Rachel W. Flurie, PharmD, BCPS

• Assistant Professor, Internal Medicine
• Department of Pharmacotherapy and Outcomes Science, School of Pharmacy
• Virginia Commonwealth University, Richmond, Virginia

https://app.pharmacy.vcu.edu/rwflurie

This usually occurs in the elderly people due to cerebral atrophy which increases the subdural space resulting in a greater tendency to rupture the veins androgen hormone secreted by cheap confido amex. Treatment the treatment of choice is evacuation of the hematoma through a burr-hole along with a washout using warm saline prostate cancer radiation cheap 60 caps confido mastercard. Bullets with a velocity of less than 300m/see cause the least damThere are two types accoding to mechanism age prostate specific antigen purchase 60caps confido, while with a velocity of more than of injury: 300m/sec prostate cancer 70 confido 60caps visa, there is a cavitation effect thyroid hormone androgen receptor discount confido 60caps on line, a prostate cancer 15 year survival rates by stage cheap 60 caps confido amex. Bullets with penetrating Injuries a velocity of more than 770m/sec have a blast-like effect. Pneumothorax is observed in almost all cases of penetrating chest injury with hemothorax occurring in about 80 percent cases. Blunt Injuries these are usually a consequence of crush injury or road traffic accidents. The flexibility of the thorax in children makes them more vulnerable to injury to the thoracic structures from pulmonary contusion to rib fracture compared to adults. Tension pneumothorax which is relieved immediately by inserting a wide bore needle at 2nd intercostal space lateral to the sternum. Pericardial tamponade-It is relieved urgently by inserting a wide bore needle to left of xiphisternum into the pericardial cavity. History A brief history is taken from the patient or witness about time of injury, weapon type anditsdirection,thepatientspositionatthe time of injury and the patients progress during transport. Other investigations if the patient has doxically that is, inwards during inspiration and outwards during expiration and may associated injuries. Bronchoscopy if there is suspected dis- occasionally be sufficient to compromise ventilation. Cardiac tamponade causing circulaintermittent positive pressure ventilation tory shock and if needle aspiration is for 2 to 3 weeks. However, if there are other underlying injuries requiring thoraRib Fractures cotomy, the flail segment can be fixed simultaneously. Plain X-ray chest shows the pneumothofractured in at least two locations either on one side of the chest or either side of the sternum. This is seen in 40 percent cases and the often described pulsus paradoxus is even less frequent. The site and extent of cardiac injury can be adequately determined by exploration. Thoracic aortography either by the femoral or brachial route is the diagnostic investigation. Fulminant pleuritis with massive pleural effusion, if mediastinal pleura have rupracoabdominal incision. The to deep cervical fascia from mandible to left hemidiaphragm is affected more than b. Fulminating mediastinitis if mediastinal nonabsorbable muscular suture with drainpleura is intact and nonabsorbable sutures. Instrumentation Injury Instrumentation injury or iatrogenic injury may occur during gastroduodenoscopy, colonoscopy, sigmoidoscopy, esophagoscopy in the form of perforation of the gut wall. Secondary survey History Blunt Injury this type of injury leads to higher mortality rates than penetrating injury and presents greater problems in diagnosis. Penetrating Injury Penetrating injury is usually caused by sharp instruments like a knife or by various types of firearms. Sharp penetrating injury in the midline is more serious than in the flanks as it may lead to injury to the great vessels. Evenminimaltendernessand spine immobilization and hemorrhage conguarding are significant. The retroperitoneal organs and structures like the kidneys, pancreas, aorta, should also be looked for recording the findings of each organ. When history and clinical examination are liver, spleen, kidneys and pancreas as well doubtful, proper investigations are helpful. Complete blood picture-A low hemat- the scan takes too much time and is not used, ocrit or a fall in hematocrit may indicate instead immediate laparotomy is the preferred option. Location of foreign body or missile is Definitive Care facilitated by the radiograph. Associated head injury and spinal cord with the adherent transverse mesocolon and injury. If it is not extensively damaged it is preserved by repair, partial splenectomy or enclosing the organ in a mesh sac. The tube is removed only after a cholangiogram shows a normal gallbladder and bile ducts with a free flow of dye into the duodenum. Isolated extrahepatic biliary tree injury may be present but the accompanying hepatic artery and the portal vein are frequently involved and the resulting bleeding is difficult to control. If bleeding is present, then Pringle maneuver is used and the hepatoduodenal ligament with all its contained structures is clamped proximally and distally after which repair is carried out. If the major bile ducts are incompletely divided the defect is repaired primarily with absorbable sutures. When the duct is completely transected repair by end to end anastomosis invariably leads to stricture formation. Therefore, some form of biliary enteric anastomosis like choledochojejunostomy or cholecystojejunostomy is done. Stomach Most penetrating wounds of the stomach are treated by means of debridement of the wound edges and primary closure in two layers. It is rarely injured in a blunt trauma as it is relatively mobile and in a protected position. If the Duodenum mesenteric laceration is transverse, the A motor vehicle accident causing a steering intestine gets devascularized and should be wheel blow to the epigastrium is the most resected. Ontheotherhand,ifthelaceration common mechanism of blunt duodenal inju- is parallel to the mesentery, then it can be ries. Treatment is surgical exploration as the bleeding is from the branches of the aorta and the inferior vena cava. Treatment Early diagnosis and prompt surgical intervention are the most important determinants Surgical Anatomy of of a successful outcome. It is bounded supeof the peritoneal cavity before closure of the riorly by the diaphragm, inferiorly by the abdomen. Proximal end colostomy and distal ture, obliteration of psoas shadow, site of mucous fistula (Hartmann procedure). Abdominal Trauma