n. (in dentistry) a protective layer placed in a prepared tooth cavity before a *filling is inserted.
Not all sufferers from coeliac disease present with gastrointestinal symptoms: doctors, using screening techniques, have increasingly identi?ed large numbers of such people. This is important because researchers have recently discovered that untreated overt and silent coeliac disease increases the risk of sufferers developing osteoporosis (brittle bone disease – see BONE, DISORDERS OF) and cancer. The osteoporosis develops because the bowel fails to absorb the CALCIUM essential for normal bone growth. Because those with coeliac disease lack the enzyme LACTASE, which is essential for digesting milk, they avoid milk – a rich source of calcium.
The key treatment is a strict, lifelong diet free of gluten. As well as returning the bowel lining to normal, this diet results in a return to normal bone density. People with coeliac disease, or parents or guardians of affected children, can obtain help and guidance from the Coeliac Society of the United Kingdom. (See also MALABSORPTION SYNDROME; SPRUE.)... coeliac disease
Causes It is likely that there is some abrasion, or break, in the lining membrane (or mucosa) of the stomach and/or duodenum, and that it is gradually eroded and deepened by the acidic gastric juice. The bacterium helicobacter pylori is present in the antrum of the stomach of people with peptic ulcers; 15 per cent of people infected with the bacterium develop an ulcer, and the ulcers heal if H. pylori is eradicated. Thus, this organism has an important role in creating ulcers. Mental stress may possibly be a provocative factor. Smoking seems to accentuate, if not cause, duodenal ulcer, and the drinking of alcohol is probably harmful. The apparent association with a given blood group, and the fact that relatives of a patient with a peptic ulcer are unduly likely to develop such an ulcer, suggest that there is some constitutional factor.
Symptoms and signs Peptic ulcers may present in di?erent ways, but chronic, episodic pain lasting several months or years is most common. Occasionally, however, there may be an acute episode of bleeding or perforation, or obstruction of the gastric outlet, with little previous history. Most commonly there is pain of varying intensity in the middle or upper right part of the abdomen. It tends to occur 2–3 hours after a meal, most commonly at night, and is relieved by some food such as a glass of milk; untreated it may last up to an hour. Vomiting is unusual, but there is often tenderness and sti?ness (‘guarding’) of the abdominal muscles. Con?rmation of the diagnosis is made by radiological examination (‘barium meal’), the ulcer appearing as a niche on the ?lm, or by looking at the ulcer directly with an endoscope (see FIBREOPTIC ENDOSCOPY). Chief complications are perforation of the ulcer, leading to the vomiting of blood, or HAEMATEMESIS; or less severe bleeding from the ulcer, the blood passing down the gut, resulting in dark, tarry stools (see MELAENA).
Treatment of a perforation involves initial management of any complications, such as shock, haemorrhage, perforation, or gastric outlet obstruction, usually involving surgery and blood replacement. Medical treatment of a chronic ulcer should include regular meals, and the avoidance of fatty foods, strong tea or co?ee and alcohol. Patients should also stop smoking and try to reduce the stress in their lives. ANTACIDS may provide symptomatic relief. However, the mainstay of treatment involves four- to six-week courses with drugs such as CIMETIDINE and RANITIDINE. These are H2 RECEPTOR ANTAGONISTS which heal peptic ulcers by reducing gastric-acid output. Of those relapsing after stopping this treatment, 60–95 per cent have infection with H. pylori. A combination of BISMUTH chelate, amoxycillin (see PENICILLIN; ANTIBIOTICS) and METRONIDAZOLE – ‘triple regime’ – should eliminate the infection: most physicians advise the triple regime as ?rst-choice treatment because it is more likely to eradicate Helicobacter and this, in turn, enhances healing of the ulcer or prevents recurrence. Surgery may be necessary if medical measures fail, but its use is much rarer than before e?ective medical treatments were developed.... duodenal ulcer
Aneurysms generally arise in the elderly, with men affected more commonly than women. The most common cause is degenerative atheromatous disease, but other rarer causes include trauma, inherited conditions such as MARFAN’S SYNDROME, or acquired conditions such as SYPHILIS or POLYARTERITIS NODOSA. Once formed, the pressure of the circulating blood within the aneurysm causes it to increase in size. At ?rst, there may be no symptoms or signs, but as the aneurysm enlarges it becomes detectable as a swelling which pulsates with each heartbeat. It may also cause pain due to pressure on local nerves or bones. Rupture of the aneurysm may occur at any time, but is much more likely when the aneurysm is large. Rupture is usually a surgical emergency, because the bleeding is arterial and therefore considerable amounts of blood may be lost very rapidly, leading to collapse, shock and even death. Rupture of an aneurysm in the circle of Willis causes subarachnoid haemorrhage, a life-threatening event. Rupture of an aneurysm in the abdominal aorta is also life-threatening.
Treatment Treatment is usually surgical. Once an aneurysm has formed, the tendency is for it to enlarge progressively regardless of any medical therapy. The surgery is often demanding and is therefore usually undertaken only when the aneurysm is large and the risk of rupture is therefore increased. The patient’s general ?tness for surgery is also an important consideration. The surgery usually involves either bypassing or replacing the affected part of the artery using a conduit made either of vein or of a man-made ?bre which has been woven or knitted into a tube. Routine X-ray scanning of the abdominal aorta is a valuable preventive procedure, enabling ‘cold’ surgery to be performed on identi?ed aneurysms.... aneurysm
Cause Asthma runs in families, so that parents with asthma have a strong risk of having children with asthma, or with other atopic (see ATOPY) illnesses such as HAY FEVER or eczema (see DERMATITIS). There is therefore a great deal of interest in the genetic basis of the condition. Several GENES seem to be associated with the condition of atopy, in which subjects have a predisposition to form ANTIBODIES of the IgE class against allergens (see ALLERGEN) they encounter – especially inhaled allergens.
The allergic response in the lining of the airway leads to an in?ammatory reaction. Many cells are involved in this in?ammatory process, including lymphocytes, eosinophils, neutrophils and mast cells. The cells are attracted and controlled by a complex system of in?ammatory mediators. The in?amed airway-wall produced in this process is then sensitive to further allergic stimuli or to non-speci?c challenges such as dust, smoke or drying from the increased respiration during exercise. Recognition of this in?ammation has concentrated attention on anti-in?ammatory aspects of treatment.
Continued in?ammation with poor control of asthma can result in permanent damage to the airway-wall such that reversibility is reduced and airway-narrowing becomes permanent. Appropriate anti-in?ammatory therapy may help to prevent this damage.
Many allergens can be important triggers of asthma. House-dust mite, grass pollen and animal dander are the commonest problems. Occupational factors such as grain dusts, hard-metals fumes and chemicals in the plastic and paint industry are important in some adults. Viral infections are another common trigger, especially in young children.
The prevalence of asthma appears to be on the increase in most countries. Several factors have been linked to this increase; most important may be the vulnerability of the immature immune system (see IMMUNITY) in infants. High exposure to allergens such as house-dust mite early in life may prime the immune system, while reduced exposure to common viral infections may delay the maturation of the immune system. In addition, maternal smoking in pregnancy and infancy increases the risk.
Clinical course The major symptoms of asthma are breathlessness and cough. Occasionally cough may be the only symptom, especially in children, where night-time cough may be mistaken for recurrent infection and treated inappropriately with antibiotics.
The onset of asthma is usually in childhood, but it may begin at any age. In childhood, boys are affected more often than girls but by adulthood the sex incidence is equal. Children who have mild asthma are more likely to grow out of the condition as they go through their teenaged years, although symptoms may recur later.
The degree of airway-narrowing, and its change with time and treatment, can be monitored by measuring the peak expiratory ?ow with a simple monitor at home – a peak-?ow meter. The typical pattern shows the peak ?ow to be lowest in the early morning and this ‘morning dipping’ is often associated with disturbance of sleep.
Acute exacerbations of asthma may be provoked by infections or allergic stimuli. If they do not respond quickly and fully to medication, expert help should be sought urgently since oxygen and higher doses of drugs will be necessary to control the attack. In a severe attack the breathing rate and the pulse rate rise and the chest sounds wheezy. The peak-?ow rate of air into the lungs falls. Patients may be unable to talk in full sentences without catching their breath, and the reduced oxygen in the blood in very severe attacks may produce the blue colour of CYANOSIS in the lips and tongue. Such acute attacks can be very frightening for the patient and family.
Some cases of chronic asthma are included in the internationally agreed description CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) – a chronic, slowly progressive disorder characterised by obstruction of the air?ow persisting over several months.
Treatment The ?rst important consideration in the treatment of asthma is avoidance of precipitating factors. When this is a speci?c animal or occupational exposure, this may be possible; it is however more di?cult for house-dust mite or pollens. Exercise-induced asthma should be treated adequately rather than avoiding exercise.
Desensitisation injections using small quantities of speci?c allergens are used widely in some countries, but rarely in the UK as they are considered to have limited value since most asthma is precipitated by many stimuli and controlled adequately with simple treatment.
There are two groups of main drugs for the treatment of asthma. The ?rst are the bronchodilators which relax the smooth muscle in the wall of the airways, increase their diameter and relieve breathlessness. The most useful agents are the beta adrenergic agonists (see ADRENERGIC RECEPTORS) such as salbutamol and terbutaline. They are best given by inhalation into the airways since this reduces the general side-effects from oral use. These drugs are usually given to reverse airway-narrowing or to prevent its onset on exercise. However, longer-acting inhaled beta agonists such as salmeterol and formoterol or the theophyllines given in tablet form can be used regularly as prevention. The beta agonists can cause TREMOR and PALPITATION in some patients.
The second group of drugs are the antiin?ammatory agents that act to reduce in?ammation of the airway. The main agents in this group are the CORTICOSTEROIDS. They must be taken regularly, even when symptoms are absent. Given by inhalation they have few side-effects. In acute attacks, short courses of oral steroids are used; in very severe disease regular oral steroids may be needed. Other drugs have a role in suppressing in?ammation: sodium cromoglycate has been available for some years and is generally less e?ective than inhaled steroids. Newer agents directed at speci?c steps in the in?ammatory pathway, such as leukotriene receptor-antagonists, are alternative agents.
Treatment guidelines have been produced by various national and international bodies, such as the British Thoracic Society. Most have set out treatment in steps according to severity, with objectives for asthma control based on symptoms and peak ?ow. Patients should have a management plan that sets out their regular treatment and their appropriate response to changes in their condition.
Advice and support for research into asthma is provided by the National Asthma Campaign.
See www.brit-thoracic.org.uk
Prognosis Asthma is diagnosed in 15–20 per cent of all pre-school children in the developed world. Yet by the age of 15 it is estimated that fewer than 5 per cent still have symptoms. A study in 2003 reported on a follow-up of persons born in 1972–3 who developed asthma and still had problems at the age of nine. By the time these persons were aged 26, 27 per cent were still having problems; around half of that number had never been free from the illness and the other half had apparently lost it for a few years but it had returned.... asthma
The outer coat consists of the sclera and the cornea; their junction is called the limbus. SCLERA This is white, opaque, and constitutes the posterior ?ve-sixths of the outer coat. It is made of dense ?brous tissue. The sclera is visible anteriorly, between the eyelids, as the ‘white of the eye’. Posteriorly and anteriorly it is covered by Tenons capsule, which in turn is covered by transparent conjunctiva. There is a hole in the sclera through which nerve ?bres from the retina leave the eye in the optic nerve. Other smaller nerve ?bres and blood vessels also pass through the sclera at di?erent points. CORNEA This constitutes the transparent, colourless anterior one-sixth of the eye. It is transparent in order to allow light into the eye and is more steeply curved than the sclera. Viewed from in front, the cornea is roughly circular. Most of the focusing power of the eye is provided by the cornea (the lens acts as the ‘?ne adjustment’). It has an outer epithelium, a central stroma and an inner endothelium. The cornea is supplied with very ?ne nerve ?bres which make it exquisitely sensitive to pain. The central cornea has no blood supply – it relies mainly on aqueous humour for nutrition. Blood vessels and large nerve ?bres in the cornea would prevent light from entering the eye. LIMBUS is the junction between cornea and sclera. It contains the trabecular meshwork, a sieve-like structure through which aqueous humour leaves the eye.
The middle coat (uveal tract) consists of the choroid, ciliary body and iris. CHOROID A highly vascular sheet of tissue lining the posterior two-thirds of the sclera. The network of vessels provides the blood supply for the outer half of the retina. The blood supply of the choroid is derived from numerous ciliary vessels which pierce the sclera in front and behind. CILIARY BODY A ring of tissue extending 6 mm back from the anterior limitation of the sclera. The various muscles of the ciliary body by their contractions and relaxations are responsible for changing the shape of the lens during ACCOMMODATION. The ciliary body is lined by cells that secrete aqueous humour. Posteriorly, the ciliary body is continuous with the choroid; anteriorly it is continuous with the iris. IRIS A ?attened muscular diaphragm that is attached at its periphery to the ciliary body, and has a round central opening – the pupil. By contraction and relaxation of the muscles of the iris, the pupil can be dilated or constricted (dilated in the dark or when aroused; constricted in bright light and for close work). The iris forms a partial division between the anterior chamber and the posterior chamber of the eye. It lies in front of the lens and forms the back wall of the anterior chamber. The iris is visible from in front, through the transparent cornea, as the ‘coloured part of the eye’. The amount and distribution of iris pigment determine the colour of the iris. The pupil is merely a hole in the centre of the iris and appears black.
The inner layer The retina is a multilayered tissue (ten layers in all) which extends from the edges of the optic nerve to line the inner surface of the choroid up to the junction of ciliary body and choroid. Here the true retina ends at the ora serrata. The retina contains light-sensitive cells of two types: (i) cones – cells that operate at high and medium levels of illumination; they subserve ?ne discrimination of vision and colour vision; (ii) rods – cells that function best at low light intensity and subserve black-and-white vision.
The retina contains about 6 million cones and about 100 million rods. Information from them is conveyed by the nerve ?bres which are in the inner part of the retina, and leave the eye in the optic nerve. There are no photoreceptors at the optic disc (the point where the optic nerve leaves the eye) and therefore there is no light perception from this small area. The optic disc thus produces a physiological blind spot in the visual ?eld.
The retina can be subdivided into several areas: PERIPHERAL RETINA contains mainly rods and a few scattered cones. Visual acuity from this area is fairly coarse. MACULA LUTEA So-called because histologically it looks like a yellow spot. It occupies an area 4·5 mm in diameter lateral to the optic disc. This area of specialised retina can produce a high level of visual acuity. Cones are abundant here but there are few rods. FOVEA CENTRALIS A small central depression at the centre of the macula. Here the cones are tightly packed; rods are absent. It is responsible for the highest levels of visual acuity.
The chambers of the eye There are three: the anterior and posterior chambers, and the vitreous cavity. ANTERIOR CHAMBER Limited in front by the inner surface of the cornea, behind by the iris and pupil. It contains a transparent clear watery ?uid, the aqueous humour. This is constantly being produced by cells of the ciliary body and constantly drained away through the trabecular meshwork. The trabecular meshwork lies in the angle between the iris and inner surface of the cornea. POSTERIOR CHAMBER A narrow space between the iris and pupil in front and the lens behind. It too contains aqueous humour in transit from the ciliary epithelium to the anterior chamber, via the pupil. VITREOUS CAVITY The largest cavity of the eye. In front it is bounded by the lens and behind by the retina. It contains vitreous humour.
