysis of nine trials totalling 3325 patients showed a 24% decrease in total mortality (P = 0. It may also relate to the intense stimulation of platelets that occurs after administration of even half-doses of lytics [17]. This probably applies to only stable patients and needs to be replicated in other settings but expands our options. Even medical insurance may refuse to pay for two such procedures in back-to-back fashion. Thus, in such patients, translating evidence into clinical practice can prove to be a major challenge. It found the final size of infarct larger in those presenting late as expected but also concluded that significant myocardial salvage can be achieved when presenting after the 12-hour limit, even when the infarct-related artery is totally occluded [26]. Substantial myocardial salvage is possible even when the infarct-related artery is occluded. Those who present late or >24 hours after fibrinolysis should be assessed clinically. Those who are unstable clinically, hemodynamically or electrically need revascularisation. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: Every minute of delay counts. Significance of coronary arterial thrombus in transmural acute myocardial infarction. Myocardial reperfusion, limitation of infarct size, reduction of left ventricular dysfunction, and improved survival. Mechanical reperfusion and long-term mortality in patients with acute myocardial infarction presenting 12 to 48 hours from onset of symptoms. Impact of national clinical guideline recommendations for revascularization of persistently occluded infarct-related arteries on clinical practice in the United States. Infarct size and myocardial salvage after primary angioplasty in patients presenting with symptoms for <12 h vs. Survival and cardiac remodeling benefits in patients undergoing late percutaneous coronary intervention of the infarct-related artery: Evidence from a meta-analysis of randomized controlled trials. The most common precipitating factor is coronary artery stenosis resulting from a partially occlusive thrombus over an eroded atherosclerotic lesion with or without superimposed coronary vasospasm or stenosis. Very rarely, non-atherosclerotic causes like arteritis, trauma, dissection, thromboembolism, catheterisation or pharmacogenetic mechanism may be responsible. Plaque rupture is the most common cause of acute coronary syndrome in males while pre-menopausal females more frequently have erosion, and again plaque rupture shows progressive occurrence in post-menopausal females. Culprit lesions responsible for acute coronary syndrome are less calcified than those for stable angina, stressing the stability of calcified lesions [5]. Physical examination needs to be directed to uncover precipitating comorbidities, to assess warning signs for complications of acute coronary syndrome and to rule out non-ischaemic and noncardiac causes for the presentation. The troponin elevation is more sensitive and specific than other cardiac biomarkers. The serial changes in the level of biomarkers are more confirmatory especially in patients of chronic stable angina. The imaging by coronary arteriography is recommended to be performed prior to and post-intracoronary vasodilator injection. The subset of left main with multi-vessel disease was obviously at the highest risk. A prospective observational study of 478 patients suggests superiority of hs-cTn with supplementary copeptin over a repeat hs-cTn [15]. This necessitates timely risk stratification to devise appropriate treatment strategies (Table 16. Anti-ischaemic measures: the risk prediction algorithms and scores help in determining the patients who need to be subjected to pharmacological or invasive anti-ischaemic measures. The principal mechanism of anti-ischaemic drugs is to lower myocardial oxygen demand by reducing heart rate, afterload, preload and myocardial contractility, and by facilitating myocardial oxygen supply by coronary vasodilatation. Aspirin: Aspirin reduces myocardial infarction or death in unstable angina (odds ratio 0. Thienopyridines: Ticlopidine, clopidogrel and prasugrel irreversibly block the P2Y12 receptors through their metabolites, independent of aspirin action. The anti-platelet action of clopidogrel is irreversible and takes several days for optimal effect without a loading dose. Prasugrel: Scores over other thienopyridines with better biotransformation to active metabolite. Prasugrel in loading as well as in maintenance doses has more rapid onset, more P2Y12 inhibition and less variability than others. The pre-specified landmark analysis in this trial to detect outcomes attributable to loading dose of study drugs showed that prasugrel is superior to clopidogrel in early and maintenance phases. A significant bleeding hazard, especially in prior stroke patients, patients beyond 75 years of age and of weight less than 60 kg, contraindicates prasugrel use in these cohorts. Instances of fatal intracerebral haemorrhage were higher with ticagrelor; however, that was balanced by more non-intracranial major bleeding with clopidogrel. Ticagrelor is associated with dyspnoea, hyperuricaemia and ventricular pauses secondary to lesser adenosine degradation and erythrocyte uptake. It should be noted that any amount of left ventricular dysfunction contraindicates use of cilostazol due to increased mortality. The study showed increased bleeding and transfusion need in the prior eptifibatide group. The patients receiving both heparin and tirofiban showed benefits at the end of 7 days, 30 days and 6 months [33]. If the patient becomes asymptomatic, this is typically followed by stress imaging. In the early invasive strategy, the optimal timing of intervention has not been determined. The elderly, women, moderate chronic kidney disease patients and diabetics are better treated with early invasive strategy. Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Heart-type fatty acid-binding protein predicts long-term mortality and re-infarction in consecutive patients with suspected acute coronary syndrome who are troponin-negative. Elevated levels of systemic pentraxin 3 are associated with thin-cap fibroatheroma in coronary culprit lesions. Dynamic high-sensitivity troponin elevations in atrial fibrillation patients might not be associated with significant coronary artery disease. Standard- vs high-dose clopidogrel based on platelet function testing after percutaneous coronary intervention. The impact of renal insufficiency on clinical outcomes in patients undergoing percutaneous coronary interventions. Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction. A comparison of aspirin plus tirofiban with aspirin plus heparin for unstable angina. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. The most common bleeding event during the index admission is procedure related, which is about 50%, followed by gastrointestinal bleeding (16%), whereas in subsequent admissions gastrointestinal bleeding makes up about 50% of the bleeding events. The occurrence of other types of bleeding (like respiratory, intracranial, intra-ocular, urogenital, etc. A multi-modality approach involving the combined use of early invasive coronary procedures as well as adjunctive potent anti-platelet therapy and antithrombotic drugs has completely revolutionised the management of acute coronary syndrome. However, the enormous strides achieved in the reduction of ischaemic events in these patients have been at the cost of an increased incidence of bleeding complications. The overall aim of classifications is to systematically report and categorise bleeding events in order to allow comparisons across various data sets. These classification systems have improved over time to become more objective and also account for blood transfusions. This score stratifies bleeding on a scale from 0 (no bleeding) to 5 (fatal bleeding) and provides the ability to assess patients subjected to myocardial revascularisation procedures and anti-platelet therapy. Overall, there is no evidence of decreased efficacy but clear evidence of increased safety with lower doses of aspirin [21]. Also, there are more instances of fatal intra-cranial bleeding but fewer instances of fatal bleeding from other sources. Consequences of bleeding include hypotension, anaemia and reduction in oxygen delivery. Furthermore, severe bleeding increases the risk of acute myocardial infarction, stroke and the need for urgent myocardial revascularisation [17,20]. Major bleeding events increase in-hospital mortality as well as mortality after discharge at 30 days and 1 year [32]. Despite major bleeding, blood transfusion in this setting is associated with increased mortality. Potential mechanisms for the detrimental effects of transfusions include platelet activation and aggregation, impaired oxygen and nitric oxide delivery capabilities [33]. Adding a protonpump inhibitor to reduce gastrointestinal bleeding events in patients at high risk of gastrointestinal toxicity who receive long-term treatment with aspirin is recommended [34]. However, these have an inherent tendency to increase the risk of bleeding complications. Each patient should undergo an individualised assessment of the baseline haemorrhagic risk as well as the ischaemic risk.

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