hypercarbia and hypotension due to more than 25cm of H2O significant cardecreased venous return to the heart. Clinical features Classifications Pathologic classifications of renal injuries is as follows. Grade 2-Nonexpanding perirenal hema toma and cortical laceration less than 1cm deep. Grade 3-Renal parenchymal laceration more than 1cm deep, no urinary extravasation. Grade 4-Renal parenchymal lacera tion extending into the renal collecting system or thrombosis of a segmented renal artery. Grade 5-Multiple Grade 4 parenchymal lacerations, avulsion of the renal vessels or a shattered kidney. Of the above, Grade 1 and 2 are regarded as minor injury and Grade 3, 4 and 5 as major injury. Thisisanindicationfor immediate arteriography to identify possible avulsion of renal pedicle or renal arterial thrombosis. It can detect minor extravasation and evaluate associated intra abdominal and retroperitoneal injuries. For ruptured kidney, abdomen is opened through a long midline incision so that other abdominal viscera can be examined. Lower ureter injury-Ureteroneocystostomy whereby the upper end of a transected ureter is implanted into the bladder is performed. Upper ureter injury-usually primary ureteroureterostomy (which is the anastomosis between two segments of the same ureter) or ileal replacement is done. Mid ureter injury-Best is primary or transureteroureterostomy (anastomosis of the transected end of one ureter into the side of the intact contralateral ureter). Iatrogenic-This is the commonest cause and occurs during the course of pelvic sur gery. Minor injury-Conservative treatment with bed rest, hydration and antibiotics for 7 to 14 days. Major injury (Ruptured kidney, shattered indigo carmine will produce vaginal leak kidney and pedicle avulsion). If recognized and treated within 24 hours mortality falls to 55 percent and, if within 12 hours, to 11 percent. Intraperitoneal rupture is more common in male usually secondary to blow, kick or fall on a fully distended bladder. Extraperitoneal rupture is usually caused by a fracture pelvis due to blunt trauma when fragments from the fracture site perforate the bladder. If the urine is infected, extraperitoneal bladder perforations may result in deep pel vic abscess and severe pelvic inflammation. They occur most often in men following pelvic fractures or falling on buttocks from a height. The laceration is repaired in two layers with 2/0 polyglycolic acid Anterior Urethral Trauma (Spongy Urethra) (Vicryl). Prognosis Pathology 350 Early recognition and treatment of bladder the injury may vary from a simple contu rupture are crucial. Untreated major perfora sion to urethral laceration as in straddle tions of the bladder are associated with 100 trauma. Chapter 56 In the latter type of injury the urethra gets crushed against the inferior edge of symphy sis pubis. The extravasation cannot extend into the thigh due to the firm attachment of the fascia to ischiopubic rami. Genitourinar y Tract Trauma Per rectal examination reveals a pelvic hematoma and the prostate may be impalpa ble as it is displaced upwards.

Chronicity of infection gives rise to fibrous thickening of the subepithelial layer and consequent thickening and inelasticity of the bladder wall prostate cancer medications discount confido line, resulting in reduced bladder capacity prostate oncology ward buy confido 60 caps without a prescription. Histologically androgen hormone vs enzyme order online confido, the chronically inflamed bladder may show cystic changes (cystitis cystica) and the development of squamous metaplasia prostate youth purchase confido 60 caps overnight delivery. It is a form of chronic abacterial Treatment cystitis man health news za order confido 60 caps free shipping, practically confined to women prostate cancer 7 out of 12 buy cheap confido 60caps on-line. This may be a form of autoimmune dis- If infection persists despite adequate treatease but essentially the cause is obscure. Steroids-The dramatic response to genitourinary tuberculosis and other irritasteroids in some cases have suggested tive lesions like calculi or tumors. When viscera can give rise to overt cystitis with malakoplakia involves the ureter, it can cause typical symptoms. The contracted bladder may require augmentation cysto- of trimethoprim and sulphonamide may be plasty. Tuberculosis of the bladder is virtually always Cystitis Cystica associated with renal tuberculosis. This is the earliest involvement of the bladder is frequently found in patients with recurrent located in the vicinity of the ureteral orifice frequency and dysuria. Encrusted cystitis results from infection of the bladder by urea splitting organisms, particu- Clinical Features larly B. The treatment is by antibiotics and attempt- Treatment ing to acidify urine which is usually resisted by Treatment should ideally be given in conthe ammonia produced by the proteus. However tracted bladder requiring urinary diversion it responds rapidly to antituberculous drugs or cystoplasty. Histologically, the plaques are made augmentation may be done either by ileup of large foamy macrophages with occa- ocystoplasty or cecocystoplasty. The fibrosional multinucleate giant cells and inter- sed supratrigonal bladder is removed and spersed lymphocytes. The cercariae (fork tailed larval form) released from the snail swim freely in fresh water, pierce the skin of man and ultimately lay their ova in venules in the bladder and ureters. In the bladder and lower third of the ureters the extruded ova from the venules damage the overlying mucosa causing terminal hematuria and later stimulate fibrosis and calcification, causing contraction of the bladder and ureteral stenosis. Hydronephrosis and pyonephrosis may follow, often bilateral leading to renal failure. The presence of eggs can be demonstrated in the vesical mucosa removed by cystoscopic biopsy. Cystoscopy may show sandy patches of calcified dead ova with degeneration of the overlying epithelium. Treatment the modern chemotherapy for bilharziasis consists of a single dose of praziquantel, which for safety may be repeated after a month. Bilharzial papillomas and carcinomas require the same surgical measures as the nonbilharzial ones. Adenocarcinoma-1 to 2 percent arises either from the urachal remnant or from areas of glandular metaplasia. Malignant-commonest is rhabdomyosarcoma less common tumors are leiomyosarcoma and fibrosarcoma. The bladder is the second most common site of genitourinary tumors after the Investigations