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When samples are submitted medicine lyrics 4mg zofran amex, without mix-up medications 4 times a day cheap zofran 4mg visa, the data is sometimes collected improperly medications ending in zole discount 4mg zofran amex. For example symptoms of high blood pressure discount zofran 8mg, reversing electrodes on an electrocardiogram may yield spurious and misleading results. Sometimes data is purposefully fabricated and otherwise corrupted to suit the personal agendas of dishonest scientists. When data errors occur, regardless of reason, it is important 42,43 to retract the publications. To preserve scientific integrity, it is sometimes necessary to discover the identity of deidentified records. In some cases, deidentification stops the data analyst from helping individuals whose confidentiality is being protected. Imagine you are conducting an analysis on a collection of deidentified data and you find patients with a genetic marker for a disease that is curable, if treated at an early stage; or you find a new biomarker that determines which patients would benefit from surgery and which patients would not. You would be compelled to contact the subjects in the database to give them information that could potentially save their lives. An irreversibly deidentified data set precludes any intervention with subjects—nobody knows their identities. Deidentified records can, under strictly controlled circumstances, be reidentified. Reidentification is typically achieved by entrusting a third party with a confidential list that maps individuals to their deidentified records. Obviously, reidentification can only occur if the Big Data resource keeps a link connecting the identifiers of their data records to the identifiers of the corresponding deidentified record. The act of assigning a public name to the deidentified record must always involve strict oversight. The data manager must have in place a protocol that describes the process whereby approval for reidentification is obtained. Reidentification provides an opportunity whereby confidentiality can be breached and human subjects can be harmed. Consequently, stewarding the reidentification process is one of the most serious responsibilities of Big Data managers. Andre Gide Identification issues are often ignored by Big Data managers who are accustomed to working on small data projects. It is worthwhile to repeat the most important ideas described in this chapter, many of which are counterintuitive and strange to those whose lives are spent outside the confusing realm of Big Data. All Big Data resources can be imagined as an identifier system for data objects and data-related events. The data in a big data resource can be imagined as character sequences that are attached to identifiers. A data object is a collection of data that contains self-describing information, and one or more data values. Deidentification is the process of stripping information from a data record that might link the record to the public name of the record’s subject. Deidentification should not be confused with the act of stripping a record of an identifier. A deidentified record must have an associated identifier, just as an identified data record must have an identifier. Where there is no identification, there can be no deidentification and no reidentification. Reidentification is the assignment of the public name associated with a data record to the deidentified record. Reidentification is sometimes necessary to verify the contents of a record or to provide information that is necessary for the well-being of the subject of a deidentified data record. Data scrubbers remove unwanted information from a data record, including information of a personal nature, and any information that is not directly related to the purpose of the data record. Data deidentification is a process whereby links to the public name of the subject of the record are removed (see Glossary items, Data cleaning, Data scrubbing). The fastest known method of data scrubbing involves preparing a list of approved words and phrases that can be retained in data records and removing every word or phrase that is not found in the approved list. When a financial analyst learns that the price of a stock has suddenly dropped, he cannot help but wonder if the drop of a single stock reflects conditions in other stocks in the same industry. If so, the analyst may check to ensure that other industries are following a downward trend. He may wonder whether the downward trend represents a shift in the national or global economies. In every case, the analyst is asking a variation on a single question: “How does this thing relate to that thingfi When data is simply stored in a database, without any general principles of organization, it is impossible to discover the relationships among the data objects. To be useful, the information in a Big Data resource must be divided into classes of data. Each data object within a class shares a set of properties chosen to enhance our ability to relate one piece of data with another. Ontologies are formal systems that assign data objects to classes and that relate classes to other classes. When the data within a Big Data resource is classified within an ontology, data analysts can determine whether observations on a single object will apply to other objects in 35 36 3. Similarly, data analysts can begin