Lens Transparent, elastic and biconvex in cross-section, it lies behind the iris and in front of the vitreous cavity. Viewed from the front it is roughly circular and about 10 mm in diameter. The diameter and thickness of the lens vary with its accommodative state. The lens consists of: CAPSULE A thin transparent membrane surrounding the cortex and nucleus. CORTEX This comprises newly made lens ?bres that are relatively soft. It separates the capsule on the outside from the nucleus at the centre of the lens. NUCLEUS The dense central area of old lens ?bres that have become compacted by new lens ?bres laid down over them. ZONULE Numerous radially arranged ?bres attached between the ciliary body and the lens around its circumference. Tension in these zonular ?bres can be adjusted by the muscles of the ciliary body, thus changing the shape of the lens and altering its power of accommodation. VITREOUS HUMOUR A transparent jelly-like structure made up of a network of collagen ?bres suspended in a viscid ?uid. Its shape conforms to that of the vitreous cavity within which it is contained: that is, it is spherical except for a shallow concave depression on its anterior surface. The lens lies in this depression.
Eyelids These are multilayered curtains of tissue whose functions include spreading of the tear ?lm over the front of the eye to prevent desiccation; protection from injury or external irritation; and to some extent the control of light entering the eye. Each eye has an upper and lower lid which form an elliptical opening (the palpebral ?ssure) when the eyes are open. The lids meet at the medial canthus and lateral canthus respectively. The inner medial canthus is ?xed; the lateral canthus more mobile. An epicanthus is a fold of skin which covers the medial canthus in oriental races.
Each lid consists of several layers. From front to back they are: very thin skin; a sheet of muscle (orbicularis oculi, whose ?bres are concentric around the palpebral ?ssure and which produce closure of the eyelids); the orbital septum (modi?ed near the lid margin to form the tarsal plates); and ?nally, lining the back surface of the lid, the conjunctiva (known here as tarsal conjunctiva). At the free margin of each lid are the eyelashes, the openings of tear glands which lie within the lid, and the lacrimal punctum. Toward the medial edge of each lid is an elevation known as the papilla: the lacrimal punctum opens into this papilla. The punctum forms the open end of the cannaliculus, part of the tear-drainage mechanism.
Orbit The bony cavity within which the eye is held. The orbits lie one on either side of the nose, on the front of the skull. They a?ord considerable protection for the eye. Each is roughly pyramidal in shape, with the apex pointing backwards and the base forming the open anterior part of the orbit. The bone of the anterior orbital margin is thickened to protect the eye from injury. There are various openings into the posterior part of the orbit – namely the optic canal, which allows the optic nerve to leave the orbit en route for the brain, and the superior orbital and inferior orbital ?ssures, which allow passage of nerves and blood vessels to and from the orbit. The most important structures holding the eye within the orbit are the extra-ocular muscles, a suspensory ligament of connective tissue that forms a hammock on which the eye rests and which is slung between the medial and lateral walls of the orbit. Finally, the orbital septum, a sheet of connective tissue extending from the anterior margin of the orbit into the lids, helps keep the eye in place. A pad of fat ?lls in the orbit behind the eye and acts as a cushion for the eye.
Conjunctiva A transparent mucous membrane that extends from the limbus over the anterior sclera or ‘white of the eye’. This is the bulbar conjunctiva. The conjunctiva does not cover the cornea. Conjunctiva passes from the eye on to the inner surface of the eyelid at the fornices and is continuous with the tarsal conjunctiva. The semilunar fold is the vertical crescent of conjunctiva at the medial aspect of the palpebral ?ssure. The caruncle is a piece of modi?ed skin just within the inner canthus.
Eye muscles The extra-ocular muscles. There are six in all, the four rectus muscles (superior, inferior, medial and lateral rectus muscles) and two oblique muscles (superior and inferior oblique muscles). The muscles are attached at various points between the bony orbit and the eyeball. By their combined action they move the eye in horizontal and vertical gaze. They also produce torsional movement of the eye (i.e. clockwise or anticlockwise movements when viewed from the front).
Lacrimal apparatus There are two components: a tear-production system, namely the lacrimal gland and accessory lacrimal glands; and a drainage system.
Tears keep the front of the eye moist; they also contain nutrients and various components to protect the eye from infection. Crying results from excess tear production. The drainage system cannot cope with the excess and therefore tears over?ow on to the face. Newborn babies do not produce tears for the ?rst three months of life. LACRIMAL GLAND Located below a small depression in the bony roof of the orbit. Numerous tear ducts open from it into predominantly the upper lid. Accessory lacrimal glands are found in the conjunctiva and within the eyelids: the former open directly on to the surface of the conjunctiva; the latter on to the eyelid margin. LACRIMAL DRAINAGE SYSTEM This consists of: PUNCTUM An elevated opening toward the medial aspect of each lid. Each punctum opens into a canaliculus. CANALICULUS A ?ne tube-like structure run-ning within the lid, parallel to the lid margin. The canaliculi from upper and lower lid join to form a common canaliculus which opens into the lacrimal sac. LACRIMAL SAC A small sac on the side of the nose which opens into the nasolacrimal duct. During blinking, the sac sucks tears into itself from the canaliculus. Tears then drain by gravity down the nasolacrimal duct. NASOLACRIMAL DUCT A tubular structure which runs down through the wall of the nose and opens into the nasal cavity.
Visual pathway Light stimulates the rods and cones of the retina. Electrochemical messages are then passed to nerve ?bres in the retina and then via the optic nerve to the optic chiasm. Here information from the temporal (outer) half of each retina continues to the same side of the brain. Information from the nasal (inner) half of each retina crosses to the other side within the optic chiasm. The rearranged nerve ?bres then pass through the optic tract to the lateral geniculate body, then the optic radiation to reach the visual cortex in the occipital lobe of the brain.... eye
(2) The surgical replacement of injured or unhealthy tissue or organ with healthy tissue or organ (also known as TRANSPLANTATION).
(3) Attachment of the early EMBRYO to the lining of the UTERUS, which occurs around six days after conception; the site where this happens is where the placenta will develop.... implantation
Menstruation depends upon a functioning ovary (see OVARIES) and this upon a healthy PITUITARY GLAND. The regular rhythm may depend upon a centre in the HYPOTHALAMUS, which is in close connection with the pituitary. After menstruation, the denuded uterine ENDOMETRIUM is regenerated under the in?uence of the follicular hormone, oestradiol. The epithelium of the endometrium proliferates, and about a fortnight after the beginning of menstruation great development of the endometrial glands takes place under the in?uence of progesterone, the hormone secreted by the CORPUS LUTEUM. These changes are made for the reception of the fertilised OVUM. In the absence of fertilisation the uterine endometrium breaks down in the subsequent menstrual discharge.
Disorders of menstruation In most healthy women, menstruation proceeds regularly for 30 years or more, with the exceptions connected with childbirth. In many women, however, menstruation may be absent, excessive or painful. The term amenorrhoea is applied to the condition of absent menstruation; the terms menorrhagia and metrorrhagia describe excessive menstrual loss – the former if the excess occurs at the regular periods, and the latter if it is irregular. Dysmenorrhoea is the name given to painful menstruation. AMENORRHOEA If menstruation has never occurred, the amenorrhoea is termed primary; if it ceases after having once become established it is known as secondary amenorrhoea. The only value of these terms is that some patients with either chromosomal abnormalities (see CHROMOSOMES) or malformations of the genital tract fall into the primary category. Otherwise, the age of onset of symptoms is more important.
The causes of amenorrhoea are numerous and treatment requires dealing with the primary cause. The commonest cause is pregnancy; psychological stress or eating disorders can cause amenorrhoea, as can poor nutrition or loss of weight by dieting, and any serious underlying disease such as TUBERCULOSIS or MALARIA. The excess secretion of PROLACTIN, whether this is the result of a micro-adenoma of the pituitary gland or whether it is drug induced, will cause amenorrhoea and possibly GALACTORRHOEA as well. Malfunction of the pituitary gland will result in a failure to produce the gonadotrophic hormones (see GONADOTROPHINS) with consequent amenorrhoea. Excessive production of cortisol, as in CUSHING’S SYNDROME, or of androgens (see ANDROGEN) – as in the adreno-genital syndrome or the polycystic ovary syndrome – will result in amenorrhoea. Amenorrhoea occasionally follows use of the oral contraceptive pill and may be associated with both hypothyroidism (see under THYROID GLAND, DISEASES OF) and OBESITY.
Patients should be reassured that amenorrhoea can often be successfully treated and does not necessarily affect their ability to have normal sexual relations and to conceive. When weight loss is the cause of amenorrhoea, restoration of body weight alone can result in spontaneous menstruation (see also EATING DISORDERS – Anorexia nervosa). Patients with raised concentration of serum gonadotrophin hormones have primary ovarian failure, and this is not amenable to treatment. Cyclical oestrogen/progestogen therapy will usually establish withdrawal bleeding. If the amenorrhoea is due to mild pituitary failure, menstruation may return after treatment with clomiphene, a nonsteroidal agent which competes for oestrogen receptors in the hypothalamus. The patients who are most likely to respond to clomiphene are those who have some evidence of endogenous oestrogen and gonadotrophin production. IRREGULAR MENSTRUATION This is a change from the normal monthly cycle of menstruation, the duration of bleeding or the amount of blood lost (see menorrhagia, below). Such changes may be the result of an upset in the balance of oestrogen and progesterone hormones which between them control the cycle. Cycles may be irregular after the MENARCHE and before the menopause. Unsuspected pregnancy may manifest itself as an ‘irregularity’, as can an early miscarriage (see ABORTION). Disorders of the uterus, ovaries or organs in the pelvic cavity can also cause irregular menstruation. Women with the condition should seek medical advice. MENORRHAGIA Abnormal bleeding from the uterus during menstruation. A woman loses on average about 60 ml of blood during her period; in menorrhagia this can rise to 100 ml. Some women have this problem occasionally, some quite frequently and others never. One cause is an imbalance of progesterone and oestrogen hormones which between them control menstruation: the result is an abnormal increase in the lining (endometrium) of the uterus, which increases the amount of ‘bleeding’ tissue. Other causes include ?broids, polyps, pelvic infection or an intrauterine contraceptive device (IUD – see under CONTRACEPTION). Sometimes no physical reason for menorrhagia can be identi?ed.
Treatment of the disorder will depend on how severe the loss of blood is (some women will become anaemic – see ANAEMIA – and require iron-replacement therapy); the woman’s age; the cause of heavy bleeding; and whether or not she wants children. An increase in menstrual bleeding may occur in the months before the menopause, in which case time may produce a cure. Medical or surgical treatments are available. Non-steroidal anti-in?ammatory drugs may help, as may tranexamic acid, which prevents the breakdown of blood clots in the circulation (FIBRINOLYSIS): this drug can be helpful if an IUD is causing bleeding. Hormones such as dydrogesterone (by mouth) may cure the condition, as may an IUD that releases small quantities of a PROGESTOGEN into the lining of the womb.
Traditionally, surgical intervention was either dilatation and curettage of the womb lining (D & C) or removal of the whole uterus (HYSTERECTOMY). Most surgery is now done using minimally invasive techniques. These do not require the abdomen to be cut open, as an ENDOSCOPE is passed via the vagina into the uterus. Using DIATHERMY or a laser, the surgeon then removes the whole lining of the womb. DYSMENORRHOEA This varies from discomfort to serious pain, and sometimes includes vomiting and general malaise. Anaemia is sometimes a cause of painful menstruation as well as of stoppage of this function.
In?ammation of the uterus, ovaries or FALLOPIAN TUBES is a common cause of dysmenorrhoea which comes on for the ?rst time late in life, especially when the trouble follows the birth of a child. In this case the pain exists more or less at all times, but is aggravated at the periods. Treatment with analgesics and remedying the underlying cause is called for.
Many cases of dysmenorrhoea appear with the beginning of menstrual life, and accompany every period. It has been estimated that 5–10 per cent of girls in their late teens or early 20s are severely incapacitated by dysmenorrhoea for several hours each month. Various causes have been suggested for the pain, one being an excessive production of PROSTAGLANDINS. There may be a psychological factor in some sufferers and, whether this is the result of inadequate sex instruction, fear, family, school or work problems, it is important to o?er advice and support, which in itself may resolve the dysmenorrhoea. Symptomatic relief is of value.... menstruation
Varieties Haemorrhoids are classi?ed into ?rst-, second- and third-degree, depending on how far they prolapse through the anal canal. First-degree ones do not protrude; second-degree piles protrude during defaecation; third-degree ones are trapped outside the anal margin, although they can be pushed back. Most haemorrhoids can be described as internal, since they are covered with glandular mucosa, but some large, long-term ones develop a covering of skin. Piles are usually found at the three, seven and eleven o’clock sites when viewed with the patient on his or her back.
Causes The veins in the anus tend to become distended because they have no valves; because they form the lowest part of the PORTAL SYSTEM and are apt to become over?lled when there is the least interference with the circulation through the portal vein; and partly because the muscular arrangements for keeping the rectum closed interfere with the circulation through the haemorrhoidal veins. An absence of ?bre from western diets is probably the most important cause. The result is that people often strain to defaecate hard stools, thus raising intra-abdominal pressure which slows the rate of venous return and engorges the network of veins in the anal mucosa. Pregnancy is an important contributory factor in women developing haemorrhoids. In some people, haemorrhoids are a symptom of disease higher up in the portal system, causing interference with the circulation. They are common in heart disease, liver complaints such as cirrhosis or congestion, and any disease affecting the bowels.
Symptoms Piles cause itching, pain and often bleeding, which may occur whenever the patient defaecates or only sometimes. The piles may prolapse permanently or intermittently. The patient may complain of aching discomfort which, with the pain, may be worsened.
Treatment Prevention is important; a high-?bre diet will help in this, and is also necessary after piles have developed. Patients should not spend a long time straining on the lavatory. Itching can be lessened if the PERINEUM is properly washed, dried and powdered. Prolapsed piles can be replaced with the ?nger. Local anaesthetic and steroid ointments can help to relieve symptoms when they are relatively mild, but do not remedy the underlying disorder. If conservative measures fail, then surgery may be required. Piles may be injected, stretched or excised according to the patient’s particular circumstances.
Where haemorrhoids are secondary to another disorder, such as cancer of the rectum or colon, the underlying condition must be treated – hence the importance of medical advice if piles persist.... haemorrhoids
Checking a hormone pro?le in the woman’s blood will help in the diagnosis of ovulatory disorders like polycystic ovaries, an early menopause, anorexia or other endocrine illnesses. Ovulation itself is best assessed by ultrasound scan at mid-cycle or by a blood hormone progesterone level in the second half of the cycle.
The FALLOPIAN TUBES may be damaged or blocked in 20–30 per cent of infertile women. This is usually caused by previous pelvic infection or ENDOMETRIOSIS, where menstrual blood is thought to ?ow backwards through the fallopian tubes into the pelvis and seed with cells from the lining of the uterus in the pelvis. This process often leads to scarring of the pelvic tissues; 5–10 per cent of infertility is associated with endometriosis.
To assess the Fallopian tubes adequately a procedure called LAPAROSCOPY is performed. An ENDOSCOPE is inserted through the umbilicus and at the same time a dye is pushed through the tubes to assess their patency. The procedure is performed under a general anaesthetic.
In a few cases the mucus around the cervix may be hostile to the partner’s sperm and therefore prevent fertilisation.
Defective production is responsible for up to a quarter of infertility. It may result from the failure of the testes (see TESTICLE) to descend in early life, from infections of the testes or previous surgery for testicular torsion. The semen is analysed to assess the numbers of sperm and their motility and to check for abnormal forms.
In a few cases the genetic make-up of one partner does not allow the couple ever to achieve a pregnancy naturally.
In about 25 per cent of couples no obvious cause can be found for their infertility.
Treatment Ovulation may be induced with drugs.