prostate. G2=moderatelydifferentiated G3=poorlydifferentiated Staging Staging is determined by depth of bladder wall invasion, extent of pelvic and lymph node spread and presence of distant metastases. T3 = Tumor invades perivesical tissue T3a= Microscopically T3b= Macroscopically(extravesicalmass). T4 = Tumor invades any of the following: Pelvic wall, prostate, uterus, vagina, abdominal wall. N2= Metastasisinasinglelymphnode> 1 cm but < 5cm in greatest dimension or multiple lymph nodes none more than 5cm in greatest dimension. Chemicals-Aniline dye workers and those working in the leather, paint and rubber industry are more susceptible to bladder cancers. Squamous cell carcinoma following Like cancer anywhere bladder cancer may squamous metaplasia. Muscle invasive tumors (T2, T3) are treated by radiotherapy and total cystectomy either alone or in combination. Partialcystectomy(partialbladderresection) can be done for localized lesions situated away from ureteral orifices and the base. The three cardinal investigations in patients with hematuria are urine analysis, Intravenous urography and cystoscopy. Urine examination shows presence of blood and demonstration of cancer cells is confirmatory. Principles of Management the most important aspect in the management of bladder tumors is to evaluate the stage and grade of the tumor as the treatment and prognosis depends on it. Extraurethral incontiRadical Cystectomy nence is loss of urine through a channel other Once the tumor has invaded the superficial than the urethra. Thus the spinal reflex is controlled by an Radiotherapy inhibitory cortical and pontine mechanism Patients unfit for surgery or unwilling to which allows conscious control over micturiaccept the consequences of surgery are tion. If the integration pathway from the pons usually older and frailer and possibly have more advanced disease than a comparable is interrupted, the function of sacral spinal segment is preserved and the detrusor cystectomy group. This is mainly treated medically by the folduce a rise of intra-abdominal pressure, raised vesical pressure. It may lowing measures: cal pressure exceeds the urethral pressure, occur in the postoperative period. A small number of patients require be diagnostic in congenital abnormalireflexia(Uninhibited bladder seen in urinary diversion. Estrogen cream in case of atrophic Clinical features Overflow incontinence is an unconvaginitis with stress incontinence. These symptoms bladder (diabetes mellitus, tabes dorsalis, are quite specific for stress incontinence. Catheterization: If all the above measures fail, the bladder foreign body, stones. If urethral catheterization is not possible with all possible attempts, then suprapuof chronic retention), rupture of the bic puncture or cystostomy is done to urethra. Diabetes-progressive lower motor between one hollow viscus and another or neuron pattern (flaccid bladder). Drugs like narcotics, anticholinerlowing neglected obstructed child- birth gics and antipsychotics. The hole in the bladder is closed with absorbable sutures and a catheter is left indwelling for 5 to 6 days. Presently suprapubic cystostomy sets are available which has simplified the Chapter 47 procedure. The catheter is connected to a closed drainage system and is changed every 4 weeks due to occurrence of encrustation and obstruction by phosphate debris. The technique involves division of the ureters which are pulled into the sigmoid colon and stitched mucosa to mucosa. As a result this center becomes excited and the desire to pass urine occurs when the bladder holds less, often considerably less than 300ml urine. These automatic contractions of the bladder occur usually at intervals of one to four hours. The distal loop is brought out through a of the spinal cord by way of the pelvic preselected site. In the Continent Urinary diversion wall of the bladder they form synapses with short postganglionic fibers. The middle portion is formed into a urethrae (external urethral sphincter) is reservoir. This which urine collects and can be removed controls the voluntary part of micturition. The understanding of this impaired func- Upper Motor Neuron, Unstable tion requires knowledge of normal neural or Uninhibited Bladder (Spastic Bladder) (fig. Following this phase the bladder may become either spastic or remains flaccid depending on the level of spinal cord injury as mentioned above. During the stage of spinal shock, the bladder has to be drained preferably by intermittent catheterization. Therefore, the micturition center in the spinal cord is completely destroyed and contraction of the detrusor is dependent only on the nerve plexus and ganglia situated in the bladder wall. There is accumulation of huge residual urine which causes back pressure on the kidneys producing hydronephrosis or even pyonephrosis. Long-term catheterization (urethral or suprapubic) may be necessary in either spastic or flaccid bladders, but this is avoided if at Thus following spinal cord injury the variall possible as it is associated with increased ous stages of bladder dysfunction may be as infection as well as blockage. Atonic Bladder in Spinal Shock If there is severe spinal cord injury, there is a stage of flaccid paralysis, below the level of injury, regardless of the stage of trauma. From the skin due to sweating and this may lead to renal failure with severe exfoliative dermatitis. Postrenal failure cases are amenable to surgiMicroscopically, there is mitochondrial cal drainage either endoscopically or by open disruption, nuclear changes and shedding surgery. Dialysis Dialysis may be indicated if conservative measures fail to control the situation. Diagnosis Acute renal failure usually comes to the attention of the physician either because of a raised serum creatinine or blood urea nitrogen level or because of oliguria. Clinical Evaluation A clinical evaluation is of utmost importance to make the diagnosis of acute renal failure. The background factors and the etiology of oliguria with azotemia should be ascertained through a careful history, thorough clinical examination and other relevant investigations. Fluid replacement - Intake of fluid is restricted to replacing the lost volumes only, i. A low protein diet with additional calories (daily intake of 3000kcal) is generally recommended and should be ordered in consultation with the dietitian. Peritoneal Dialysis Versus Hemodialysis Peritoneal dialysis is the simplest form of treatment, although hemodialysis may be necessary. Peritoneal