to ask whether observations that hold true for a class of objects will relate to other classes of objects. Basically, ontologies help scientists fulfill one of their most important tasks—determining how things relate to other things. This chapter will describe how ontologies are constructed and how they are used for scientific discovery in Big Data resources. The discussion will begin with a discussion of the simplest form of ontology—classification. When we walk down the street, we see images of concrete and asphalt and millions of blades of grass, birds, dogs, other persons, and so on. The mathematician and 44 philosopher Karl Pearson (1857–1936) has likened the human mind to a “sorting machine. The green stuff on the ground is classified as “grass,” and the grass is subclassified under some larger grouping, such as “plants. Every culture has some particular way to impose a uniform way of perceiving the environment. In English-speaking cultures, the term “hat” denotes a universally recognized object. Hats may be composed of many different types of materials and they may vary greatly in size, weight, and shape. Nonetheless, we can almost always identify a hat when we see one, and we can distinguish a hat from all other types of objects. An object is not classified as a hat simply because it shares a few structural similarities with other hats. A hat is classified as a hat because it has a class relationship; all hats are items of clothing that fit over the head. Through observation, he knew that a large group of animals was distinguished by a gestational period in which a developing embryo is nourished by a placenta, and the offspring are delivered into the world as formed but small versions of the adult animals. Aristotle knew that these features, characteristic of mammals, were absent in all other types of animals. Aristotle was ridiculed by his contemporaries for whom it was obvious that dolphins were a type of fish. Unlike Aristotle, they based their classification on similarities, not on relationships. They saw that dolphins looked like fish and dolphins swam in the ocean like fish, and this was all the proof they needed to conclude that dolphins were indeed fish. For about 2000 years following the death of Aristotle, biologists persisted in their belief that dolphins were a type of fish. Aristotle discovered and taught the most important principle of classification: that classes are built on relationships among class members, not by 45 counting similarities.

Organisational aspects Authors: Rossella Di Bidino symptoms quiz purchase zofran online pills, Marjetka Jelenc symptoms jet lag purchase 8mg zofran with visa, Matteo Ruggeri 3 treatment vitiligo 8 mg zofran amex. Result cards of other domains in this project (from published data medications may be administered in which of the following ways buy zofran 8mg free shipping, preferably) In addition to the basic search performed for the project, a domain-specific search for organisational studies was performed. Transferability of data was assessed taking into account how differences among national health systems could impact the information available and provided. Pazopanib treatment11 should only be initiated by a physician experienced in the administration of anti-cancer agents. When the decision to treat a patient with pazopanib is taken, treatment is continued until disease progression or toxicity, patient’s decision or death. No additional special training is required for oncologists or urologists with experience in managing patients with renal cancer (G0003). Monitoring at an organisational level would benefit from a specific database of clinical monitoring results in order to evaluate the efficacy and effectiveness of pazopanib treatment and assess, as early as possible, the presence of related adverse events. With this scope and purpose, it is reasonable to take a pragmatic approach and focus on ‘standard care’ as the reference for comparison. Standard care is the currently accepted standard clinical care, which is most routinely used; the one that the new therapy is intended to replace fully or partially. Sorafenib, which is58 recommended as second-line treatment (after prior cytokine therapy) and defined in the scope of this project, is a tyrosine kinase inhibitor similar to sunitinib. In addition, two patients’ forums also revealed no significant patientrelated social issues to be considered for this rapid assessment. Discussion Considering the Social Domain ‘not relevant’ to this project does not mean that the use of pazopanib has no influence on patients’ social lives, nor does it mean that the social consequences for patients are unimportant. What it means, however, is that the difference in social consequences is not significant when sunitinib is replaced with pazopanib. While pazopanib can be11 administered for a period of 6 weeks, sunitinib users are often unable to tolerate it after 4 weeks of administration. They require a 2-week rest period and possibly a subsequent dose adjustment to maintain tolerability. The reported more favourable toxicity profile of pazopanib might help pazopanib users to have better social functioning. Pazopanib’s oral mode of uptake may have a social advantage due to its ease of use. Pazopanib users face no complications of injection and do not have to go regularly to the clinic or hospital for injection or infusion. This is not unexpected given the