In some cases damaged Fallopian tubes may be repaired by tubal surgery. If the tubes are destroyed beyond repair a pregnancy may be achieved with in vitro fertilisation (IVF) – see under ASSISTED CONCEPTION.
Endometriosis may be treated either with drugs or laser therapy, and pregnancy rates after both forms of treatment are between 40–50 per cent, depending on the severity of the disease.
Few options exist for treating male-factor infertility. These are arti?cial insemination by husband or donor and more recently in vitro fertilisation. Drug treatment and surgical repair of VARICOCELE have disappointing results.
Following investigations, between 30 and 40 per cent of infertile couples will achieve a pregnancy usually within two years.
Some infertile men cannot repair any errors in the DNA in their sperm, and it has been found that the same DNA repair problem occurs in malignant cells of some patients with cancer. It is possible that these men’s infertility might be nature’s way of stopping the propagation of genetic defects. With the assisted reproduction technique called intracytoplasmic sperm injection, some men with defective sperm can fertilise an ovum. If a man with such DNA defects fathers a child via this technique, that child could be sterile and might be at increased risk of developing cancer. (See ARTIFICIAL INSEMINATION; ASSISTED CONCEPTION.)... infertility
Causes There is a major immunogenetic predisposition to rheumatoid arthritis in people carrying the HLA-DR4 antigen (see HLA SYSTEM). Other minor immunogenetic factors have also been implicated. In addition, there is a degree of familial clustering which suggests other unidenti?ed genetic factors. Genetic factors cannot alone explain aetiology, and environmental and chance factors must be important, but these have yet to be identi?ed.
Epidemiology Rheumatoid arthritis more commonly occurs in women from the age of 30 onwards, the sex ratio being approximately 4:1. Typical rheumatoid arthritis may occur in adolescence, but in childhood chronic SYNOVITIS usually takes one of a number of di?erent patterns, classi?ed under juvenile chronic arthritis.
Pathology The primary lesion is an in?ammation of the synovial membrane of joints. The synovial ?uid becomes diluted with in?ammatory exudate: if this persists for months it leads to progressive destruction of articular CARTILAGE and BONE. Cartilage is replaced by in?ammatory tissue known as pannus; a similar tissue invades bone to form erosions. Synovitis also affects tendon sheaths, and may lead to adhesion ?brosis or attrition and rupture of tendons. Subcutaneous and other bursae may be involved. Necrobiotic nodules also occur at sites outside synovium, including the subcutaneous tissues, the lungs, the pericardium and the pleura.
Clinical features Rheumatoid arthritis varies from the very mild to the severely disabling. Many mild cases probably go undiagnosed. At least 50 per cent of patients continue to lead a reasonably normal life; around 25 per cent are signi?cantly disabled in terms of work and leisure activities; and a minority become markedly disabled and are limited in their independence. There is often an early acute phase, followed by substantial remission, but in other patients gradual step-wise deterioration may occur, with progressive involvement of an increasing number of joints.
The diagnosis of rheumatoid arthritis is largely based on clinical symptoms and signs. Approximately 70 per cent of patients have rheumatoid factor ANTIBODIES in the SERUM but, because of the large number of false positives and false negatives, this test has very little value in clinical practice. It may be a useful pointer to a worse prognosis in early cases if the level is high. X-RAYS may help in diagnosing early cases and are particularly helpful when considering surgery or possible complications such as pathological fracture. Patients commonly develop ANAEMIA, which may be partly due to gastrointestinal blood loss from antiin?ammatory drug treatment (see below).
Treatment involves physical, pharmacological, and surgical measures, together with psychological and social support tailored to the individual patient’s needs. Regular activity should be maintained. Resting of certain joints such as the wrist with splints may be helpful at night or to assist prolonged manual activities. Sound footwear is important. Early use of antirheumatic drugs reduces long-term disability. Drug treatment includes simple ANALGESICS, NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS), and slow-acting drugs including GOLD SALTS (in the form of SODIUM AUROTHIOMALATE), PENICILLAMINE, SULFASALAZINE, METHOTREXATE and AZATHIOPRINE.
The non-steroidal agents are largely e?ective in reducing pain and early-morning sti?ness, and have no e?ect on the chronic in?ammatory process. It is important, especially in the elderly, to explain to patients the adverse effects of NSAIDs, the dosage of which can be cut by prescribing paracetamol at the same time. Combinations of anti-rheumatic drugs seem better than single agents. The slow-acting drugs take approximately three months to act but have a more global e?ect on chronic in?ammation, with a greater reduction in swelling and an associated fall in erythrocyte sedimentation rate (ESR) and rise in the level of HAEMOGLOBIN. Local CORTICOSTEROIDS are useful, given into individual joints. Systemic corticosteroids carry serious problems if continued long term, but may be useful under special circumstances. Much research is currently going on into the use of tumour necrosis factor antagonists such as INFLIXIMAB and etanercept, but their precise role remains uncertain.... rheumatoid arthritis
Cells in the conjunctiva produce a fluid that lubricates the lids and the cornea.... conjunctiva
Decubitus ulcer Also known as pressure or bed sore. Occurs when there is constant pressure on and inadequate oxygenation of an area of skin, usually overlying a bony protuberance. Elderly or in?rm people, or individuals with debilitating, emaciating or neurological illnesses, are vulnerable to the condition. Long-term pressure from a bed, wheelchair, cast or splint is the usual cause. Loss of skin sensation is a contributory factor, and muscle and bone as well as skin may be affected.
Treatment The most important treatment is prevention, keeping the patient’s back, buttocks, heels and other pressure-points clean and dry, and regularly changing his or her position. If ulcers do develop, repeated local DEBRIDEMENT, protective dressings and (in serious cases) surgical treatment are required, accompanied by an appropriate antibiotic if infection is persistent.
Venous ulcer This occurs on the lower leg or ankle and is caused by chronic HYPERTENSION in the deep leg VEINS, usually the consequences of previous deep vein thrombosis (DVT) – see THROMBOSIS; VEINS, DISEASES OF – which has destroyed the valvular system in the vein(s). The ulcer is usually preceded by chronic OEDEMA, often local eczema (see DERMATITIS), and bleeding into the skin that produces brown staining. Varicose veins may or may not be present. Control of the oedema by compression and encouragement to walk is central to management.... ulcer
Symptoms The onset may be sudden or insidious. In the acute form there is severe diarrhoea and the patient may pass up to 20 stools a day. The stools, which may be small in quantity, are ?uid and contain blood, pus and mucus. There is always fever, which runs an irregular course. In other cases the patient ?rst notices some irregularity of the movement of the bowels, with the passage of blood. This becomes gradually more marked. There may be pain but usually a varying amount of abdominal discomfort. The constant diarrhoea leads to emaciation, weakness and ANAEMIA. As a rule the acute phase passes into a chronic stage. The chronic form is liable to run a prolonged course, and most patients suffer relapses for many years. SIGMOIDOSCOPY, BIOPSY and abdominal X-RAYS are essential diagnostic procedures.
Treatment Many patients may be undernourished and need expert dietary assessment and appropriate calorie, protein, vitamin and mineral supplements. This is particularly important in children with the disorder. While speci?c nutritional treatment can initiate improvement in CROHN’S DISEASE, this is not the case with ulcerative colitis. CORTICOSTEROIDS, given by mouth or ENEMA, help to control the diarrhoea. Intravenous nutrition may be required. The anaemia is treated with iron supplements, and with blood infusions if necessary. Blood cultures should be taken, repeatedly if the fever persists. If SEPTICAEMIA is suspected, broad-spectrum antibiotics should be given. Surgery to remove part of the affected colon may be necessary and an ILEOSTOMY is sometimes required. After recovery, the patient should remain on a low-residue diet, with regular follow-up by the physician, Mesalazine and SULFASALAZINE are helpful in the prevention of recurrences.
Patients and their relatives can obtain help and advice from the National Association for Colitis and Crohn’s Disease.... ulcerative colitis
It is often caused by a heavy intake of starches, salt, sugar, white flour products, and especially dairy products including milk. Some cases are due to poor diet, low blood calcium, vitamin and mineral deficiency. May manifest as catarrh of the nose, throat, stomach, bowels, bronchi or bladder. Alternatives:–Teas made from any of the following: Angelica, Avens, Coltsfoot, Comfrey leaves, German Chamomile, Elderflowers, Eyebright, Garlic, Ginseng, Gotu Kola, Ground Ivy, Hyssop, Marshmallow leaves, Mullein, Mouse-ear, Parsley, Plantain, Marsh Cudweed, White Horehound, Yarrow.
Garlic. Good results reported.
Traditional combination. Equal parts, herbs: Angelica, Eyebright, Yarrow. 1 heaped teaspoon to each cup of boiling water.
Fenugreek seeds. 2 teaspoons to each cup water simmered 5 minutes; 1 cup thrice daily. Or grind to a powder in a blender to sprinkle on salads or cereals.
Tablets/capsules. Garlic, Iceland Moss, Lobelia, Poke root, Goldenseal (Gerard). Horseradish and Garlic (Blackmore).
Tinctures. Alternatives. (1) Goldenseal: 3-5 drops. Formulae: (2) Angelica 2; Ginger 1. (3) Lobelia 1; Goldenseal 1; Juniper 1. One teaspoon – thrice daily.
Tincture Myrrh, BPC 1973. 3-5 drops in water thrice daily.
Tea Tree oil. 2-3 drops on teaspoon honey, or in water, thrice daily.
Heath and Heather Catarrh pastilles. Squills, Menthol, Pine oil, Eucalyptus oil.
Antifect. (Potter’s) Germicidal for blocked sinuses, etc.
Eric Powell. Liquid extracts: Angelica 1oz; Juniper 1oz; Peppermint half an ounce; Root Ginger half an ounce. 1-2 teaspoons in water thrice daily.
BHP (1983). (Bronchial) Irish Moss, Cinnamon, Liquorice.
Gargle. 3 drops Tincture Myrrh in half glass water.
Inhalation. Small handful Chamomile flowers or Eucalyptus leaves to 2 pints boiling water in washbasin. Cover head with towel and inhale 10 minutes. Or – see: FRIAR’S BALSAM.
Aromatherapy. Essential oils, diluted with 20 parts water, as injection for nasal catarrh: Eucalyptus, Thyme, Pine, Garlic, Hyssop, Tea Tree.
For catarrh of the womb and vagina: see LEUCORRHOEA.
Diet. Refer: GENERAL DIET. Commence with 3-day fast.
Supplementation. Vitamins A and D as in Cod Liver oil. Vitamins B-complex, C and E.
General. Cold sponge-down, deep-breathing exercises. Sea-bathing. Smoking promotes congestion.
Note: However inconvenient, catarrh has one useful protective role – it helps prevent bacteria and toxins reaching tissue. For instance, when present in the nasal organs it may prevent mercury vapour from teeth- amalgam reaching the brain. ... catarrh
Bacteria invades where there has been continued irritation, such as that of ‘sand’ or ‘gravel’ in the urine. Bacillus coli resides in the rectum but may invade the bladder. Urine is often turbid and evil- smelling. By travelling down the ureters, kidney infection may be conveyed to the lining of the bladder.
A common cause is dietetic indiscretion such as too much spicy food (curries, peppers), vinegar, coffee, alcohol, tea – too much and too strong, cola and other stimulants. Too much meat concentrates the urine, as do other high purine foods. Eighty per cent of women have at least one experience of cystitis during their lifetime. Other common causes: vaginal deodorants, freshener tissues, pants washed in biological washing powders, tampons, bubble-bath liquids, sexual aids such as spermicidal creams. The Pill.
Plenty of fluid should be drunk, either in the form of herbal teas (Alfalfa, etc) or bottled waters rather than coffee or tea. These dilute the irritating effect of uric acid in the urine.
Treatment. Bed-rest, abundant herb teas, non-caffeine drinks or plain water. Barley water.
Alternatives. Agrimony, Bearberry, Buchu (urinary antiseptic), Cornsilk (soothing to mucous surfaces), Couchgrass, Elderflowers, Juniper (not with inflammation), Lime flowers, Parsley, Parsley Piert, Pellitory, Plantain, Wild Carrot, Marshmallow (burning), Mullein, Rupturewort, Yarrow.
Tea: formula No 1. Equal parts: Cornsilk, Elderflowers, Marshmallow. Mix. 1-2 teaspoons to each cup boiling water; infuse 5-10 minutes; 1 cup freely.
Tea: formula No 2. Equal parts: Bearberry, Buchu, Couchgrass. Mix. 1 heaped teaspoon to each cup boiling water; infuse 5-10 minutes; 1 cup freely.
Barberry bark. 1 teaspoon to each cup cold water; steep overnight. 1 cup freely, next day.
Maria Treben’s tea. Equal parts: Horsetail, Ladysmantle, Shepherd’s Purse, Yarrow. 2 teaspoons to each cup boiling water. Infuse 15 minutes: 2-3 cups daily.
Tablets/capsules. Buchu, Dandelion, Echinacea, Goldenseal, Potter’s “Antitis”.
Formula. Marshmallow root 2; Echinacea 2; Goldenseal 1. Mix. Dose: Powders: 500mg (two 00 capsules or one-third teaspoon). Liquid extracts: 1 teaspoon. Tinctures: 2 teaspoons. 2-3 times daily.
E.G. Jones MNIMH. Tinctures, equal parts: Kava Kava, Saw Palmetto, Sweet Sumach. 20-30 drops in water thrice daily. Consistent results reported.
Practitioner. Where much pus is present in the urine, inject: 5 drops Tincture Myrrh to each cup warm water, per catheter.
External. Fomentations to low centre abdomen (including genital area). Two towels are required: one squeezed out in hot water and placed in position for 5 minutes. Replace with one squeezed out in cold water; apply for 1 minute. Repeat applications for half an hour daily. Hot hip baths twice weekly. Aromatherapy. 5 drops each: Cajeput and Juniper in bathwater.
Diet. Fresh and conservatively-cooked vegetables, adequate protein (vegetable), polyunsaturated oils. Organic foods with an absence of additives and tartrazine colourings, potassium broth, watermelon, carrots and carrot juice, baked potatoes, whole grains, parsnips, Garlic. Yoghurt, pumpkin seeds; Slippery Elm gruel at almost every meal. Herb teas. Avoid hot spices, condiments, coffee, tea and cola drinks.
Supplements. Vitamins A, B, C, E, bioflavonoids, beta carotene, dolomite, propolis, zinc. ... cystitis
Aspirin is not usually given to children because there is a slight risk of Reye’s syndrome (a rare brain and liver disorder) developing. Aspirin may cause irritation of the stomach lining, resulting in indigestion or nausea. Prolonged use may cause bleeding from the stomach due to gastric erosion or peptic ulcer.... aspirin
The major cause of peptic ulcers is
HELICOBACTER PYLORI bacterial infection, which can damage the lining of the stomach and duodenum, allowing the acid stomach contents to attack it. Analgesic drugs, alcohol, excess acid production, and smoking can also damage the stomach lining. Ulcers can also form in the oesophagus, when acidic juice from the stomach enters it (see acid reflux), and in the duodenum.
There may be no symptoms, or there may be burning or gnawing pain in the upper abdomen. Other possible symptoms include loss of appetite, nausea, and vomiting. The ulcer may also bleed. If severe, it may result in haematemesis
(vomiting of blood) and melaena, and is a medical emergency. Chronic bleeding may cause iron-deficiency anaemia. Rarely, an ulcer may perforate the wall of the digestive tract and lead to peritonitis.