dialysis is preferred in patients who cannot tolerate hypotensive episodes or the heparinization required to perform hemodialysis. Hemodialysis, on the other hand, achieves more rapid clearance of the plasma and is especially useful in treating hyperkalemia, fluid overload and drug overdoses. Generally the term chronic renal failure is applied in cases of renal failure of more than several months duration. Chapter 48 the most common causes are diabetic nephropathy, hypertension and glomeruloneephritis. Conservative treatment-In case of estabClinical Features lished chronic renal failure conservative 1. Coagulopathy-due to decreased platelet transplantation are used when conservative adhesiveness. Hazards of hyperkalemia are cardiac con- Transplantation means implanting a tissue duction abnormalities and dysrhythmias. It is also more cium secondary to decreased activity cost-effective than dialysis. Plasma sodium concentration is usually normal in patients with chronic renal failure.

There is a sudden onset of pain with characteristic gross and rapid dilatation of the sigmoid loop prostate cancer epidemiology discount 60caps confido with visa. If left untreated prostate 73 order 60caps confido fast delivery, the strangulated bowel undergoes gangrene resulting in death from peritonitis androgen hormone yaki purchase generic confido. Sites Most commonly it affects the sigmoid prostate yew cheap 60 caps confido otc, cecum Volvulus of Cecum and small intestine prostate yeast order confido 60 caps line, but volvulus of the gall- this is usually associated with a congenital bladder and stomach may occur prostate oncology 77030 purchase 60caps confido otc. X-ray of the abdomen shows a grossly dilated cecum, which is rotated clockwise upon its mesentery and frequently located Gastrointestinal Surger y in the left upper quadrant of the abdomen. The definitive treatment of cecal volvulus even when the bowel is viable is cecal resecTreatment tion and ileocolic anastomosis. Cecopexy and cecostomy are both advoThe mainstay of treatment of this condition is surgery. Although it is a part of the large gut, it is devoid of taeniae coli, sacculations, appendices epiploicae and mesentery. The rectum presents a series of three lateral curvatures; two are convex to the right side and one to the left side. The curvatures contain three transverse folds of mucous membrane and circular muscle, called valves of Houston, projecting left, right and left from above downwards. A layer of fascia, called the fascia of Denonvilliers separates the rectum from the anterior structures and forms the plane Relations. Laterally, the rectum sacrum and coccyx and the middle sacral is supported by the levator ani. The superior rectal artery, continuation of Anteriorly the upper two-thirds of the the inferior mesenteric artery, is the prinrectum are covered by peritoneum and relate cipal artery of the rectum. The inferior rectal artery, a branch of one-third lies prostate, bladder base and semthe internal pudendal artery, anastomoinal vesicle in the male or the vagina in the ses with the middle rectal artery at the female. Middle rectal artery, a branch from the anterior division of internal iliac artery. The superior rectal vein drains into the inferior mesenteric vein (portal system). The middle and inferior rectal veins drain into the internal iliac and internal pudendal veins respectively. Section 8 Efferents from the pararectal nodes (upper and middle members) accompany the superior rectal artery to the inferior mesenteric nodes. Lymph vessels from the lower part of rectum pass to the internal iliac nodes along the middle rectal artery. The usual drainage flow is upwards along the superior rectal nodes of Gerota to the inferior mesenteric nodes. For this reason, surgical ablation of malignant disease consists of wide clearance of these proximal lymph nodes. Gastrointestinal Surger y is less mobile than in the upper part of the anal canal. The lower limit of the pecten often has a whitish appearance because of which it is referred to as the white line of Hilton. Anal columns of Morgagni-These are longitudinal folds of mucous membrane with submucous coat and macularis mucosae, 10 to 12 in number. Anal valves of Morgagni are short transverse folds of mucous membrane that connect the lower ends of the anal columns. Anal sinus crypt-Above each anal valve there is a depression in the mucosa which is called the anal sinus. Pectinate line or dentate line is the imaginary line along which the anal valves are situated. Internal sphincter-It is the condensation of the circular muscle of the lower part of the rectum and anal canal. Anorectal ring-At the anorectal junction puborectalis, deep part of sphincter ani externus and sphincter ani internus colMiddle Part lectively forms the anorectal ring. Sphincter ani externus or external sphincter-It is a voluntary muscle along the columns are not present here. The mucosa Relations It is related in front with the perineal body which separates it from the membranous part of the urethra and the bulbs of the penis in the male and from the lower part of the vagina in the female. Behind it is in relation with the anococcygeal ligament which separates it from the tip of the coccyx. For the whole length it is surrounded by sphincter muscles the tone of which keeps it closed. Anatomical Anal canal It extends from the pectinate line to the anal verge (lower 15 mm + 8 mm). The pectinate line indicates the site of attachment of the anal membrane in fetus. The upper part is about 15 mm long, the middle part about 15 mm long and the lower part about 8 mm long. From above the pectinate line lymph vessels drain to the internal iliac nodes and vessels from below the pectinate line drain to the Treatment superficial inguinal nodes. In infants and children-The mother is advised digital reposition of the prolapse Nerve Supply after lubricating with lignocaine jelly. It causes aseptic both sympathetic (inferior hypogastric plexus) fibrosis and mucosa gets adhered to other and parasympathetic by pelvic splanchnic layers. Below the pectinate line by the somatic (inferior rectal branch of internal pudendal complete Prolapse nerve S2, S3, S4) nerves. Complete Prolapse or Procidentia the prolapse consists of the entire thickness of the rectal wall. A sheet of Ivalon sponge (polyvinyl alcohol) sponge is then sutured to the presacral fascia and periosteum of the sacrum. Many workers believe that prolapse of the ene) mesh can be kept behind the recrectum