fact that even for effectiveness and safety more evidence is needed. We have considered not only pazopanib but all pharmaceuticals that are subject to the same law because the legal consequences described in the results are the same for all of them. National price control and reimbursement schemes can affect the use of new pharmaceutical products. We will deal with price control regulation, but national reimbursement systems need to be dealt with nationally in each case as they vary. I0015 What legal consequences does market authorisation through a centralised procedure entailfi Summary of main results Law on pharmaceuticals in the European Union is a highly regulated and harmonised field. The centralised procedure is compulsory for authorising biotechnology-derived and hightechnology medicines. They are required to give accurate and necessary information to the patient in a clearly legible and comprehensible manner. Member states can organise, manage and finance their health services nationally; including insurance schemes for medication, but these measures should be transparent. Price control and66 reimbursement schemes can limit access to medication in practise; however, an analysis of all the national systems was not performed. The content of the pilot report should thus be relevant beyond the national context. While there is no established methodology for a synthesis of relative effectiveness, the pilot participants had to create this and test it with the topic of pazopanib. Finally, the report was also discussed with the marketing authorisation holder at a face-to-face meeting in March 2012. The authors found the four first most relevant, but the last four also gained some support (see Figure 2). Pilot authors noticed that the generic questions in the model were not always sufficient or clearly formulated. Some important research questions could not be fitted under any of the generic questions, and sometimes the generic question allowed varied interpretations. The structure of eight separate domains was perceived as useful for dividing the interests and work across agencies and individuals. The parallel work of the domains was however considered to increase the risk of duplication of work as a natural sequence of assessment; the approach of starting from background information and then moving to safety and effectiveness was missing. We tried to reduce the overlap between domains by having regular e-meetings and within domains by email discussions. It was noted that not all of the apparent duplication is unnecessary; sometimes similar issues need to be considered from slightly different points of view in different domains. This was a deliberate choice while it was planned that the relevant outcomes would be discussed and determined for each domain separately. In order to achieve European relevance all treatment alternatives to pazopanib should be included as comparators. Multiple comparators require multiple analyses, however, and the number of analyses may be further increased by multiple indications of the pharmaceutical under assessment. Inclusion of interferon and interleukin was questioned as they were considered old medicines, but they were kept in the scope to ensure applicability of the results. The possibility of engaging the marketing authorisation holder in the scoping process could also be explored. Although the scope was documented in detail, readers considered that a justification for the choice of comparators and outcomes would have been helpful. In the Legal domain it was considered impossible to examine all the regulations on pazopanib from each Member State. In addition, the authors of the Legal Domain chose to present legal information that is generalisable for all pharmaceuticals that are subject to the same market access regulation as pazopanib instead of for pazopanib specifically. Authors also commented that it was sometimes difficult to identify particular methods for a single question, and it was frustrating and time consuming to repeat the methods and references for each card. A common complaint was that browsing was cumbersome: it was difficult to get an overall picture of the whole from the separate cards. Methodological guidelines the guidelines were used by the relevant domain teams (mainly effectiveness and safety) to some extent. They were either too long or too complicated, and did not always offer a solution to the problem described. Each of the 27 authors used a mean of 9 days for the assessment; the amount of input varied between 4 and 30 days. Author team members had discussions mainly through email and raised discussion items, such as reporting of evidence tables, for e-meetings. The authors were mostly content with the communication in their own domain team but felt that there was too little information exchange across the domains. Sometimes the different working practices, approaches or perceptions were considered to be a struggle. The English language of the report is not a concern for most of the agencies who responded (20 out of 25 responses). Many respondents indicated that it was difficult to assess the validity of the results of the last four domains. Some 87% thought it at least likely that the credibility of the report is increased through broad participation (Figure 5). In addition, 87% of respondents thought performing joint assessments was at least likely to reduce duplication of work in Europe.