An ulcer is usually diagnosed by an endoscopy of the stomach and duodenum; less commonly, a barium meal (see barium X-ray examination) is performed. Tests will be carried out to see whether the individual is infected with the HELICOBACTER bacterium. If this is the case, a combination of antibiotics and an ulcerhealing drug will be given. A further test may be done to check that treatment has been successful. If HELICOBACTER is not detected – for example, in ulcers caused by nonsteroidal anti-inflammatory drugs (NSAIDs) – treatment is with proton pump inhibitors or H-blockers, and the NSAIDs will be stopped. Surgery is now rarely needed for peptic ulcers, except to treat complications such as bleeding or perforation.... peptic ulcer
sprue, tropical A disease of the small intestine that causes failure to absorb nutrients from food. It occurs mainly in India, the Far East, and the Caribbean. Sprue leads to malnutrition and megaloblastic anaemia. It may be due to an intestinal infection. Symptoms include appetite and weight loss, an inflamed mouth, and fatty diarrhoea. Diagnosis is confirmed by jejunal biopsy. Sprue responds well to antibiotic drug treatment and vitamin and mineral supplements. sputum Mucous material produced by cells lining the respiratory tract. Sputum production may be increased by respiratory tract infection, an allergic reaction (see asthma), or inhalation of irritants.... sprue
Various processes that can occur include in?ammation, ulceration, infection or tumour. Abdominal disease may be of rapid onset, described as acute, or more long-term when it is termed chronic.
An ‘acute abdomen’ is most commonly caused by peritonitis – in?ammation of the membrane that lines the abdomen. If any structure in the abdomen gets in?amed, peritonitis may result. Causes include injury, in?ammation of the Fallopian tubes (SALPINGITIS), and intestinal disorders such as APPENDICITIS, CROHN’S DISEASE, DIVERTICULITIS or a perforated PEPTIC ULCER. Disorders of the GALLBLADDER or URINARY TRACT may also result in acute abdominal pain.
General symptoms of abdominal disease include:
Pain This is usually ill-de?ned but can be very unpleasant, and is termed visceral pain. Pain is initially felt near the mid line of the abdomen. Generally, abdominal pain felt high up in the mid line originates from the stomach and duodenum. Pain that is felt around the umbilicus arises from the small intestine, appendix and ?rst part of the large bowel, and low mid-line pain comes from the rest of the large bowel. If the diseased organ secondarily in?ames or infects the lining of the abdominal wall – the PERITONEUM – peritonitis occurs and the pain becomes more de?ned and quite severe, with local tenderness over the site of the diseased organ itself. Hence the pain of appendicitis begins as a vague mid-line pain, and only later moves over to the right iliac fossa, when the in?amed appendix has caused localised peritonitis. PERFORATION of one of the hollow organs in the abdomen – for example, a ruptured appendix or a gastric or duodenal ulcer (see STOMACH, DISEASES OF) eroding the wall of the gut – usually causes peritonitis with resulting severe pain.
The character of the pain is also important. It may be constant, as occurs in in?ammatory diseases and infections, or colicky (intermittent) as in intestinal obstruction.
Swelling The commonest cause of abdominal swelling in women is pregnancy. In disease, swelling may be due to the accumulation of trapped intestinal contents within the bowel, the presence of free ?uid (ascites) within the abdomen, or enlargement of one or more of the abdominal organs due to benign causes or tumour.
Constipation is the infrequent or incomplete passage of FAECES; sometimes only ?atus can be passed and, rarely, no bowel movements occur (see main entry for CONSTIPATION). It is often associated with abdominal swelling. In intestinal obstruction, the onset of symptoms is usually rapid with complete constipation and severe, colicky pain. In chronic constipation, the symptoms occur more gradually.
Nausea and vomiting may be due to irritation of the stomach, or to intestinal obstruction when it may be particularly foul and persistent. There are also important non-abdominal causes, such as in response to severe pain or motion sickness.
Diarrhoea is most commonly due to simple and self-limiting infection, such as food poisoning, but may also indicate serious disease, especially if it is persistent or contains blood (see main entry for DIARRHOEA).
Jaundice is a yellow discoloration of the skin and eyes, and may be due to disease in the liver or bile ducts (see main entry for JAUNDICE).
Diagnosis and treatment Abdominal diseases are often di?cult to diagnose because of the multiplicity of the organs contained within the abdomen, their inconstant position and the vagueness of some of the symptoms. Correct diagnosis usually requires experience, often supplemented by specialised investigations such as ULTRASOUND. For this reason sufferers should obtain medical advice at an early stage, particularly if the symptoms are severe, persistent, recurrent, or resistant to simple remedies.... abdomen, diseases of
Nutritional Profile Energy value (calories per serving): Low Protein: Moderate Fat: None Saturated fat: None Cholesterol: None Carbohydrates: High Fiber: None Sodium: Low Major vitamin contribution: B vitamins Major mineral contribution: Phosphorus
About the Nutrients in This Food Beer and ale are fermented beverages created by yeasts that convert the sugars in malted barley and grain to ethyl alcohol (a.k.a. “alcohol,” “drink- ing alcohol”).* The USDA /Health and Human Services Dietary Guidelines for Americans defines one drink as 12 ounces of beer, five ounces of wine, or 1.25 ounces of distilled spirits. One 12-ounce glass of beer has 140 calo- ries, 86 of them (61 percent) from alcohol. But the beverage—sometimes nicknamed “liquid bread”—is more than empty calories. Like wine, beer retains small amounts of some nutrients present in the food from which it was made. * Because yeasts cannot digest t he starches in grains, t he grains to be used in mak ing beer and ale are allowed to germinate ( “malt” ). When it is t ime to make t he beer or ale, t he malted grain is soaked in water, forming a mash in which t he starches are split into simple sugars t hat can be digested (fermented) by t he yeasts. If undisturbed, t he fermentat ion will cont inue unt il all t he sugars have been digested, but it can be halted at any t ime simply by raising or lowering t he temperature of t he liquid. Beer sold in bott les or cans is pasteurized to k ill t he yeasts and stop t he fermentat ion. Draft beer is not pasteurized and must be refrigerated unt il tapped so t hat it will not cont inue to ferment in t he container. The longer t he shipping t ime, t he more likely it is t hat draft beer will be exposed to temperature variat ions t hat may affect its qualit y—which is why draft beer almost always tastes best when consumed near t he place where it was brewed. The Nutrients in Beer (12-ounce glass)
| Nutrients | Beer | %R DA |
| Calcium | 17 mg | 1.7 |
| Magnesium | 28.51 mg | 7–9* |
| Phosphorus | 41.1 mg | 6 |
| Potassium | 85.7 mg | (na) |
| Zinc | 0.06 mg | 0.5– 0.8* |
| Thiamin | 0.02 mg | 1.6 –1.8* |
| R iboflavin | 0.09 mg | 7– 8* |
| Niacin | 1.55 mg | 10 |
| Vitamin B6 | 0.17 mg | 13 |
| Folate | 20.57 mcg | 5 |
Diets That May Restrict or Exclude This Food Bland diet Gluten-free diet Low-purine (antigout) diet
Buying This Food Look for: A popular brand that sells steadily and will be fresh when you buy it. Avoid: Dusty or warm bottles and cans.
Storing This Food Store beer in a cool place. Beer tastes best when consumed within two months of the day it is made. Since you cannot be certain how long it took to ship the beer to the store or how long it has been sitting on the grocery shelves, buy only as much beer as you plan to use within a week or two. Protect bottled beer and open bottles or cans of beer from direct sunlight, which can change sulfur compounds in beer into isopentyl mercaptan, the smelly chemical that gives stale beer its characteristic unpleasant odor.
When You Are Ready to Serve This Food Serve beer only in absolutely clean glasses or mugs. Even the slightest bit of grease on the side of the glass will kill the foam immediately. Wash beer glasses with detergent, not soap, and let them drain dry rather than drying them with a towel that might carry grease from your hands to the glass. If you like a long-lasting head on your beer, serve the brew in tall, tapering glasses to let the foam spread out and stabilize. For full flavor, serve beer and ales cool but not ice-cold. Very low temperatures immo- bilize the molecules that give beer and ale their flavor and aroma.
What Happens When You Cook This Food When beer is heated (in a stew or as a basting liquid), the alcohol evaporates but the flavor- ing agents remain intact. Alcohol, an acid, reacts with metal ions from an aluminum or iron pot to form dark compounds that discolor the pot or the dish you are cooking in. To prevent this, prepare dishes made with beer in glass or enameled pots.
Medical Uses and/or Benefits Reduced risk of heart attack. Data from the American Cancer Society’s Cancer Prevention Study 1, a 12-year survey of more than 1 million Americans in 25 states, shows that men who take one drink a day have a 21 percent lower risk of heart attack and a 22 percent lower risk of stroke than men who do not drink at all. Women who have up to one drink a day also reduce their risk of heart attack. Numerous later studies have confirmed these findings. Lower risk of stroke. In January 1999, the results of a 677-person study published by researchers at New York Presbyterian Hospital-Columbia University showed that moder- ate alcohol consumption reduces the risk of stroke due to a blood clot in the brain among older people (average age: 70). How the alcohol prevents stroke is still unknown, but it is clear that moderate use of alcohol is a key. Heavy drinkers (those who consume more than seven drinks a day) have a higher risk of stroke. People who once drank heavily, but cut their consumption to moderate levels, can also reduce their risk of stroke. Numerous later studies have confirmed these findings. Lower cholesterol levels. Beverage alcohol decreases the body’s production and storage of low-density lipoproteins (LDLs), the protein and fat particles that carr y cholesterol into your arteries. As a result, people who drink moderately tend to have lower cholesterol levels and higher levels of high density lipoproteins (HDLs), the fat and protein particles that carr y cholesterol out of the body. The USDA /Health and Human Services Dietar y Guidelines for Americans defines moderation as two drinks a day for a man, one drink a day for a woman. Stimulating the appetite. Alcoholic beverages stimulate the production of saliva and the gastric acids that cause the stomach contractions we call hunger pangs. Moderate amounts of alcoholic beverages, which may help stimulate appetite, are often prescribed for geriatric patients, convalescents, and people who do not have ulcers or other chronic gastric problems that might be exacerbated by the alcohol. Dilation of blood vessels. Alcohol dilates the capillaries (the tiny blood vessels just under the skin), and moderate amounts of alcoholic beverages produce a pleasant flush that temporar- ily warms the drinker. But drinking is not an effective way to warm up in cold weather since the warm blood that flows up to the capillaries will cool down on the surface of your skin and make you even colder when it circulates back into the center of your body. Then an alco- hol flush will make you perspire, so that you lose more heat. Excessive amounts of beverage alcohol may depress the mechanism that regulates body temperature.
Adverse Effects Associated with This Food Increased risk of breast cancer. In 2008, scientists at the National Cancer Institute released data from a seven-year survey of more than 100,000 postmenopausal women showing that even moderate drinking (one to two drinks a day) may increase by 32 percent a woman’s risk of developing estrogen-receptor positive (ER+) and progesterone-receptor positive (PR+) breast cancer, tumors whose growth is stimulated by hormones. No such link was found between consuming alcohol and the risk of developing ER-/PR- tumors (not fueled by hor- mones). The finding applies to all types of alcohol: beer, wine, and spirits. Increased risk of oral cancer (cancer of the mouth and throat). Numerous studies confirm the American Cancer Society’s warning that men and women who consume more than two drinks a day are at higher risk of oral cancer than are nondrinkers or people who drink less. Note: The Dietary Guidelines for Americans describes one drink as 12 ounces of beer, five ounces of wine, or 1.5 ounces of distilled spirits. Increased risk of cancer of the colon and rectum. In the mid-1990s, studies at the University of Oklahoma suggested that men who drink more than five beers a day are at increased risk of rectal cancer. Later studies suggested that men and women who are heavy beer or spirits drinkers (but not those who are heavy wine drinkers) have a higher risk of colorectal cancers. Further studies are required to confirm these findings. Fetal alcohol syndrome. Fetal alcohol syndrome is a specific pattern of birth defects—low birth weight, heart defects, facial malformations, and mental retardation—first recognized in a study of babies born to alcoholic women who consumed more than six drinks a day while pregnant. Subsequent research has found a consistent pattern of milder defects in babies born to women who consume three to four drinks a day or five drinks on any one occasion while pregnant. To date, there is no evidence of a consistent pattern of birth defects in babies born to women who consume less than one drink a day while pregnant, but two studies at Columbia University have suggested that as few as two drinks a week while preg- nant may raise a woman’s risk of miscarriage. (“One drink” means 12 ounces of beer, five ounces of wine, or 1.25 ounces of distilled spirits.) Alcoholism. Alcoholism is an addiction disease, the inability to control one’s alcohol consumption. It is a potentially life-threatening condition, with a higher risk of death by accident, suicide, malnutrition, or acute alcohol poisoning, a toxic reaction that kills by para- lyzing body organs, including the heart. Malnutrition. While moderate alcohol consumption stimulates appetite, alcohol abuse depresses it. In addition, an alcoholic may drink instead of eating. When an alcoholic does eat, excess alcohol in his/her body prevents absorption of nutrients and reduces the ability to synthesize new tissue. Hangover. Alcohol is absorbed from the stomach and small intestine and carried by the bloodstream to the liver, where it is oxidized to acetaldehyde by alcohol dehydrogenase (ADH), the enzyme our bodies use to metabolize the alcohol we produce when we digest carbohydrates. The acetaldehyde is converted to acetyl coenzyme A and either eliminated from the body or used in the synthesis of cholesterol, fatty acids, and body tissues. Although individuals vary widely in their capacity to metabolize alcohol, on average, normal healthy adults can metabolize the alcohol in one quart of beer in approximately five to six hours. If they drink more than that, they will have more alcohol than the body’s natural supply of ADH can handle. The unmetabolized alcohol will pile up in the bloodstream, interfering with the liver’s metabolic functions. Since alcohol decreases the reabsorption of water from the kidneys and may inhibit the secretion of an antidiuretic hormone, they will begin to urinate copiously, losing magnesium, calcium, and zinc but retaining more irritating uric acid. The level of lactic acid in the body will increase, making them feel tired and out of sorts; their acid-base balance will be out of kilter; the blood vessels in their heads will swell and throb; and their stomachs, with linings irritated by the alcohol, will ache. The ultimate result is a “hangover” whose symptoms will disappear only when enough time has passed to allow their bodies to marshal the ADH needed to metabolize the extra alcohol in their blood. Changes in body temperature. Alcohol dilates capillaries, tiny blood vessels just under the skin, producing a “flush” that temporarily warms the drinker. But drinking is not an effective way to stay warm in cold weather. Warm blood flowing up from the body core to the surface capillaries is quickly chilled, making you even colder when it circulates back into your organs. In addition, an alcohol flush triggers perspiration, further cooling your skin. Finally, very large amounts of alcohol may actually depress the mechanism that regulates body temperature. Impotence. Excessive drinking decreases libido (sexual desire) and interferes with the ability to achieve or sustain an erection. “Beer belly.” Data from a 1995, 12,000 person study at the University of North Carolina in Chapel Hill show that people who consume at least six beers a week have more rounded abdomens than people who do not drink beer. The question left to be answered is which came first: the tummy or the drinking.