starts as an intussusception. This is sutured in the middle to the Clinical Features presacral fascia with 3 or 4 interrupted 2-0 prolene sutures. Its aim is Treatment to reinforce the internal sphincter with a stainless steel wire at the same time narA number of operations have been designed rowing the anal opening. A steel wire or a thick silk suture is the more commonly practiced procedures are: applied all around the anus after reducing Abdominal Procedures the prolapse. Exposure to food additives, alcohol, lonizing radiation, bile acids promotes development of carcinoma. Genetic Factors proctocolectomy with ileal reservoir and Intermediate nodes along the ileocolic, ileoanal anastomosis. Chapter 35 Rectum and Anal Canal and later on 1 or 2 doses may be given 6 hours and 16 hours in the postoperative period. Colonoscopy-If the main symptom is bleeding or anemia, colonoscopy is the is detected. Treatment of polyp as well as laser Dukes clinical Staging therapy is possible during colonoscopy. Prognosis as Per Dukes Staging the Ba-enema gives good anatomical and topographical information, which not Stage 5-year survival only diagnoses a polyp or carcinoma but Stage A 80% demonstrates the site and configuration of Stage B 60% the lesion, thereby helping the planning of Stage C 30% operation. Antibiotic Prophylaxis If the history suggests that the problem Injection Cefuroxime 1. Additional risk factors are obesity, varicose veins and a previous history of thrombosis or embolism. Carcinoma of mid transverse colon - transverse colectomy ligating only the middle colic artery followed by colocolic anastomosis between ascending and descending colon. Carcinoma hepatic flexure or right transverse colon-extended right hemicolectomy is done. Almost the whole area supplied by the right branch of middle colic artery is excised. Carcinoma left colon-Treatment of choice is left hemicolectomy which involves removal of left one-third of transverse colon, splenic flexure, whole of descending colon and upper part of pelvic colon followed by end to end anastomosis between transverse and pelvic colon. Carcinoma pelvic colon-Wedge resection of the pelvic colon along with the growth followed by pelvirectal anastomosis. Carcinoma upper 1/3rd of rectum- the operation of choice is high anterior 225 Section 8 resection which includes removal of growth along with the nodes followed by colorectal anastomosis. Carcinoma lower 1/3rd of rectum- this refers to growth within 7cm from the anal verge. Wide area of perineal skin with part of ischiorectal fossa, muscles and peritoneum of pelvic floor. This is followed by permanent end colostomy done by bringing the sigmoid colon outside in the left iliac fossa. Carcinoma of middle 1/3rd of rectum-This refers to growth between 7 to 11 cm from the anal verge. Low fistulae Palliative Surgery for Nonresectable is a defective fusion, it gives rise to various Growths anorectal malformations. This may extend to the vestibule (Rectovestibular or shotgun perineum) types the anomalies may be divided into two broad groups viz. High or Rectal-The rectum ends above the pelvic floor that is supralevator anomaly. Low or anal-The gut has developed to a point below the pelvic floor, that is, infralevator anomaly. The sites of communications varies accordingly whether the defect is high or low and also varies whether the baby is male or female (Table 35. When the growth is slow growing, this operation In the fifth week of intrauterine life, there gives good palliation. When the growth is widely fixed to the bladder and posteriorly post allantoic gut gives rise to rectum and upper 2cm of anal posterior abdominal wall. Onexaminationlowanomalies like anal stenosis, microscopic anus and covered anus (normally located anus but covered by a thin layer of skin) should be easily diagnosed by close inspection, if necessary with a magnifying glass. In high anomalies the patient is mostly a male infant with acute intestinal obstruction. In the majority of cases, meconium is passed per urethra or there is a speck of meconium at the tip of the penis. In about 10 percent cases, there is a blind agenesis, no gas or meconium comes out of urethra. Invertogram-This is the straight X-ray of the child inverted to know whether the Chapter 35 Rectum and Anal Canal there is a hemangiomatous condition of this artery, called an arterial pile which may produce severe bleeding at operation. Idiopathic or primary-The predisposing has to wait till the rectal gas appears and factors are pregnancy, prolonged standsometimes it takes about a day or more for ing, etc. High anomaly-More difficult to treat than low anomalies, usually this is Classification. Preliminary transverse colostomy to Depending upon the location of hemorrhoids relieve intestinal obstruction. External hemorrhoids-Situated below neal pull through operation is done the pectinate line. In between these three major piles there Piles is derived from Pila (Latin) which may be smaller secondary piles. Hemorrhoid is a condition, where there is varicosity in the veins of anorec- Arterial Pile tal region which subsequently leads to A branch of superior rectal artery may enter hemorrhage. Proctoscopy-As the proctoscope is removed, the piles prolapses into the lumen of proctoscope as cherry red masses. Strangulation-This occurs when the prolapsed piles are gripped by the internal sphincter and get irreducible. Fibrosis-After 2 to 3 weeks, thrombosed piles become fibrosed, often with spontaneous cure. Sitz bath-The patient is asked to sit in warm water with the anal region and buttocks dipped in water for about 20 minutes, 2 to 3 times a day. Antibiotics, laxatives (stool softener) and antiinflammatory drugs are beneficial. Injection of Sclerosant-The agent commonly used is 5 percent phenol in almond oil. The idea is to cause thrombosis of the piles as well as the vessels draining them, and to create fibrosis in the submucous coat so that the lax mucous membrane retracts. The procedure is painless but there will be continuous mucus discharge for 3 to 4 weeks. Hemorrhoidectomy-This is the ligation and excision of the pile mass under spinal or general anesthesia. The term fistula in ano is loosely applied to both fistula and sinuses in relation to the anal canal. The great majority result as a sequelae causative Organisms to a perianal abscess, which has either been the usual organism is E. Perianal abscess-It is the most common anorectal abscess and lies immediately Classification beneath the perianal skin.