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There is typical fever medications 5113 buy generic zofran from india, night sweats medicine 5e cheap 4mg zofran, arthralgias medications errors discount zofran line, anorexia medications valium purchase zofran discount, weight loss, intimal proliferation with infiltration of mononuclear and syncopal episodes. Complications are common between 3rd and 4th There is pain over involved arteries and pulses are weeks of illness. Vertebral Visual changes, dizziness, diplopia, dysarthria, dysphagia Prognosis Coeliac axis Abdominal pain, nausea, vomiting Three per cent develop fatal complications. Prognosis Superior mesenteric Abdominal pain, nausea, vomiting for uneventful recovery is excellent. Iliac Leg claudication Pulmonary Atypical chest pain, dyspnoea Coronary Chest pain–myocardial infarction Behcet’s Syndrom e It is a multisystem disorder presenting with recurrent oral or genital ulcers as well as ocular involvement. Diagnosis the diagnosis of Takayasu’s arteritis should be suspected Clinical Features in a young woman who develops a decrease or absence of peripheral pulse, discrepancies in blood pressure and • Patients have recurrent aphthous ulcers which are arterial bruits. Pathergy test: this is an abnormal inflammatory Genital ulcer does not affect glanspenis and urethra. Diagnostic Criteria • Involvement of eyes may be in the form of posterior In addition to recurrent oral ulcers if the patient has any uveitis, iritis, retinal vessel occlusion and optic two of the following criteria, the diagnosis is confirmed. Chapter 11 Oncology 724 Manual of Practical Medicine Selected Tum our Suppressor Genes Responsible Basic Concepts for Fam ilial Cancer Syndrom es Oncology is the study of tumours. Neoplasia means abnormal new growth, which may be benign or Gene Chromosome Syndrome malignant. Over Chrom osom al Translocations can Cause Cancer activation of proto-oncogenes by point mutation, amplification or dysregulation results in the formation Translocation Genes Malignancy of oncogenes. Cell Biology of Cancer Tum our Suppressor Genes and Cancer is most common in tissues with rapid turnover Fam ilial Cancers especially those exposed to environmental carcinogens and whose proliferation is regulated by hormones. Most of the genes responsible for the dominantly inheriTissues with rapid turnover: ted cancer syndromes are tumour suppressor genes. Evidences that mutations can cause cancer include: Tissues with no turnover: They persist throughout life • Malignant tumours are clonal nature. In cancer, cell growth is not regulated by external • Recurring sites of chromosome change are observed signals. Oncology 725 Oncogenes and Associated Hum an Tum ours Liquid Tum ours Leukaemias and lymphomas comprise the liquid group. Category Proto-oncogene Associated human tumours the treatment of liquid tumour is usually chemotherapy Growth factors or radiation or both. Ethanol Liver, oesophageal and head and neck cancers Histological distinction between benign and malignant H. It is defined as low, moderate, or Polycyclic hydrocarbon Lung and skin cancer Schistosomiasis Bladder cancer high depending on the amount of tissues that loses its Ultraviolet radiations Skin cancer normal appearance. It is useful for assessing the Tobacco Cancer of upper aerodigestive tract prognosis of many tumours, but not useful for treatment and bladder plans. Vinyl chloride Angiosarcoma liver 726 Manual of Practical Medicine • Mucosal damage from physical agents like hot tea, Aetiology of Cancers chronic achalasia, radiation induced strictures. There are several other • Host susceptibility environmental factors that exert potent effects on gene. Burkitt’s lymphoma Exogenous sources of nitrate converting bacteria • Bacterially contaminated food Human T cell T cell lymphoma • H. Animal fat increases anaerobes in the gut microflora which converts normal bile acids into carcinogens. High Head and Neck Cancer animal fat increases cholesterol level which increases the risk for colon cancer. Dietary fibre does not alter the Includes tumours of oral cavity, nasopharynx, incidence of colorectal cancer. Pancreatic Cancer • Increasing frequency with age Bladder Cancer • > 50 yrs—40% risk • Cigarette smoking (risk persist for 10 years after • > 70 yrs—70% risk stopping smoking) • Obesity • Exposure to aniline dyes, drugs—phenacetin, • Long standing diabetes mellitus cyclophosphamide • Chronic pancreatitis • Radiation • Cigarette smoking. Corticosteroids, cannabinoids and metoclopramide also Skin Cancer improve the appetite. Various colours like black, brown, red, pink, • Primary and metastatic lesions of bone within a single nevus • Soft tissue involvement 2. Number more than 100 (normal—10-40 or nil in • Colicky pain can be due to visceral involvement 15% of individuals). Oesophageal Cancer Pruritus • Dysphagia for solid foods and later for semisolids • Drug reaction • Dysphagia denotes more than 60% of oesophageal • Cholestatic jaundice circumference involvement • Renal failure—uraemia • Odynophagia—pain on swallowing • Malignant disease—lymphoma, leukaemia • Retrosternal