Food/Drug Interactions Acetaminophen (Tylenol, etc.). The FDA recommends that people who regularly have three or more drinks a day consult a doctor before using acetaminophen. The alcohol/acetamino- phen combination may cause liver failure. Disulfiram (Antabuse). Taken with alcohol, disulfiram causes flushing, nausea, low blood pressure, faintness, respiratory problems, and confusion. The severity of the reaction gener- ally depends on how much alcohol you drink, how much disulfiram is in your body, and how long ago you took it. Disulfiram is used to help recovering alcoholics avoid alcohol. (If taken with alcohol, metronidazole [Flagyl], procarbazine [Matulane], quinacrine [Atabrine], chlorpropamide (Diabinase), and some species of mushrooms may produce a mild disulfi- ramlike reaction.) Anticoagulants. Alcohol slows the body’s metabolism of anticoagulants (blood thinners) such as warfarin (Coumadin), intensif ying the effect of the drugs and increasing the risk of side effects such as spontaneous nosebleeds. Antidepressants. Alcohol may increase the sedative effects of antidepressants. Drinking alcohol while you are taking a monoamine oxidase (M AO) inhibitor is especially hazard- ous. M AO inhibitors inactivate naturally occurring enzymes in your body that metabolize tyramine, a substance found in many fermented or aged foods. Tyramine constricts blood vessels and increases blood pressure. If you eat a food containing tyramine while you are taking an M AO inhibitor, you cannot effectively eliminate the tyramine from your body. The result may be a hypertensive crisis. Ordinarily, fermentation of beer and ale does not produce tyramine, but some patients have reported tyramine reactions after drinking some imported beers. Beer and ale are usually prohibited to those using M AO inhibitors. Aspirin, ibuprofen, ketoprofen, naproxen, and nonsteroidal anti-inflammatory drugs. Like alcohol, these analgesics irritate the lining of the stomach and may cause gastric bleeding. Combining the two intensifies the effect. Insulin and oral hypoglycemics. Alcohol lowers blood sugar and interferes with the metabo- lism of oral antidiabetics; the combination may cause severe hypoglycemia. Sedatives and other central nervous system depressants (tranquilizers, sleeping pills, antidepres- sants, sinus and cold remedies, analgesics, and medication for motion sickness). Alcohol inten- sifies sedation and, depending on the dose, may cause drowsiness, respiratory depression, coma, or death.... beer
Nutritional Profile Energy value (calories per serving): Low Protein: Trace Fat: Trace Saturated fat: None Cholesterol: None Carbohydrates: Trace Fiber: Trace Sodium: Low Major vitamin contribution: None Major mineral contribution: None
About the Nutrients in This Food Coffee beans are roasted seeds from the fruit of the evergreen coffee tree. Like other nuts and seeds, they are high in proteins (11 percent), sucrose and other sugars (8 percent), oils (10 to 15 percent), assorted organic acids (6 percent), B vitamins, iron, and the central nervous system stimulant caffeine (1 to 2 percent). With the exceptions of caffeine, none of these nutrients is found in coffee. Like spinach, rhubarb, and tea, coffee contains oxalic acid (which binds calcium ions into insoluble compounds your body cannot absorb), but this is of no nutritional consequence as long as your diet contains adequate amounts of calcium-rich foods. Coffee’s best known constituent is the methylxanthine central ner- vous system stimulant caffeine. How much caffeine you get in a cup of coffee depends on how the coffee was processed and brewed. Caffeine is Caffeine Content/Coffee Servings Brewed coffee 60 mg/five-ounce cup Brewed/decaffeinated 5 mg/five-ounce cup Espresso 64 mg/one-ounce serving Instant 47 mg/rounded teaspoon
The Most Nutritious Way to Serve This Food In moderation, with high-calcium foods. Like spinach, rhubarb, and tea, coffee has oxalic acid, which binds calcium into insoluble compounds. This will have no important effect as long as you keep your consumption moderate (two to four cups of coffee a day) and your calcium consumption high.
Diets That May Restrict or Exclude This Food Bland diet Gout diet Diet for people with heart disease (regular coffee)
Buying This Food Look for: Ground coffee and coffee beans in tightly sealed, air- and moisture-proof containers. Avoid: Bulk coffees or coffee beans stored in open bins. When coffee is exposed to air, the volatile molecules that give it its distinctive flavor and richness escape, leaving the coffee flavorless and/or bitter.
Storing This Food Store unopened vacuum-packed cans of ground coffee or coffee beans in a cool, dark cabinet—where they will stay fresh for six months to a year. They will lose some flavor in storage, though, because it is impossible to can coffee without trapping some flavor- destroying air inside the can. Once the can or paper sack has been opened, the coffee or beans should be sealed as tight as possible and stored in the refrigerator. Tightly wrapped, refrigerated ground coffee will hold its freshness and flavor for about a week, whole beans for about three weeks. For longer storage, freeze the coffee or beans in an air- and moistureproof container. ( You can brew coffee directly from frozen ground coffee and you can grind frozen beans without thawing them.)
Preparing This Food If you make your coffee with tap water, let the water run for a while to add oxygen. Soft water makes “cleaner”-tasting coffee than mineral-rich hard water. Coffee made with chlorinated water will taste better if you refrigerate the water overnight in a glass (not plastic) bottle so that the chlorine evaporates. Never make coffee with hot tap water or water that has been boiled. Both lack oxygen, which means that your coffee will taste flat. Always brew coffee in a scrupulously clean pot. Each time you make coffee, oils are left on the inside of the pot. If you don’t scrub them off, they will turn rancid and the next pot of coffee you brew will taste bitter. To clean a coffee pot, wash it with detergent, rinse it with water in which you have dissolved a few teaspoons of baking soda, then rinse one more time with boiling water.
What Happens When You Cook This Food In making coffee, your aim is to extract flavorful solids (including coffee oils and sucrose and other sugars) from the ground beans without pulling bitter, astringent tannins along with them. How long you brew the coffee determines how much solid material you extract and how the coffee tastes. The longer the brewing time, the greater the amount of solids extracted. If you brew the coffee long enough to extract more than 30 percent of its solids, you will get bitter compounds along with the flavorful ones. (These will also develop by let- ting coffee sit for a long time after brewing it.) Ordinarily, drip coffee tastes less bitter than percolator coffee because the water in a drip coffeemaker goes through the coffee only once, while the water in the percolator pot is circulated through the coffee several times. To make strong but not bitter coffee, increase the amount of coffee—not the brewing time.
How Other Kinds of Processing Affect This Food Drying. Soluble coffees (freeze-dried, instant) are made by dehydrating concentrated brewed coffee. These coffees are often lower in caffeine than regular ground coffees because caffeine, which dissolves in water, is lost when the coffee is dehydrated. Decaffeinating. Decaffeinated coffee is made with beans from which the caffeine has been extracted, either with an organic solvent (methylene chloride) or with water. How the coffee is decaffeinated has no effect on its taste, but many people prefer water-processed decaf- feinated coffee because it is not a chemically treated food. (Methylene chloride is an animal carcinogen, but the amounts that remain in coffees decaffeinated with methylene chloride are so small that the FDA does not consider them hazardous. The carcinogenic organic sol- vent trichloroethylene [TCE], a chemical that causes liver cancer in laboratory animals, is no longer used to decaffeinate coffee.)
Medical Uses and/or Benefits As a stimulant and mood elevator. Caffeine is a stimulant. It increases alertness and concentra- tion, intensifies muscle responses, quickens heartbeat, and elevates mood. Its effects derive from the fact that its molecular structure is similar to that of adenosine, a natural chemical by-product of normal cell activity. Adenosine is a regular chemical that keeps nerve cell activ- ity within safe limits. When caffeine molecules hook up to sites in the brain when adenosine molecules normally dock, nerve cells continue to fire indiscriminately, producing the jangly feeling sometimes associated with drinking coffee, tea, and other caffeine products. As a rule, it takes five to six hours to metabolize and excrete caffeine from the body. During that time, its effects may vary widely from person to person. Some find its stimu- lation pleasant, even relaxing; others experience restlessness, nervousness, hyperactivity, insomnia, flushing, and upset stomach after as little as one cup a day. It is possible to develop a tolerance for caffeine, so people who drink coffee every day are likely to find it less imme- diately stimulating than those who drink it only once in a while. Changes in blood vessels. Caffeine’s effects on blood vessels depend on site: It dilates coronary and gastrointestinal vessels but constricts blood vessels in your head and may relieve headache, such as migraine, which symptoms include swollen cranial blood vessels. It may also increase pain-free exercise time in patients with angina. However, because it speeds up heartbeat, doc- tors often advise patients with heart disease to avoid caffeinated beverages entirely. As a diuretic. Caffeine is a mild diuretic sometimes included in over-the-counter remedies for premenstrual tension or menstrual discomfort.
Adverse Effects Associated with This Food Stimulation of acid secretion in the stomach. Both regular and decaffeinated coffees increase the secretion of stomach acid, which suggests that the culprit is the oil in coffee, not its caffeine. Elevated blood levels of cholesterol and homocysteine. In the mid-1990s, several studies in the Netherlands and Norway suggested that drinking even moderate amounts of coffee (five cups a day or less) might raise blood levels of cholesterol and homocysteine (by-product of protein metabolism considered an independent risk factor for heart disease), thus increas- ing the risk of cardiovascular disease. Follow-up studies, however, showed the risk limited to drinking unfiltered coffees such as coffee made in a coffee press, or boiled coffees such as Greek, Turkish, or espresso coffee. The unfiltered coffees contain problematic amounts of cafestol and kahweol, two members of a chemical family called diterpenes, which are believed to affect cholesterol and homocysteine levels. Diterpenes are removed by filtering coffee, as in a drip-brew pot. Possible increased risk of miscarriage. Two studies released in 2008 arrived at different conclusions regarding a link between coffee consumption and an increased risk of miscar- riage. The first, at Kaiser Permanente (California), found a higher risk of miscarriage among women consuming even two eight-ounce cups of coffee a day. The second, at Mt. Sinai School of Medicine (New York), found no such link. However, although the authors of the Kaiser Permanente study described it as a “prospective study” (a study in which the research- ers report results that occur after the study begins), in fact nearly two-thirds of the women who suffered a miscarriage miscarried before the study began, thus confusing the results. Increased risk of heartburn /acid reflux. The natural oils in both regular and decaffeinated coffees loosen the lower esophageal sphincter (LES), a muscular valve between the esopha- gus and the stomach. When food is swallowed, the valve opens to let food into the stomach, then closes tightly to keep acidic stomach contents from refluxing (flowing backwards) into the esophagus. If the LES does not close efficiently, the stomach contents reflux and cause heartburn, a burning sensation. Repeated reflux is a risk factor for esophageal cancer. Masking of sleep disorders. Sleep deprivation is a serious problem associated not only with automobile accidents but also with health conditions such as depression and high blood pres- sure. People who rely on the caffeine in a morning cup of coffee to compensate for lack of sleep may put themselves at risk for these disorders. Withdrawal symptoms. Caffeine is a drug for which you develop a tolerance; the more often you use it, the more likely you are to require a larger dose to produce the same effects and the more likely you are to experience withdrawal symptoms (headache, irritation) if you stop using it. The symptoms of coffee-withdrawal can be relieved immediately by drinking a cup of coffee.
Food/Drug Interactions Drugs that make it harder to metabolize caffeine. Some medical drugs slow the body’s metabolism of caffeine, thus increasing its stimulating effect. The list of such drugs includes cimetidine (Tagamet), disulfiram (Antabuse), estrogens, fluoroquinolone antibiotics (e.g., ciprofloxacin, enoxacin, norfloxacin), fluconazole (Diflucan), fluvoxamine (Luvox), mexi- letine (Mexitil), riluzole (R ilutek), terbinafine (Lamisil), and verapamil (Calan). If you are taking one of these medicines, check with your doctor regarding your consumption of caf- feinated beverages. Drugs whose adverse effects increase due to consumption of large amounts of caffeine. This list includes such drugs as metaproterenol (Alupent), clozapine (Clozaril), ephedrine, epinephrine, monoamine oxidase inhibitors, phenylpropanolamine, and theophylline. In addition, suddenly decreasing your caffeine intake may increase blood levels of lithium, a drug used to control mood swings. If you are taking one of these medicines, check with your doctor regarding your consumption of caffeinated beverages. Allopurinol. Coffee and other beverages containing methylxanthine stimulants (caffeine, theophylline, and theobromine) reduce the effectiveness of the antigout drug allopurinol, which is designed to inhibit xanthines. Analgesics. Caffeine strengthens over-the-counter painkillers (acetaminophen, aspirin, and other nonsteroidal anti-inflammatories [NSAIDS] such as ibuprofen and naproxen). But it also makes it more likely that NSAIDS will irritate your stomach lining. Antibiotics. Coffee increases stomach acidity, which reduces the rate at which ampicillin, erythromycin, griseofulvin, penicillin, and tetracyclines are absorbed when they are taken by mouth. (There is no effect when the drugs are administered by injection.) Antiulcer medication. Coffee increases stomach acidity and reduces the effectiveness of nor- mal doses of cimetidine and other antiulcer medication. False-positive test for pheochromocytoma. Pheochromocytoma, a tumor of the adrenal glands, secretes adrenalin, which is converted to VM A (vanillylmandelic acid) by the body and excreted in the urine. Until recently, the test for this tumor measured the levels of VM A in the patient’s urine and coffee, which contains VM A, was eliminated from patients’ diets lest it elevate the level of VM A in the urine, producing a false-positive test result. Today, more finely drawn tests make this unnecessary. Iron supplements. Caffeine binds with iron to form insoluble compounds your body cannot absorb. Ideally, iron supplements and coffee should be taken at least two hours apart. Birth control pills. Using oral contraceptives appears to double the time it takes to eliminate caffeine from the body. Instead of five to six hours, the stimulation of one cup of coffee may last as long as 12 hours. Monoamine oxidase (MAO) inhibitors. Monoamine oxidase inhibitors are drugs used to treat depression. They inactivate naturally occurring enzymes in your body that metabolize tyra- mine, a substance found in many fermented or aged foods. Tyramine constricts blood vessels and increases blood pressure. Caffeine is a substance similar to tyramine. If you consume excessive amounts of a caffeinated beverage such as coffee while you are taking an M AO inhibitor, the result may be a hypertensive crisis. Nonprescription drugs containing caffeine. The caffeine in coffee may add to the stimulant effects of the caffeine in over-the-counter cold remedies, diuretics, pain relievers, stimulants, and weight-control products containing caffeine. Some cold pills contain 30 mg caffeine, some pain relievers 130 mg, and some weight-control products as much as 280 mg caffeine. There are 110 –150 mg caffeine in a five-ounce cup of drip-brewed coffee. Sedatives. The caffeine in coffee may counteract the drowsiness caused by sedative drugs; this may be a boon to people who get sleepy when they take antihistamines. Coffee will not, however, “sober up” people who are experiencing the inebriating effects of alcoholic beverages. Theophylline. Caffeine relaxes the smooth muscle of the bronchi and may intensif y the effects (and/or increase the risk of side effects) of this antiasthmatic drug.... coffee
– but can be the result of excess secretions from the mucous linings of the vagina or rectum.... discharge
Nutritional Profile Energy value (calories per serving): Moderate to high Protein: None Fat: None Saturated fat: None Cholesterol: None Carbohydrates: None (except for cordials which contain added sugar) Fiber: None Sodium: Low Major vitamin contribution: None Major mineral contribution: Phosphorus
About the Nutrients in This Food Spirits are the clear liquids produced by distilling the fermented sugars of grains, fruit, or vegetables. The yeasts that metabolize these sugars and convert them into alcohol stop growing when the concentration of alcohol rises above 12–15 percent. In the United States, the proof of an alcoholic beverage is defined as twice its alcohol content by volume: a beverage with 20 percent alcohol by volume is 40 proof. This is high enough for most wines, but not high enough for most whiskies, gins, vodkas, rums, brandies, and tequilas. To reach the concentra- tion of alcohol required in these beverages, the fermented sugars are heated and distilled. Ethyl alcohol (the alcohol in beer, wine, and spirits) boils at a lower temperature than water. When the fermented sugars are heated, the ethyl alcohol escapes from the distillation vat and condenses in tubes leading from the vat to a collection vessel. The clear liquid that collects in this vessel is called distilled spirits or, more technically, grain neutral spirits. Gins, whiskies, cordials, and many vodkas are made with spirits American whiskeys (which include bourbon, rye, and distilled from grains. blended whiskeys) and Canadian, Irish, and Scotch whiskies are all made from spirits aged in wood barrels. They get their flavor from the grains and their color from the barrels. (Some whiskies are also colored with caramel.) Vodka is made from spirits distilled and filtered to remove all flavor. By law, vodkas made in America must be made with spirits distilled from grains. Imported vodkas may be made with spirits distilled either from grains or potatoes and may contain additional flavoring agents such as citric acid or pepper. Aquavit, for example, is essentially vodka flavored with caraway seeds. Gin is a clear spirit flavored with an infusion of juniper berries and other herbs (botanicals). Cordials (also called liqueurs) and schnapps are flavored spirits; most are sweetened with added sugar. Some cordials contain cream. Rum is made with spirits distilled from sugar cane (molasses). Tequila is made with spirits distilled from the blue agave plant. Brandies are made with spirits distilled from fruit. (Arma- gnac and cognac are distilled from fermented grapes, calvados and applejack from fermented apples, kirsch from fermented cherries, slivovitz from fermented plums.) Unless they contain added sugar or cream, spirits have no nutrients other than alcohol. Unlike food, which has to be metabolized before your body can use it for energy, alcohol can be absorbed into the blood-stream directly from the gastrointestinal tract. Ethyl alcohol provides 7 calories per gram.