Syndromes

• Hematoma (collection of blood under the skin after injury)
• Lung diseases
• Bleeding
• Several days to a week before the procedure, you may be asked to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), warfarin (Coumadin), naproxen (Aleve, Naprosyn), and other drugs like these.
• Decreased alertness, including coma
• Breathing problems
• Emotional or anxiety disorder
• Breathing tube
• Which urea cycle abnormality they have

It is therefore not surprising that pharmacologic blockade of l-type calcium channels by dihydropyridine drugs like nifedipine can substantially reduce the contractility of colonic smooth muscle man health problems order confido 60 caps free shipping. Release of calcium from intracellular stores mens health rat race purchase generic confido, which is triggered by excitatory neurotransmitters mens health books generic confido 60caps visa, may also play a role in muscle contraction androgen binding protein hormone order confido in india. The submucosal plexus comprises at least 2 networks: Meissner plexus man health report garcinia test discount generic confido canada, which lies closer to the mucosa prostate oncology 1 order confido 60 caps without a prescription, and Schabadasch plexus, which lies adjacent to the circular muscle; some authors have identified an additional intermediate plexus. Internodal strands that contain hundreds of axons run within and between the different plexuses. Finer nerve trunks innervate the various target tissues of the intestinal wall, including the longitudinal muscle layer, circular muscle, muscularis mucosae, mucosal crypts, and mucosal epithelium. Within the ganglia of each plexus, different functional classes of enteric nerve cell bodies are intermingled, and differences in the proportions of cell types between the plexuses have been observed. Parasympathetic efferent pathways (filled cell bodies) arise from the dorsal motor nucleus (of the vagus nerve) in the brainstem and pass through the vagus nerve and prevertebral sympathetic ganglia, through the lumbar colonic nerves to the proximal colon. Parasympathetic pathways also extend from nuclei in the sacral spinal cord and run through the pelvic nerves to either synapse in the pelvic plexus ganglia or run directly into the bowel wall. Sympathetic pathways (open cell bodies) consist of preganglionic neurons in the thoracic spinal cord that synapse with sympathetic postganglionic neurons either in the inferior mesenteric plexus or pelvic plexus. Enteric nerve cell bodies in the colon receive input from both parasympathetic and sympathetic pathways. Viscerofugal enteric neurons project out of the bowel to the prevertebral ganglia. Afferent pathways consist of vagal afferent neurons from the proximal colon with cell bodies in the nodose ganglia. The striated muscles of the pelvic floor (including the external anal sphincter) are supplied by motor neurons with cell bodies in the spinal cord and axons that run in the pudendal nerves. Triangles represent transmitter release sites; combs represent sensory transduction sites. Primary Afferent Neurons Much of the motor and secretory activity of the intestine can be conceptualized as a series of reflexes evoked by mechanical or chemical stimuli. These neurons are located in both myenteric and submucosal plexuses and characteristically have several long axonal processes. These mucosal stimuli probably work at least in part by activating specialized enteroendocrine cells Auerbach myenteric plexus and the submucosal plexuses (Meissner and Schabadasch plexuses) are shown, along with some of their major classes of enteric neurons. Auerbach myenteric plexus Longitudinal muscle Oral Sensory neuron ending Motor (output) neuron ending Aboral Interneuron axon projection Motor Neurons Enteric motor neurons typically have smaller cell bodies than afferent neurons, with a few short dendrites and a single long axon. Separate populations of motor neurons innervate the circular and longitudinal muscle layers. Typically, axons of excitatory motor neurons project either directly to the smooth muscle close to their cell bodies or orad for up to 10 mm. Inhibitory motor neurons are typically slightly larger than excitatory motor neurons and also have short dendrites and a single axon, but unlike excitatory motor neurons, they project aborally to the smooth muscle layer for distances of 1 to 15 mm in the human colon. Interstitial cells probably mediate a large component of the electrical effects on smooth muscle of neurotransmitters released by enteric motor neurons. Inhibitory motor neurons are usually tonically active, modulating the ongoing contractile activity of the colonic circular smooth muscle. Inhibitory motor neurons are particularly important in relaxing sphincteric muscles in the ileocecal junction and the internal anal sphincter. Typical polarity of excitatory and inhibitory motor neurons to human colonic smooth muscle is illustrated in. From the new position of the bolus, another set of polarized reflexes is triggered, and peristaltic propulsion results. The ascending excitatory reflex and the descending inhibitory reflex are sometimes called the "law of the intestine. Ascending cholinergic interneurons in the human colon have axons that project up to 40 mm orad and extend the spread of ascending excitatory reflex pathways. In addition, several classes of descending interneurons are present in the human colon, with axons that project 70 mm or further aborally. Some of these interneurons are involved in spreading descending inhibition along the colon, but others are likely to be involved in the propagation of migratory contractions. In addition to the sensory neurons, interneurons, and motor neurons, viscerofugal nerve cells project to the sympathetic prevertebral ganglia, vasomotor neurons innervate blood vessels, and secretomotor neurons stimulate secretion from the colonic epithelium. Sympathetic