pain, pain radiating to back, etc. Breathlessness Gastric Cancer • Malignant pleural effusion, pericardial effusion Small superficial and surgically removable lesion is • Massive ascites usually asymptomatic. Hypertrophic Osteoarthropathy Colorectal Cancer It is an advanced stage of clubbing associated with • Unexplained iron deficiency anaemia leading to polyarthritis and periostitis involving the long bones, fatigue, palpitation, and at times angina most often seen in non-small cell lung cancer and • Occult blood in stools—positive or negative owing metastatic mediastinal nodes due to other cancers. Sm all Bowel Cancer Other M anifestations • Periumbilical pain made worse by eating. Oncology 731 Bladder Cancer Gastric Cancer • Gross haematuria • Double contrast radiographic examination • Irritative symptoms—increased frequency, dysuria, • Gastroscopy and biopsy urgency. Prostate Cancer Colorectal Cancer Symptoms of outlet obstruction • Fecal haemoccult test • Hesitancy • Sigmoidoscopy/colonoscopy • Diminished stream • Double contrast—air barium enema. Anal Cancer Testicular Cancer • Digital rectal examination • Painless testicular mass • Proctoscopy. Diagnosis Breast Cancer • Diagnostic mammography Tumour tissue biopsy is essential to confirm the • Fine needle aspiration diagnosis. The biopsy technique • Sestamibi imaging that involves cutting into the tumour carry with them • Excision biopsy the risk of facilitating spread of tumour. Oncology 733 Node Karnofsky Perform ance Index • Palpation Performance status Functional capability of the patients • Aspiration • Biopsy 100 Normal • Radiology. Prostate 1015 10-50 50-75 2 Com plications Perform ance Status Infections in Cancer Patients Various scales are used to assess the functional capability Infections in cancer patients increase morbidity and of the patient. Alterations in the immune system either as a and also the efficacy and toxicity of management. Fully result of the disease per se or as a result of chemo/ active patients are likely to fare well and the bed-ridden radiotherapy predisposes the individual to intercurrent patients are likely to fare worse. Chronic disseminated candidiasis (Amphotericin B Clostridium difficile induced diarrhoeas and Fluconazole) Infections and Cancer Cancer Underlying immune abnormality Organisms causing infection Multiple myeloma Hypogammaglobulinaemia Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis Chronic lymphocytic leukaemia Hypogammaglobulinaemia S. Progressive multifocal leucoencephalopathy Infections of neutropaenic patients Granulocyte transfusion is reserved for patients Cardiovascular Infections unresponsive to antibiotics. Intravenous catheters Bacterial endocarditis Vaccination of Cancer Patients Valve damage They respond less well to vaccines than normal host. Nonbacterial thrombotic endocarditis Vaccination should not be given concurrently with cytotoxic chemotherapy. Thrombophlebitis Unknown Lung cancer Pancreatic cancer Ectopic Acrom egaly Gastrointestinal cancer Breast cancer Genitourinary cancer Clinical Features Ovarian cancer Prostate cancer Increasing size of hands and feet Lymphoma Facial disfigurement, hypertension, diabetes mellitus Muscle weakness, amenorrhoea-galactorrhoea, impotence. M anagem ent M anagem ent Erythrocytosis Treat the cancer Treat the underlying cancer Periodic phlebotomy Octreotide 100-250 µgm every 8 hrs. Gynaecom astia Thrombocytosis > 400,000/µL Treat the underlying cancer this indicates advanced stage cancer and poor It resolves in 75% of cases. Nonislet Cell Tum our Hypoglycaem ia Eosinophilia > 5000/µL Dyspnoea due to pulmonary infiltrates Clinical Features Oral/inhaled glucocorticoids Headache, fatigue, confusion, seizures Treat the underlying cancer. Clinical Features • Visual disturbance Investigations • Ataxia, stupor X-ray of spine • Dizziness Erosion of pedicles (winking owl sign) • Coma, death. Seizures M anagem ent Causes High dose dexamethasone—8 mg 6th hourly Primary/metastatic tumour Radiation therapy Metabolic disturbance Surgery and chemotherapy. Breast cancer 742 Manual of Practical Medicine Leukaemias and lymphoma Airway Obstruction Radiation Drug induced. Chronic effusive pericarditis with thickened M anagem ent pericardium (up to 20 years after irradiation). Obstruction proximal to larynx—tracheostomy is life saving Clinical Features Distal obstructions—laser treatment, photodynamic therapy and stenting Dyspnoea, cough, chest pain Emergency radiotherapy and glucocorticoids may Distended jugular veins open the airway. Hepatomegaly Peripheral oedema Paradoxical pulse and pulsus alternans Haem optysis Friction rub and cardiac tamponade. Causes M anagem ent Twenty per cent of patients with lung cancer Metastasis from breast, colon, kidney, melanoma and Cardiac tamponade warrants immediate pericarcinoid tumours. M alignant Pleural Effusion Caused by invasion by tumour or obstruction to Intestinal Obstruction lymphatic drainage. Causes M anagem ent Colorectal and ovarian cancers Drainage of pleural fluid followed by instillation of Metastatic lesions of lung and breast cancers and sclerosing agents melanoma.