The Most Nutritious Way to Serve This Food The USDA /Health and Human Services Dietary Guidelines for Americans defines one drink as 12 ounces of beer, five ounces of wine, or 1.25 ounces of distilled spirits, and “moderate drinking” as two drinks a day for a man, one drink a day for a woman.
Diets That May Restrict or Exclude This Food Bland diet Lactose-free diet (cream cordials made with cream or milk) Low-purine (antigout) diet
Buying This Food Look for: Tightly sealed bottles stored out of direct sunlight, whose energy might disrupt the structure of molecules in the beverage and alter its flavor. Choose spirits sold only by licensed dealers. Products sold in these stores are manufac- tured under the strict supervision of the federal government.
Storing This Food Store sealed or opened bottles of spirits in a cool, dark cabinet.
Preparing This Food All spirits except unflavored vodkas contain volatile molecules that give the beverage its characteristic taste and smell. Warming the liquid excites these molecules and intensifies the flavor and aroma, which is the reason we serve brandy in a round glass with a narrower top that captures the aromatic molecules as they rise toward the air when we warm the glass by holding it in our hands. Whiskies, too, though traditionally served with ice in America, will have a more intense flavor and aroma if served at room temperature.
What Happens When You Cook This Food The heat of cooking evaporates the alcohol in spirits but leaves the flavoring intact. Like other alcoholic beverages, spirits should be added to a recipe near the end of the cooking time to preserve the flavor while cooking away any alcohol bite. Alcohol is an acid. If you cook it in an aluminum or iron pot, it will combine with metal ions to form dark compounds that discolor the pot and the food you are cooking. Any recipe made with spirits should be prepared in an enameled, glass, or stainless-steel pot.
Medical Uses and/or Benefits Reduced risk of heart attack. Data from the American Cancer Society’s Cancer Prevention Study 1, a 12-year survey of more than 1 million Americans in 25 states, shows that men who take one drink a day have a 21 percent lower risk of heart attack and a 22 percent lower risk of stroke than men who do not drink at all. Women who have up to one drink a day also reduce their risk of heart attack. Numerous later studies have confirmed these findings. Lower cholesterol levels. Beverage alcohol decreases the body’s production and storage of low density lipoproteins (LDLs), the protein and fat particles that carry cholesterol into your arteries. As a result, people who drink moderately tend to have lower cholesterol levels and higher levels of high density lipoproteins (HDLs), the fat and protein particles that carry cholesterol out of the body. Numerous later studies have confirmed these findings. Lower risk of stroke. In January 1999, the results of a 677-person study published by researchers at New York Presbyterian Hospital-Columbia University showed that moderate alcohol consumption reduces the risk of stroke due to a blood clot in the brain among older people (average age: 70). How alcohol prevents stroke is still unknown, but it is clear that moderate use is a key. Heavy drinkers (those who consume more than seven drinks a day) have a higher risk of stroke. People who once drank heavily, but cut their consumption to moderate levels, reduce their risk of stroke. Stimulating the appetite. Alcoholic beverages stimulate the production of saliva and the gastric acids that cause the stomach contractions we call hunger pangs. Moderate amounts of alcoholic beverages, which may help stimulate appetite, are often prescribed for geriatric patients, convalescents, and people who do not have ulcers or other chronic gastric problems that might be exacerbated by the alcohol. Dilation of blood vessels. Alcoholic beverages dilate the tiny blood vessels just under the skin, bringing blood up to the surface. That’s why moderate amounts of alcoholic beverages (0.2–1 gram per kilogram of body weight, or two ounces of whiskey for a 150-pound adult) temporarily warm the drinker. But the warm blood that flows up to the surface of the skin will cool down there, making you even colder when it circulates back into the center of your body. Then an alcohol flush will make you perspire, so you lose more heat. Excessive amounts of beverage alcohol may depress the mechanism that regulates body temperature.
Adverse Effects Associated with This Food Alcoholism. Alcoholism is an addiction disease, the inability to control one’s alcohol consumption. It is a potentially life-threatening condition, with a higher risk of death by accident, suicide, malnutrition, or acute alcohol poisoning, a toxic reaction that kills by para- lyzing body organs, including the heart. Fetal alcohol syndrome. Fetal alcohol syndrome is a specific pattern of birth defects—low birth weight, heart defects, facial malformations, learning disabilities, and mental retarda- tion—first recognized in a study of babies born to alcoholic women who consumed more than six drinks a day while pregnant. Subsequent research has found a consistent pattern of milder defects in babies born to women who drink three to four drinks a day or five drinks on any one occasion while pregnant. To date there is no evidence of a consistent pattern of birth defects in babies born to women who consume less than one drink a day while preg- nant, but two studies at Columbia University have suggested that as few as two drinks a week while pregnant may raise a woman’s risk of miscarriage. (One drink is 12 ounces of beer, five ounces of wine, or 1.25 ounces of distilled spirits.) Increased risk of breast cancer. In 2008, scientists at the National Cancer Institute released data from a seven-year survey of more than 100,000 postmenopausal women showing that even moderate drinking (one to two drinks a day) may increase by 32 percent a woman’s risk of developing estrogen-receptor positive (ER+) and progesterone-receptor positive (PR+) breast cancer, tumors whose growth is stimulated by hormones. No such link was found between consuming alcohol and the risk of developing ER-/PR- tumors (not fueled by hor- mones). The finding applies to all types of alcohol: beer, wine, and distilled spirits. Increased risk of oral cancer (cancer of the mouth and throat). Numerous studies confirm the A merican Cancer Societ y’s warn ing that men and women who consume more than t wo drinks a day are at higher risk of oral cancer than are nondrinkers or people who drink less. Increased risk of cancer of the colon and rectum. In the mid-1990s, studies at the University of Oklahoma suggested that men who drink more than five beers a day are at increased risk of rectal cancer. Later studies suggested that men and women who are heavy beer or spirits drinkers (but not those who are heavy wine drinkers) have a higher risk of colorectal cancers. Further studies are required to confirm these findings. Malnutrition. While moderate alcohol consumption stimulates appetite, alcohol abuses depresses it. In addition, an alcoholic may drink instead of eating. When an alcoholic does eat, excess alcohol in his/her body prevents absorption of nutrients and reduces the ability to synthesize new tissue. Hangover. Alcohol is absorbed from the stomach and small intestine and carried by the bloodstream to the liver, where it is oxidized to acetaldehyde by alcohol dehydrogenase (ADH), the enzyme our bodies use every day to metabolize the alcohol we produce when we digest carbohydrates. The acetaldehyde is converted to acetyl coenzyme A and either eliminated from the body or used in the synthesis of cholesterol, fatty acids, and body tis- sues. Although individuals vary widely in their capacity to metabolize alcohol, an adult of average size can metabolize the alcohol in four ounces (120 ml) whiskey in approximately five to six hours. If he or she drinks more than that, the amount of alcohol in the body will exceed the available supply of ADH. The surplus, unmetabolized alcohol will pile up in the bloodstream, interfering with the liver’s metabolic functions. Since alcohol decreases the reabsorption of water from the kidneys and may inhibit the secretion of an antidiuretic hormone, the drinker will begin to urinate copiously, losing magnesium, calcium, and zinc but retaining uric acid, which is irritating. The level of lactic acid in the body will increase, making him or her feel tired and out of sorts; the acid-base balance will be out of kilter; the blood vessels in the head will swell and throb; and the stomach, its lining irritated by the alcohol, will ache. The ultimate result is a hangover whose symptoms will disappear only when enough time has passed to allow the body to marshal the ADH needed to metabolize the extra alcohol in the person’s blood. Changes in body temperature. Alcohol dilates capillaries, tiny blood vessels just under the skin, producing a “flush” that temporarily warms the drinker. But drinking is not an effective way to stay warm in cold weather. Warm blood flowing up from the body core to the surface capillaries is quickly chilled, making you even colder when it circulates back into your organs. In addition, an alcohol flush triggers perspiration, further cooling your skin. Finally, very large amounts of alcohol may actually depress the mechanism that regulates body temperature. Impotence. Excessive drinking decreases libido (sexual desire) and interferes with the ability to achieve or sustain an erection. Migraine headache. Some alcoholic beverages contain chemicals that inhibit PST, an enzyme that breaks down certain alcohols in spirits so that they can be eliminated from the body. If they are not broken down by PST, these alcohols will build up in the bloodstream and may trigger a migraine headache. Gin and vodka appear to be the distilled spirits least likely to trigger headaches, brandy the most likely.
Food/Drug Interactions Acetaminophen (Tylenol, etc.). FDA recommends that people who regularly have three or more drinks a day consult a doctor before using acetaminophen. The alcohol/acetaminophen combination may cause liver failure. Anti-alcohol abuse drugs (disulfiram [Antabuse]). Taken concurrently with alcohol, the anti- alcoholism drug disulfiram can cause flushing, nausea, a drop in blood pressure, breathing difficulty, and confusion. The severity of the symptoms, which may var y among individu- als, generally depends on the amount of alcohol consumed and the amount of disulfiram in the body. Anticoagulants. Alcohol slows the body’s metabolism of anticoagulants (blood thinners), intensif ying the effect of the drugs and increasing the risk of side effects such as spontane- ous nosebleeds. Antidepressants. Alcohol may strengthen the sedative effects of antidepressants. Aspirin, ibuprofen, ketoprofen, naproxen and nonsteroidal anti-inflammatory drugs. Like alco- hol, these analgesics irritate the lining of the stomach and may cause gastric bleeding. Com- bining the two intensifies the effect. Insulin and oral hypoglycemics. Alcohol lowers blood sugar and interferes with the metabo- lism of oral antidiabetics; the combination may cause severe hypoglycemia. Sedatives and other central nervous system depressants (tranquilizers, sleeping pills, antide- pressants, sinus and cold remedies, analgesics, and medication for motion sickness). Alcohol intensifies the sedative effects of these medications and, depending on the dose, may cause drowsiness, sedation, respiratory depression, coma, or death. MAO inhibitors. Monoamine oxidase (M AO) inhibitors are drugs used as antidepressants or antihypertensives. They inhibit the action of natural enzymes that break down tyramine, a substance formed naturally when proteins are metabolized. Tyramine is a pressor amine, a chemical that constricts blood vessel and raises blood pressure. If you eat a food that contains tyramine while you are taking an M AO inhibitor, the pressor amine cannot be eliminated from your body and the result may be a hypertensive crisis (sustained elevated blood pressure). Brandy, a distilled spirit made from wine (which is fermented) contains tyramine. All other distilled spirits may be excluded from your diet when you are taking an M AO inhibitor because the spirits and the drug, which are both sedatives, may be hazard- ous in combination.... distilled spirits
Nutritional Profile Energy value (calories per serving): Low Protein: Low Fat: Low Saturated fat: Low Cholesterol: None Carbohydrates: High Fiber: High Sodium: Low (fresh or dried fruit) High (dried fruit treated with sodium sulfur compounds) Major vitamin contribution: Vitamin C Major mineral contribution: Potassium
About the Nutrients in This Food Apples are a high-fiber fruit with insoluble cellulose and lignin in the peel and soluble pectins in the flesh. Their most important vitamin is vitamin C. One fresh apple, 2.5 inches in diameter, has 2.4 g dietary fiber and 4.6 mg vitamin C (6 percent of the R DA for a woman, 5 percent of the R DA for a man). The sour taste of all immature apples (and some varieties, even when ripe) comes from malic acid. As an apple ripens, the amount of malic acid declines and the apple becomes sweeter. Apple seeds contain amygdalin, a naturally occurring cyanide/sugar compound that degrades into hydrogen cyanide. While accidentally swal- lowing an apple seed once in a while is not a serious hazard for an adult, cases of human poisoning after eating apple seeds have been reported, and swallowing only a few seeds may be lethal for a child.
The Most Nutritious Way to Serve This Food Fresh and unpared, to take advantage of the fiber in the peel and preserve the vitamin C, which is destroyed by the heat of cooking.
Diets That May Restrict or Exclude This Food Antiflatulence diet (raw apples) Low-fiber diet
Buying This Food Look for: Apples that are firm and brightly colored: shiny red Macintosh, Rome, and red Delicious; clear green Granny Smith; golden yellow Delicious. Avoid: Bruised apples. When an apple is damaged the injured cells release polyphenoloxi- dase, an enzyme that hastens the oxidation of phenols in the apple, producing brownish pigments that darken the fruit. It’s easy to check loose apples; if you buy them packed in a plastic bag, turn the bag upside down and examine the fruit.
Storing This Food Store apples in the refrigerator. Cool storage keeps them from losing the natural moisture that makes them crisp. It also keeps them from turning brown inside, near the core, a phe- nomenon that occurs when apples are stored at warm temperatures. Apples can be stored in a cool, dark cabinet with plenty of circulating air. Check the apples from time to time. They store well, but the longer the storage, the greater the natural loss of moisture and the more likely the chance that even the crispest apple will begin to taste mealy.
Preparing This Food Don’t peel or slice an apple until you are ready to use it. When you cut into the apple, you tear its cells, releasing polyphenoloxidase, an enzyme that darkens the fruit. Acid inactivates polyphenoloxidase, so you can slow the browning (but not stop it completely) by dipping raw sliced and/or peeled apples into a solution of lemon juice and water or vinegar and water or by mixing them with citrus fruits in a fruit salad. Polyphenoloxidase also works more slowly in the cold, but storing peeled apples in the refrigerator is much less effective than immersing them in an acid bath.
What Happens When You Cook This Food When you cook an unpeeled apple, insoluble cellulose and lignin will hold the peel intact through all normal cooking. The flesh of the apple, though, will fall apart as the pectin in its cell walls dissolves and the water inside its cells swells, rupturing the cell walls and turning the apples into applesauce. Commercial bakers keep the apples in their apple pies firm by treating them with calcium; home bakers have to rely on careful timing. To prevent baked apples from melting into mush, core the apple and fill the center with sugar or raisins to absorb the moisture released as the apple cooks. Cutting away a circle of peel at the top will allow the fruit to swell without splitting the skin. Red apple skins are colored with red anthocyanin pigments. When an apple is cooked, the anthocyanins combine with sugars to form irreversible brownish compounds.