Innervation the major sympathetic innervation of the proximal colon arises from the inferior mesenteric ganglion and projects through the lumbar colonic nerves to the ascending and transverse colon A smaller number of sympathetic neurons in the celiac and superior mesenteric ganglia, in the paravertebral chain ganglia, and in the pelvic plexus ganglia (inferior hypogastric ganglia) also project to the colon These neurons receive a powerful cholinergic drive from preganglionic nerve cell bodies in the intermediolateral column of the thoracolumbar spinal cord (principally segments L2-L5). Sympathetic efferent neurons also receive input from the enteric viscerofugal neurons and from extrinsic spinal sensory neurons with cell bodies in the dorsal root ganglia, forming several reflex loops with the distal bowel. Retrograde tracing with DiI shows the polarized projections of motor neurons to human colon longitudinal muscle (A and D). These polarized projections are typical of inhibitory and excitatory motor neurons to both longitudinal and circular muscle layers. Sympathetic nerve fibers from prevertebral ganglia cause vasoconstriction of the mucosal and submucosal blood vessels. Another target for sympathetic axons is the circuitry of the submucosal plexus (largely Meissner plexus) involved in controlling epithelial secretion. Hence, these pathways inhibit colonic motor activity, reduce blood flow, and inhibit secretion to limit water loss from the body during times of sympathetic activation. In addition, some sympathetic axons innervate the smooth muscle directly, particularly the ileocecal junction and internal anal sphincter, where they cause contraction; these effects are also consistent with reducing enteric motor activity during sympathetic arousal. Parasympathetic axons project to the enteric ganglia in the colon, where they make excitatory cholinergic synapses onto enteric nerve cell bodies. Sacral parasympathetic pathways play an important role in increasing the propulsive activity of the distal colon before defecation. They are probably also involved in triggering the sequences of propagating complexes that start in the transverse and ascending colon up to an hour before defecation. Vagal afferent neurons with nerve cell bodies located in the nodose ganglia project to the proximal colon and run with the vagal efferent parasympathetic pathways. Currently, their exact role in reflex control and sensation in the colon is not clear, but they are unlikely to be involved in the transmission of pain. Lumbar spinal afferents project along the lumbar splanchnic nerves, through the prevertebral inferior mesenteric ganglion, and through the lumbar colonic nerves to the colon, where they terminate in sensory endings in the mesentery, muscular layers, and mucosa throughout the entire colon and rectum. In addition, a population of spinal afferents with cell bodies in the sacral dorsal root ganglia projects along the pelvic nerves to the colon and traverses the pelvic Parasympathetic Innervation the colon receives parasympathetic innervation from both the vagus nerve and pathways in the sacral spinal cord. Branches of the vagus nerve reach the prevertebral ganglia (superior hypogastric plexus) and then run with sympathetic axons to the cecum and the ascending and transverse colon. The distal colon is largely supplied by sacral parasympathetic axons via the pelvic nerves (pelvic splanchnic nerves). Some of these cholinergic spinal efferent neurons synapse first onto nerve cell bodies in the pelvic plexus (inferior hypogastric plexus), and others project directly to the colon. Evidence indicates that many sacral/pelvic spinal afferent neurons comprise a functionally distinct population from the lumbar spinal afferents. Sacral afferents include many mechanoreceptors with low thresholds and wide dynamic ranges; these mechanoreceptors are probably responsible for graded sensations of rectal filling and activation of defecatory reflexes. These sensory neurons and some higher-threshold sacral afferents are responsible for generating pain sensations from all regions of the colon and rectum. They respond to gross distention of the bowel wall, traction on the mesenteric membranes, powerful colonic contractions, or chemical stimulation of the mucosa by bile acids, high osmolarity, and other stimuli. It is well established that the sensitivity of many spinal afferents is greatly increased by inflammation in the colon wall. In addition to their role in sensation, spinal afferents also have axon branches (collaterals) in enteric ganglia and prevertebral sympathetic ganglia and on mucosal blood vessels, where they play a role in generating peripheral reflex responses to noxious stimuli. In summary, sacral afferent and efferent (parasympathetic) pathways run in parallel and connect the distal bowel with neural circuitry in the sacral spinal cord via pelvic and rectal nerves. The important role of these pathways in both rectal sensation and generating the enhanced motility required for defecation is clearly demonstrated by the effects of nerve lesions at several levels. Thus, severing of peripheral nerves and distal spinal cord injury can lead to loss of rectal sensation and to severely impaired defecatory ability. These receptors are important for detecting rectal filling, triggering sensations of urgency, facilitating rectal accommodation, and differentiating the composition (stool or gas) of rectal content (see Chapter 129). The mechanical properties of this body comprise a "contractile element" that generates tone or contraction, a "series elastic element," and a "parallel element" that corresponds to connective tissue. Contractions result from the entry of Ca2+ ions via voltage-dependent channels (l-type Ca2+ channels), often in the form of smooth muscle action potentials. These propagate modestly across the gap junctions between muscle cells and lead to