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Peripheral leukocytobe treated with sodium restriction and oral diuretics sis symptoms 6dpo zofran 8 mg low cost, acidosis treatment 9mm kidney stones buy zofran 4 mg cheap, and worsening renal function are other rather than with serial paracentesis treatment 7 february generic zofran 4 mg visa. Liver transplantaindications to 9 medications that cause fatigue purchase zofran visa perform abdominal paracentesis in pation should be considered in patients with cirrhosis and tients with ascites. Initial tests on ascitic fiuid include cell count and peritonitis is treated with tetracycline. The management of ascites in Intestinal and Liver Disease: Pathophysiology, Diagnosis, and Treatcirrhosis: Report on Consensus Conference of the International Asciment. Gallstone disease is the most common cause; howport its use to evaluate sphincter of Oddi function; ever, biliary parasites, infectious agents, blood clots, and however, this remain controversial. The pain may medicine studies is this setting varies widely and be confused with peptic ulcer disease, bowel obstruction, depends on the availability of biliary manometry (see pancreatitis, urinary calculi, diverticulitis, some metabolic section E) and should be individualized based on the disorders, or functional bowel disease. The absence of gallstones in the proper clinical setting asymptomatic gallbladder disease and biliary tract dilation (atypical symptoms and/or normal liver tests and pan(following cholecystectomy) are very common and a failure creatic enzymes) should prompt the evaluation for of detection may lead to potentially harmful and ineffective nonbiliary cause such as peptic ulcer or functional interventions, including biliary endoscopy and surgery. The initial history should focus on the location, duraclude peptic ulcer disease and gastroduodenal tumors, tion, and character of the symptoms as described earand a side-viewing endoscope should be used when lier. There is commonly a history of similar, although tumors of the major ampulla are suspected. Total bilirubin and aminotransferase levels sludge (microlithiasis), parasites, or biliary dyskinesia. When gallstones are detected on ultrasound within the tectomy) is seen in about 75% of those with choleclogallbladder and liver tests are significantly elevated, cholithiasis. Other causes of pain, such as pancreatitis choledocholithiasis should be considered. If liver tests and nephrolithiasis, may also be detected during ultraare falling and there are no signs of cholangitis, cholesonography. Endoscopic biliary drainage for severe acute choleffectively dissolve gallstones but is experimental and angitis. Diagnosis and treatment of sphincter of Oddi drainage performed by interventional radiologists can be dysfunction. Aortic aneurysm repair also places the patient according to the presumed site of bleeding. In emergent at risk for ischemic colitis because of interruption of situations, the sequence of history taking, physical examithe inferior mesenteric artery in the absence of adenation, diagnostic evaluation, and treatment should be quate collateral circulation. Nonocclusive ischemic abbreviated or altered to meet immediate demands, and vascular disease of the bowel occurs in older patients prompt resuscitation may be necessary. Melena, or black stool, may develop with as little as heart failure or cardiac arrhythmia. A bleeding may cause vomiting of blood (hematemesis) few patients develop bowel infarction and require or appear as red blood per rectum (hematochezia). However, age, cardiovascuare associated with advanced age, whereas none is a lar status, and rate of blood loss affect these postural probable consideration in a 25-year-old. Neoplasm (carcinoma, lymphoma, leiomyoma, leiomyosarcoma, polyps) Determination of platelet count and clotting factors Hemobilia Vascular-enteric fistula (usually aortic aneurysm or graft) is important so that abnormalities can be corrected promptly. In patients with marginal liver function, the inAngiodysplasia/arteriovenous malformations creased protein load from blood in the gut may induce Antibiotic-associated colitis or aggravate hepatic encephalopathy; gastric lavage and Radiation enteritis or colitis Amyloidosis control of bleeding are particularly important in the Meckel’s diverticulum treatment of these patients. Selective arteriography of the celiac axis, the superior Age >60 years Abdominal or pelvic irradiation and inferior mesenteric arteries, or their branches may Recurrent bleeding be useful if endoscopy has failed to reveal a diagnosis. Stigmata of recent hemorrhage in an ulcer Angiodysplastic lesions and vascular tumors can be suspected by their radiographic appearance, and bleeding from other arterial lesions may be identified by a D. If a periphCapsule endoscopy, which uses a wireless camera in eral vein is not available, use a jugular, subclavian, or a swallowed capsule, creates thousands of pictures and femoral vein. Rapidly infuse normal saline eral hours to interpret the pictures, it is more useful in until blood is available. Blood from the esophagus or stomach studies usually require the skills of an endoscopist or a pools in the stomach, and in! Early surgical consultation may be valuable nal ulcers, blood refiuxes into the stomach. Removal of gastric contents facilitates subsequent endoscopy and decompresses the stomach. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Comsolitary rectal ulcer, vasculitis, endometriosis, intussusmonly used terms to describe the passage of blood from ception, portal colopathy, and diversion colitis. Rectal bleeding patient’s hemodynamic status, possible amount of blood involves a wide clinical spectrum ranging from self-limited loss, source of bleeding, and associated comorbidities. These characteristics can serve as indicators to guide a A thorough history and physical examination is mandiagnostic approach and subsequent treatment. Emergent esophagogastroduodenoscopy younger patients, infectious or infiammatory conditions should be performed if fresh blood is present in gastric are more likely. The utility of anoscopy/sigmoidoscopy in the initial blood passing per rectum is crucial. Flexible sigmoidoscopy may be diagnostic for bright-red blood signifies distal colon or rectal origin. However, there is great controemia, infiammatory or infectious), vascular disease, hyversy on the appropriate time to perform colonospotension or recent vascular surgery (ischemia), anocopy. Angiography can also be used evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Diarrhea is one of the most common complaints types of Escherichia coli may be prudent. Generbe more closely evaluated for evidence of invasive ally, perform a biopsy irrespective of gross findings. The simplest test that can be performed in the office to continued diarrhea, further evaluation may be required. To evaluate infection by an invasive bacterial organism, a stool culture is necessary. Gastroenteritis: etiology, pathophysiology and clinical manifesother pathogens, more specific testing for Amoeba, tations. A rectal examination may reveal pelvic or sphincter dysthe common pathophysiologic mechanism of diarrhea is function. The physical examination can also help in idenan incomplete absorption of water from the lumen. This can tifying systemic causes of diarrhea such as right-sided occur in several ways, such as reduced rate of net water abheart murmurs, enlarged hard liver and fiushing (carcisorption (abnormal electrolyte secretion), intraluminal osnoid), arthritis (infiammatory bowel disease, Whipple’s, motic water retention (osmotic load), decreased mucosal and other enteric infections), dermatitis herpetiformis surface area, and abnormalities in intestinal motility. Routine laboratory studies should be obtained as part diagnosis is based on stool characteristics. It is also essenprotein) are important diagnostic tools for detecting tial to inquire about a previous history of radiation infiammatory diarrhea. Medication use has been of this test for detecting infiammatory and neoplastic described as the causative factor in up to 4% of papathology in chronic diarrhea has not been estabtients with chronic diarrhea. Conditions such as celiac sprue, small bowel a history of specific stool characteristics such as the lymphoma, and refractory sprue have been associpresence of blood, mucus, oil droplets, or undigested ated with positive guaiac results. Other coexisting symptoms, including • Stool fat is used to determine the presence of steatorabdominal pain, cramps, fever, excessive fiatulence, rhea, which is defined as a loss of fat in stool! On physical examination, prompt determination of the using the following formula: 290 " 2(Na # K). If the severity of symptoms is mandatory and is initially more osmotic gap is small ($50), unabsorbed electrolytes important than obtaining a specific diagnosis. A good retain water in the lumen, which is characteristic of place to start is to evaluate the patient’s intravascular secretory diarrhea. When proper carbohydrate absorption fails to take Serologic and other specific testing should be ordered place in the small intestine, excessive bacterial ferfor each suspected diagnosis. Magnesium these cases, watery stool can either have a secredirectly measured in the stool! The underlying abnormality present in infiammatory phenolphthalein, and reducing substances can be diarrhea is disruption and infiammation of the mucosa. However, these are not routinely recompseudomembranous colitis, ischemia, radiation enteromended unless the results would directly alter the colitis, and neoplasia. These include alphawith biopsy may be indicated to evaluate for structural 1-antitrypsin to look for protein-losing enteropathy changes, depending on the clinical circumstances. Fatty diarrhea (or steatorrhea) can be secondary to a cosal defects rather than pancreatic digestive defects.