How Other Kinds of Processing Affect This Food Juice. Apple juice comes in two versions: “cloudy” (unfiltered) and “clear” (filtered). Cloudy apple juice is made simply by chopping or shredding apples and then pressing out and straining the juice. Clear apple juice is cloudy juice filtered to remove solid particles and then treated with enzymes to eliminate starches and the soluble fiber pectin. Since 2000, follow- ing several deaths attributed to unpasteurized apple juice contaminated with E. coli O157: H7, the FDA has required that all juices sold in the United States be pasteurized to inactivate harmful organisms such as bacteria and mold. Note: “Hard cider” is a mildly alcoholic bever- age created when natural enzyme action converts the sugars in apple juice to alcohol; “non- alcohol cider” is another name for plain apple juice. Drying. To keep apple slices from turning brown as they dry, apples may be treated with sulfur compounds that may cause serious allergic reactions in people allergic to sulfites.
Medical Uses and/or Benefits As an antidiarrheal. The pectin in apple is a natural antidiarrheal that helps solidif y stool. Shaved raw apple is sometimes used as a folk remedy for diarrhea, and purified pectin is an ingredient in many over-the-counter antidiarrheals. Lower cholesterol levels. Soluble fiber (pectin) may interfere with the absorption of dietary fats, including cholesterol. The exact mechanism by which this occurs is still unknown, but one theory is that the pectins in the apple may form a gel in your stomach that sops up fats and cholesterol, carrying them out of your body as waste. Potential anticarcinogenic effects. A report in the April 2008 issue of the journal Nutrition from a team of researchers at the Universit y of Kaiserslautern, in Germany, suggests that several natural chemicals in apples, including but yrate (produced naturally when the pectin in apples and apple juice is metabolized) reduce the risk of cancer of the colon by nourishing and protecting the mucosa (lining) of the colon.
Adverse Effects Associated with This Food Intestinal gas. For some children, drinking excess amounts of apple juice produces intestinal discomfort (gas or diarrhea) when bacteria living naturally in the stomach ferment the sugars in the juice. To reduce this problem, the American Academy of Pediatrics recommends that children ages one to six consume no more than four to six ounces of fruit juice a day; for children ages seven to 18, the recommended serving is eight to 12 ounces a day. Cyanide poisoning. See About the nutrients in this food. Sulfite allergies (dried apples). See How other kinds of processing affect this food.
Food/Drug Interactions Digoxin (Lanoxicaps, Lanoxin). Pectins may bind to the heart medication digoxin, so eating apples at the same time you take the drug may reduce the drug’s effectiveness.... apples
Atherosclerosis is due to the deposition of CHOLESTEROL into the walls of arteries. The process starts in childhood with the development of fatty streaks lining the arteries. In adulthood these progress, scarring and calcifying to form irregular narrowings within the arteries and eventually leading to blockage of the vessel. The consequence of the narrowing or blockage depends on which vessels are involved
– diseased cerebral vessels cause strokes; coronary vessels cause angina and heart attacks; renal vessels cause renal failure; and peripheral arteries cause limb ischaemia (localised bloodlessness).
Risk factors predisposing individuals to atherosclerosis include age, male gender, raised plasma cholesterol concentration, high blood pressure, smoking, a family history of atherosclerosis, diabetes and obesity.
Arteritis occurs in a variety of conditions that produce in?ammation in the arteries. Examples include syphilis – now rare in Britain
– which produces in?ammation of the aorta with subsequent dilatation (aneurysm formation) and risk of rupture; giant cell arteritis (temporal arteritis), a condition usually affecting the elderly, which involves the cranial arteries and leads to headache, tenderness over the temporal arteries and the risk of sudden blindness; Takayasu’s syndrome, predominantly affecting young females, which involves the aortic arch and its major branches, leading to the absence of pulse in affected vessels; and polyarteritis nodosa, a condition causing multiple small nodules to form on the smaller arteries. General symptoms such as fever, malaise, weakness, anorexia and weight loss are accompanied by local manifestations of ischaemia (bloodlessness) in di?erent parts of the body.... arteries, diseases of
Examination of the ear includes inspection of the external ear. An auriscope is used to examine the external ear canal and the ear drum. If a more detailed inspection is required, a microscope may be used to improve illumination and magni?cation.
Tuning-fork or Rinne tests are performed to identify the presence of DEAFNESS. The examiner tests whether the vibrating fork is audible at the meatus, and then the foot of the fork is placed on the mastoid bone of the ear to discover at which of the two sites the patient can hear the vibrations for the longest time. This can help to di?erentiate between conductive and nerve deafness.
Hearing tests are carried out to determine the level of hearing. An audiometer is used to deliver a series of short tones of varying frequency to the ear, either through a pair of headphones or via a sound transducer applied directly to the skull. The intensity of the sound is gradually reduced until it is no longer heard and this represents the threshold of hearing, at that frequency, through air and bone respectively. It may be necessary to play a masking noise into the opposite ear to prevent that ear from hearing the tones, enabling each ear to be tested independently.
General symptoms The following are some of the chief symptoms of ear disease: DEAFNESS (see DEAFNESS). EARACHE is most commonly due to acute in?ammation of the middle ear. Perceived pain in this region may be referred from other areas, such as the earache commonly experienced after tonsillectomy (removal of the TONSILS) or that caused by carious teeth (see TEETH, DISORDERS OF). The treatment will depend on the underlying cause. TINNITUS or ringing in the ear often accompanies deafness, but is sometimes the only symptom of ear disease. Even normal people sometimes experience tinnitus, particularly if put in soundproofed surroundings. It may be described as hissing, buzzing, the sound of the sea, or of bells. The intensity of the tinnitis usually ?uctuates, sometimes disappearing altogether. It may occur in almost any form of ear disease, but is particularly troublesome in nerve deafness due to ageing and in noise-induced deafness. The symptom seems to originate in the brain’s subcortical regions, high in the central nervous system. It may be a symptom of general diseases such as ANAEMIA, high blood pressure and arterial disease, in which cases it is often synchronous with the pulse, and may also be caused by drugs such as QUININE, salicylates (SALICYLIC ACID and its salts, for example, ASPIRIN) and certain ANTIBIOTICS. Treatment of any underlying ear disorder or systemic disease, including DEPRESSION, may reduce or even cure the tinnitis, but unfortunately in many cases the noises persist. Management involves psychological techniques and initially an explanation of the mechanism and reassurance that tinnitus does not signify brain disease, or an impending STROKE, may help the person. Tinnitus maskers – which look like hearing aids – have long been used with a suitably pitched sound helping to ‘mask’ the condition.
Diseases of the external ear
WAX (cerumen) is produced by specialised glands in the outer part of the ear canal only. Impacted wax within the ear canal can cause deafness, tinnitis and sometimes disturbance of balance. Wax can sometimes be softened with olive oil, 5-per-cent bicarbonate of soda or commercially prepared drops, and it will gradually liquefy and ‘remove itself’. If this is ineffective, syringing by a doctor or nurse will usually remove the wax but sometimes it is necessary for a specialist (otologist) to remove it manually with instruments. Syringing should not be done if perforation of the tympanic membrane (eardrum) is suspected. FOREIGN BODIES such as peas, beads or buttons may be found in the external ear canal, especially in children who have usually introduced them themselves. Live insects may also be trapped in the external canal causing intense irritation and noise, and in such cases spirit drops are ?rst instilled into the ear to kill the insect. Except in foreign bodies of vegetable origin, where swelling and pain may occur, syringing may be used to remove some foreign bodies, but often removal by a specialist using suitable instrumentation and an operating microscope is required. In children, a general anaesthetic may be needed. ACUTE OTITIS EXTERNA may be a di?use in?ammation or a boil (furuncle) occurring in the outer ear canal. The pinna is usually tender on movement (unlike acute otitis media – see below) and a discharge may be present. Initially treatment should be local, using magnesium sulphate paste or glycerine and 10-per-cent ichthaminol. Topical antibiotic drops can be used and sometimes antibiotics by mouth are necessary, especially if infection is acute. Clotrimazole drops are a useful antifungal treatment. Analgesics and locally applied warmth should relieve the pain.
CHRONIC OTITIS EXTERNA producing pain and discharge, can be caused by eczema, seborrhoeic DERMATITIS or PSORIASIS. Hair lotions and cosmetic preparations may trigger local allergic reactions in the external ear, and the chronic disorder may be the result of swimming or use of dirty towels. Careful cleaning of the ear by an ENT (Ear, Nose & Throat) surgeon and topical antibiotic or antifungal agents – along with removal of any precipitating cause – are the usual treatments. TUMOURS of the ear can arise in the skin of the auricle, often as a result of exposure to sunlight, and can be benign or malignant. Within the ear canal itself, the commonest tumours are benign outgrowths from the surrounding bone, said to occur in swimmers as a result of repeated exposure to cold water. Polyps may result from chronic infection of the ear canal and drum, particularly in the presence of a perforation. These polyps are soft and may be large enough to ?ll the ear canal, but may shrink considerably after treatment of the associated infection.
Diseases of the middle ear
OTITIS MEDIA or infection of the middle ear, usually occurs as a result of infection spreading up the Eustachian tubes from the nose, throat or sinuses. It may follow a cold, tonsillitis or sinusitis, and may also be caused by swimming and diving where water and infected secretions are forced up the Eustachian tube into the middle ear. Primarily it is a disease of children, with as many as 1.5 million cases occurring in Britain every year. Pain may be intense and throbbing or sharp in character. The condition is accompanied by deafness, fever and often TINNITUS.
In infants, crying may be the only sign that something is wrong – though this is usually accompanied by some localising manifestation such as rubbing or pulling at the ear. Examination of the ear usually reveals redness, and sometimes bulging, of the ear drum. In the early stages there is no discharge, but in the later stages there may be a discharge from perforation of the ear drum as a result of the pressure created in the middle ear by the accumulated pus. This is usually accompanied by an immediate reduction in pain.
Treatment consists of the immediate administration of an antibiotic, usually one of the penicillins (e.g. amoxicillin). In the majority of cases no further treatment is required, but if this does not quickly bring relief then it may be necessary to perform a myringotomy, or incision of the ear drum, to drain pus from the middle ear. When otitis media is treated immediately with su?cient dosage of the appropriate antibiotic, the chances of any permanent damage to the ear or to hearing are reduced to a negligible degree, as is the risk of any complications such as mastoiditis (discussed later in this section). CHRONIC OTITIS MEDIA WITH EFFUSION or glue ear, is the most common in?ammatory condition of the middle ear in children, to the extent that one in four children in the UK entering school has had an episode of ‘glue ear’. It is characterised by a persistent sticky ?uid in the middle ear (hence the name); this causes a conductive-type deafness. It may be associated with enlarged adenoids (see NOSE, DISORDERS OF) which impair the function of the Eustachian tube. If the hearing impairment is persistent and causes problems, drainage of the ?uid, along with antibiotic treatment, may be needed – possibly in conjunction with removal of the adenoids. The insertion of grommets (ventilation tubes) was for a time standard treatment, but while hearing is often restored, there may be no long-term gain and even a risk of damage to the tympanic membrane, so the operation is less popular than it was a decade or so ago. MASTOIDITIS is a serious complication of in?ammation of the middle ear, the incidence of which has been dramatically reduced by the introduction of antibiotics. In?ammation in this cavity usually arises by direct spread of acute or chronic in?ammation from the middle ear. The signs of this condition include swelling and tenderness of the skin behind the ear, redness and swelling inside the ear, pain in the side of the head, high fever, and a discharge from the ear. The management of this condition in the ?rst instance is with antibiotics, usually given intravenously; however, if the condition fails to improve, surgical treatment is necessary. This involves draining any pus from the middle ear and mastoid, and removing diseased lining and bone from the mastoid.
Diseases of the inner ear
MENIÈRE’S DISEASE is a common idiopathic disorder of ENDOLYMPH control in the semicircular canals (see EAR), characterised by the triad of episodic VERTIGO with deafness and tinnitus. The cause is unknown and usually one ear only is affected at ?rst, but eventually the opposite ear is affected in approximately 50 per cent of cases. The onset of dizziness is often sudden and lasts for up to 24 hours. The hearing loss is temporary in the early stages, but with each attack there may be a progressive nerve deafness. Nausea and vomiting often occur. Treatment during the attacks includes rest and drugs to control sickness. Vasodilator drugs such as betahistine hydrochloride may be helpful. Surgical treatment is sometimes required if crippling attacks of dizziness persist despite these measures. OTOSCLEROSIS A disorder of the middle ear that results in progressive deafness. Often running in families, otosclerosis affects about one person in 200; it customarily occurs early in adult life. An overgrowth of bone ?xes the stapes (the innermost bone of the middle ear) and stops sound vibrations from being transmitted to the inner ear. The result is conductive deafness. The disorder usually affects both ears. Those affected tend to talk quietly and deafness increases over a 10–15 year period. Tinnitus often occurs, and occasionally vertigo.
Abnormal hearing tests point to the diagnosis; the deafness may be partially overcome with a hearing aid but surgery is eventually needed. This involves replacing the stapes bone with a synthetic substitute (stapedectomy). (See also OTIC BAROTRAUMA.)... ear, diseases of
Treatment The choking person should take slow, deep inspirations, which do not force the particle further in (as sudden catchings of the breath between the coughs do), and which produce more powerful coughs. If the coughing is weak, one or two strong blows with the palm of the hand over either shoulder blade, timed to coincide with coughs, aid the e?ect of the coughing. If this is ine?ective, the Heimlich manoeuvre may be used. This involves hugging the person from behind with one’s hands just under the diaphragm. A sudden upward compressive movement is made which serves to dislodge any foreign body. In the case of a baby, sit down with left forearm resting on thigh. Place the baby chest-down along the forearm, holding its head and jaw with the ?ngers and thumb. The infant’s head should be lower than its trunk. Gently deliver three or four blows between the shoulder blades with the free hand. The resuscitator should not attempt blind ?nger-sweeps at the back of the mouth; these can impact a foreign body in the larynx.
If normal breathing (in adult or child) cannot be quickly restored, seek urgent medical help. Sometimes an emergency TRACHEOSTOMY is necessary to restore the air supply to the lungs. (See APPENDIX 1: BASIC FIRST AID.)... choking
Habitat: Cultivated all over India.
English: Lemon.Ayurvedic: Jambira, Jambh, Jambhir, Jaamphal, Nimbu, Nimbuka, Naaranga, Limpaka, Dantashatha, Airaavata, Neebu (bigger var.).Unani: Utraj.Siddha/Tamil: Periya elumuchhai.Action: Fruit—antiscorbutic, carminative, stomachic, antihistaminic, antibacterial. Used during coughs, colds, influenza and onset of fever (juice of roasted lemon), hiccoughs, biliousness. Fruit juice—used externally for ringworm (mixed with salt), erysipelas, also in the treatment of leprosy and white spots. Leaves and stems—antibacterial.