relatively localized nonpropagating areas of contraction. The mechanical state of intestinal muscle is described by the plot of changes in stress (the force applied to the muscle) against strain (the response of the muscle to the applied force); the slope is referred to as compliance. When muscle is activated by either excitatory enteric neuronal input or depolarizing myogenic mechanisms, it tends to generate tension, shorten, or both. This means that the stress/strain relationship becomes steeper, and compliance is decreased. However, passive viscoelastic properties of the intestine make this analysis complex. A muscle that is very distensible, because of powerful inhibitory motor neuron activity, is said to have a high compliance. During muscular excitation, the resistance of the bowel wall to stretch increases and is said to have a low compliance for the time it is activated. If bowel contents are fluid and there is no downstream resistance to impede flow, activated smooth muscle will rapidly shorten. The contents will then be propelled, with a minimal increase in intraluminal pressure. From this brief consideration, it should be clear that deducing the relationships of intraluminal pressure, propulsion of content, and excitation of smooth muscle from any of the recording techniques listed earlier (see "Methods to Record Colonic Motility") is more complex than is sometimes appreciated. The narrowed distal rectum, or anorectal junction, is formed by the longitudinal muscle coat of the rectum, which is joined by the sling fibers of the puborectalis muscle, attachments of the levator ani muscles, and proximal margins of the internal and external anal sphincters. The puborectalis and levator ani muscles have important roles in maintaining continence and in defecation. These striated muscles form part of the pelvic floor and are in a state of constant tone that serves to pull the rectum anteriorly and elevate it, thereby reducing the anorectal angle; this mechanical effect tends to prevent entry of stool into the upper anal canal. The internal anal sphincter is a thickened band of smooth muscle with relatively high spontaneous tone that is in continuity with the circular smooth muscle of the rectum. By contrast, the external anal sphincter is a striated muscle and is located distal to but partly overlying the internal sphincter. The external sphincter also has a high resting tone, but unlike that of its internal counterpart, its tone can be influenced by voluntary efforts to help maintain continence. As expected, the sources of innervation of the internal and external anal sphincters are different. The internal sphincter directly receives a powerful inhibitory innervation from intrinsic enteric inhibitory motor neurons and also extrinsic input from lumbar sympathetic and sacral parasympathetic nerves that project via the pelvic plexus ganglia. The external anal sphincter and other pelvic floor muscles are innervated through the pudendal nerve (S3-S4) by motor neurons with cell bodies in the spinal cord. The external sphincter and surrounding connective tissue also receive sensory innervation via the pudendal nerves. A subset of the data is displayed in (A), in which data from every 10th sensor are shown. Note that the nonpropagating activity shown in (A) actually consists of a series of retrograde-propagating contractions (red arrows) that travel a short distance along the colon. It is also apparent that even with highresolution recording, there remain some episodes of nonpropagating activity (blue hatched circle). These motor patterns propagate in an anal direction and represent the manometric equivalents of colonic mass movement. Propagating Motor Patterns When enteric excitatory motor neurons are strongly activated, powerful lumen-occlusive contractions often result. These can last longer than slow waves and can propagate substantial distances along the colon. Low-amplitude propagating sequences are also recorded in the colon and can be further classified as antegrade (aboral) or retrograde (orad). Based on low-resolution manometric recordings, it was reported that in the healthy colon, antegrade propagating sequences are at least 3-fold more abundant than retrograde propagating sequences. Short-extent motor patterns that propagate in a retrograde direction are the predominant colonic activity in the descending and sigmoid colon. Data are displayed as (A) a low-resolution recording (10-cm spacing) and (B) high-resolution recording (1-cm spacing). In (A), a series of apparent anally propagating motor patterns can be seen (antegrade propagating sequences [blue arrows]). However, when the complete data set is viewed, these propagating events can be seen to move in an oral direction (retrograde propagating sequences [red arrows]). A catheter with sensors spaced at 10-cm intervals does not provide sufficient resolution to record some of the propagating events that exist in the colon. Rectal Motor Complexes Periodic contractile activity predominates in the sigmoid colon and rectum. Short-extent retrograde propagating pressure waves (previously mislabeled as "nonpropagating pressure waves") make up a much higher proportion of activity in the distal colon. Thus, motor activity in the distal colon may function to retard forward flow (see "Relationships Between Colonic Motor Patterns and Flow"). In the fasting state, cecal filling is slow and erratic, and chyme is retained in the distal ileum for prolonged periods. A specialized band of muscle forms a low-pressure tonic sphincter21 and prominent 6 cpm phasic contractions are likely to contribute to the resistance of the ileocecal junction. Phasic and tonic activity are inhibited during episodes of flow from the terminal ileum or distention of the ileum. A compressed 90-minute section of tracing is shown in (A) at low-resolution recording (10-cm spacing).

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