All parts of the plants of citrus sp. contain coumarins and psoralins. The fruits contain flavonoids and li- monoids. The flavonoids comprise three main groups—flavanones, fla- vones and 3-hydroxyflavylium (antho- cyanins); flavanones being predominantly followed by flavones and antho- cyanins. Bitter flavonoids do not occur in lemon and lime.Lemon juice is a richer source of antiscorbutic vitamin (contains 4050 mg/100 g of vitamin C) than lime, and a fair source of carotene and vitamin B1. Volatile oil (about 2.5% of the peel) consists of about 75% limonene, alpha-and beta-pinenes, alpha-ter- pinene and citral. The fruit juice also contains coumarins and bioflavonoids.The acid content of the fruit, once digested, provides an alkaline effect within the body and is found useful in conditions where acidity is a contributory factor (as in case of rheumatic conditions). The bioflavonoids strengthen the inner lining of blood vessels, especially veins and capillaries, and help counter varicose veins, arteriosclerosis, circulatory disorders and infections of liver, stomach and intestines.Major flavonoid glycosides, isolated from citrus peels and juices, include hesperidin (with properties of vitamin P). Rutin and other flavanones, isolated from citrus fruits, form the principal components of vitamin P. Flavanone glycosides contained in lemon and lime juices are eriocitrin 47 and 94; hesperidin 84 and 196 mg/l, respectively.The composition of cold pressed lime oil is quite similar to lemon oil, but citral content of lime oil is higher.Monoterpene alcohols and their esters, aldehydes—geraniol, geranial and neral, contribute to the characteristic aroma of lemon and lime.Dosage: Fruit—6-12 g (Juice—5- 10 ml). (API Vol. IV.)... citrus limonAdrenal glands These two glands, also known as suprarenal glands, lie immediately above the kidneys. The central or medullary portion of the glands forms the secretions known as ADRENALINE (or epinephrine) and NORADRENALINE. Adrenaline acts upon structures innervated by sympathetic nerves. Brie?y, the blood vessels of the skin and of the abdominal viscera (except the intestines) are constricted, and at the same time the arteries of the muscles and the coronary arteries are dilated; systolic blood pressure rises; blood sugar increases; the metabolic rate rises; muscle fatigue is diminished. The super?cial or cortical part of the glands produces steroid-based substances such as aldosterone, cortisone, hydrocortisone, and deoxycortone acetate, for the maintenance of life. It is the absence of these substances, due to atrophy or destruction of the suprarenal cortex, that is responsible for the condition known as ADDISON’S DISEASE. (See CORTICOSTEROIDS.)
Ovaries and testicles The ovary (see OVARIES) secretes at least two hormones – known, respectively, as oestradiol (follicular hormone) and progesterone (corpus luteum hormone). Oestradiol develops (under the stimulus of the anterior pituitary lobe – see PITUITARY GLAND below, and under separate entry) each time an ovum in the ovary becomes mature, and causes extensive proliferation of the ENDOMETRIUM lining the UTERUS, a stage ending with shedding of the ovum about 14 days before the onset of MENSTRUATION. The corpus luteum, which then forms, secretes both progesterone and oestradiol. Progesterone brings about great activity of the glands in the endometrium. The uterus is now ready to receive the ovum if it is fertilised. If fertilisation does not occur, the corpus luteum degenerates, the hormones cease acting, and menstruation takes place.
The hormone secreted by the testicles (see TESTICLE) is known as TESTOSTERONE. It is responsible for the growth of the male secondary sex characteristics.
Pancreas This gland is situated in the upper part of the abdomen and, in addition to the digestive enzymes, it produces INSULIN within specialised cells (islets of Langerhans). This controls carbohydrate metabolism; faulty or absent insulin production causes DIABETES MELLITUS.
Parathyroid glands These are four minute glands lying at the side of, or behind, the thyroid (see below). They have a certain e?ect in controlling the absorption of calcium salts by the bones and other tissues. When their secretion is defective, TETANY occurs.
Pituitary gland This gland is attached to the base of the brain and rests in a hollow on the base of the skull. It is the most important of all endocrine glands and consists of two embryologically and functionally distinct lobes.
The function of the anterior lobe depends on the secretion by the HYPOTHALAMUS of certain ‘neuro-hormones’ which control the secretion of the pituitary trophic hormones. The hypothalamic centres involved in the control of speci?c pituitary hormones appear to be anatomically separate. Through the pituitary trophic hormones the activity of the thyroid, adrenal cortex and the sex glands is controlled. The anterior pituitary and the target glands are linked through a feedback control cycle. The liberation of trophic hormones is inhibited by a rising concentration of the circulating hormone of the target gland, and stimulated by a fall in its concentration. Six trophic (polypeptide) hormones are formed by the anterior pituitary. Growth hormone (GH) and prolactin are simple proteins formed in the acidophil cells. Follicle-stimulating hormone (FSH), luteinising hormone (LH) and thyroid-stimulating hormone (TSH) are glycoproteins formed in the basophil cells. Adrenocorticotrophic hormone (ACTH), although a polypeptide, is derived from basophil cells.
The posterior pituitary lobe, or neurohypophysis, is closely connected with the hypothalamus by the hypothalamic-hypophyseal tracts. It is concerned with the production or storage of OXYTOCIN and vasopressin (the antidiuretic hormone).
PITUITARY HORMONES Growth hormone, gonadotrophic hormone, adrenocorticotrophic hormone and thyrotrophic hormones can be assayed in blood or urine by radio-immunoassay techniques. Growth hormone extracted from human pituitary glands obtained at autopsy was available for clinical use until 1985, when it was withdrawn as it is believed to carry the virus responsible for CREUTZFELDT-JAKOB DISEASE (COD). However, growth hormone produced by DNA recombinant techniques is now available as somatropin. Synthetic growth hormone is used to treat de?ciency of the natural hormone in children and adults, TURNER’S SYNDROME and chronic renal insu?ciency in children.
Human pituitary gonadotrophins are readily obtained from post-menopausal urine. Commercial extracts from this source are available and are e?ective for treatment of infertility due to gonadotrophin insu?ciency.
The adrenocorticotrophic hormone is extracted from animal pituitary glands and has been available therapeutically for many years. It is used as a test of adrenal function, and, under certain circumstances, in conditions for which corticosteroid therapy is indicated (see CORTICOSTEROIDS). The pharmacologically active polypeptide of ACTH has been synthesised and is called tetracosactrin. Thyrotrophic hormone is also available but it has no therapeutic application.
HYPOTHALAMIC RELEASING HORMONES which affect the release of each of the six anterior pituitary hormones have been identi?ed. Their blood levels are only one-thousandth of those of the pituitary trophic hormones. The release of thyrotrophin, adrenocorticotrophin, growth hormone, follicle-stimulating hormone and luteinising hormone is stimulated, while release of prolactin is inhibited. The structure of the releasing hormones for TSH, FSH-LH, GH and, most recently, ACTH is known and they have all been synthesised. Thyrotrophin-releasing hormone (TRH) is used as a diagnostic test of thyroid function but it has no therapeutic application. FSH-LH-releasing hormone provides a useful diagnostic test of gonadotrophin reserve in patients with pituitary disease, and is now used in the treatment of infertility and AMENORRHOEA in patients with functional hypothalamic disturbance. As this is the most common variety of secondary amenorrhoea, the potential use is great. Most cases of congenital de?ciency of GH, FSH, LH and ACTH are due to defects in the hypothalamic production of releasing hormone and are not a primary pituitary defect, so that the therapeutic implication of this synthesised group of releasing hormones is considerable.
GALACTORRHOEA is frequently due to a microadenoma (see ADENOMA) of the pituitary. DOPAMINE is the prolactin-release inhibiting hormone. Its duration of action is short so its therapeutic value is limited. However, BROMOCRIPTINE is a dopamine agonist with a more prolonged action and is e?ective treatment for galactorrhoea.
Thyroid gland The functions of the thyroid gland are controlled by the pituitary gland (see above) and the hypothalamus, situated in the brain. The thyroid, situated in the front of the neck below the LARYNX, helps to regulate the body’s METABOLISM. It comprises two lobes each side of the TRACHEA joined by an isthmus. Two types of secretory cells in the gland – follicular cells (the majority) and parafollicular cells – secrete, respectively, the iodine-containing hormones THYROXINE (T4) and TRI-IODOTHYRONINE (T3), and the hormone CALCITONIN. T3 and T4 help control metabolism and calcitonin, in conjunction with parathyroid hormone (see above), regulates the body’s calcium balance. De?ciencies in thyroid function produce HYPOTHYROIDISM and, in children, retarded development. Excess thyroid activity causes thyrotoxicosis. (See THYROID GLAND, DISEASES OF.)... endocrine glands
Chronic bronchitis is typi?ed by chronic productive cough for at least three months in two successive years (provided other causes such as TUBERCULOSIS, lung cancer and chronic heart failure have been excluded). The characteristics of emphysema are abnormal and permanent enlargement of the airspaces (alveoli) at the furthermost parts of the lung tissue. Rupture of alveoli occurs, resulting in the creation of air spaces with a gradual breakdown in the lung’s ability to oxygenate the blood and remove carbon dioxide from it (see LUNGS). Asthma results in in?ammation of the airways with the lining of the BRONCHIOLES becoming hypersensitive, causing them to constrict. The obstruction may spontaneously improve or do so in response to bronchodilator drugs. If an asthmatic patient’s airway-obstruction is characterised by incomplete reversibility, he or she is deemed to have a form of COPD called asthmatic bronchitis; sufferers from this disorder cannot always be readily distinguished from those people who have chronic bronchitis and/ or emphysema. Symptoms and signs of emphysema, chronic bronchitis and asthmatic bronchitis overlap, making it di?cult sometimes to make a precise diagnosis. Patients with completely reversible air?ow obstruction without the features of chronic bronchitis or emphysema, however, are considered to be suffering from asthma but not from COPD.
The incidence of COPD has been increasing, as has the death rate. In the UK around 30,000 people with COPD die annually and the disorder makes up 10 per cent of all admissions to hospital medical wards, making it a serious cause of illness and disability. The prevalence, incidence and mortality rates increase with age, and more men than women have the disorder, which is also more common in those who are socially disadvantaged.
Causes The most important cause of COPD is cigarette smoking, though only 15 per cent of smokers are likely to develop clinically signi?cant symptoms of the disorder. Smoking is believed to cause persistent airway in?ammation and upset the normal metabolic activity in the lung. Exposure to chemical impurities and dust in the atmosphere may also cause COPD.
Signs and symptoms Most patients develop in?ammation of the airways, excessive growth of mucus-secreting glands in the airways, and changes to other cells in the airways. The result is that mucus is transported less e?ectively along the airways to eventual evacuation as sputum. Small airways become obstructed and the alveoli lose their elasticity. COPD usually starts with repeated attacks of productive cough, commonly following winter colds; these attacks progressively worsen and eventually the patient develops a permanent cough. Recurrent respiratory infections, breathlessness on exertion, wheezing and tightness of the chest follow. Bloodstained and/or infected sputum are also indicative of established disease. Among the symptoms and signs of patients with advanced obstruction of air?ow in the lungs are:
RHONCHI (abnormal musical sounds heard through a STETHOSCOPE when the patient breathes out).
marked indrawing of the muscles between the ribs and development of a barrel-shaped chest.
loss of weight.
CYANOSIS in which the skin develops a blue tinge because of reduced oxygenation of blood in the blood vessels in the skin.
bounding pulse with changes in heart rhythm.
OEDEMA of the legs and arms.
decreasing mobility.
Some patients with COPD have increased ventilation of the alveoli in their lungs, but the levels of oxygen and carbon dioxide are normal so their skin colour is normal. They are, however, breathless so are dubbed ‘pink pu?ers’. Other patients have reduced alveolar ventilation which lowers their oxygen levels causing cyanosis; they also develop COR PULMONALE, a form of heart failure, and become oedematous, so are called ‘blue bloaters’.
Investigations include various tests of lung function, including the patient’s response to bronchodilator drugs. Exercise tests may help, but radiological assessment is not usually of great diagnostic value in the early stages of the disorder.
Treatment depends on how far COPD has progressed. Smoking must be stopped – also an essential preventive step in healthy individuals. Early stages are treated with bronchodilator drugs to relieve breathing symptoms. The next stage is to introduce steroids (given by inhalation). If symptoms worsen, physiotherapy – breathing exercises and postural drainage – is valuable and annual vaccination against INFLUENZA is strongly advised. If the patient develops breathlessness on mild exertion, has cyanosis, wheezing and permanent cough and tends to HYPERVENTILATION, then oxygen therapy should be considered. Antibiotic treatment is necessary if overt infection of the lungs develops.
Complications Sometimes rupture of the pulmonary bullae (thin-walled airspaces produced by the breakdown of the walls of the alveoli) may cause PNEUMOTHORAX and also exert pressure on functioning lung tissue. Respiratory failure and failure of the right side of the heart (which controls blood supply to the lungs), known as cor pulmonale, are late complications in patients whose primary problem is emphysema.
Prognosis This is related to age and to the extent of the patient’s response to bronchodilator drugs. Patients with COPD who develop raised pressure in the heart/lung circulation and subsequent heart failure (cor pulmonale) have a bad prognosis.... chronic obstructive pulmonary disease (copd)
Simple colic often results from the build-up of indigestible material in the alimentary tract, leading to spasmodic contractions in the muscular lining. Other causes include habitual constipation, with accumulation of faecal material; simple colic also occurs as an accompaniment of neurological disorders. Major risks include sudden obstruction of the bowel from twisting, INTUSSUSCEPTION, or as a result of a tumour or similar condition. (See also INTESTINE, DISEASES OF.)
Lead colic (traditional names include painter’s colic, colica pictonum, Devonshire colic, dry belly-ache) is due to the absorption of lead into the system. (See LEAD POISONING.)
Biliary colic and renal colic are the terms applied to that violent pain which is produced, in the one case where a biliary calculus or gall-stone passes down from the gallbladder into the intestine, and in the other where a renal calculus descends from the kidney along the ureter into the bladder. (See GALL-BLADDER, DISEASES OF and KIDNEYS, DISEASES OF.)
Treatment This consists of means to relieve the spasmodic pain with warmth and analgesics, and removal, where possible, of the underlying cause.
Infantile colic is a common condition in babies under three months, sometimes continuing for a little longer. The babies cry persistently and appear to their parents to have abdominal pain, although this remains unproven. Swaddling and massage can help, as can simply stimulating the child with movement and noise (rocking and singing). Medication is usually unhelpful, although the most severely affected deserve help because of the deleterious e?ect of infantile colic on family life.... colic
Colitis is classi?ed as an INFLAMMATORY BOWEL DISEASE (IBD) and ULCERATIVE COLITIS is a particularly troublesome form, the cause of which is not known. CROHN’S DISEASE may also cause colitis and is included in the umbrella designation IBD (see also IRRITABLE BOWEL SYNDROME (IBS)).... colitis
Crohn’s disease is rare in the developing world, but in the western world the incidence is increasing and is now 6–7 per 100,000 population. Around 80,000 people in the UK have the disorder with more than 4,000 new cases occurring annually. Commonly Crohn’s disease starts in young adults, but a second incidence surge occurs in people over 70 years of age. Both genetic and environmental factors are implicated in the disease – for example, if one identical twin develops the disease, the second twin stands a high chance of being affected; and 10 per cent of sufferers have a close relative with in?ammatory bowel disease. Among environmental factors are low-residue, high-re?ned-sugar diets, and smoking.
Symptoms and signs of Crohn’s disease depend on the site affected but include abdominal pain, diarrhoea (sometimes bloody), ANOREXIA, weight loss, lethargy, malaise, ANAEMIA, and sore tongue and lips. An abdominal mass may be present. Complications can be severe, including life-threatening in?ammation of the colon (which may cause TOXAEMIA), perforation of the colon and the development of ?stulae between the bowel and other organs in the abdomen or pelvis. If Crohn’s disease persists for a decade or more there is an increased risk of the victim developing colon cancer. Extensive investigations are usually necessary to diagnose the disease; these include blood tests, bacteriological studies, ENDOSCOPY and biopsy, and barium X-ray examinations.
Treatment As with ulcerative colitis, treatment is aimed primarily at controlling symptoms. Physicians, surgeons, radiologists and dietitians usually adopt a team approach, while counsellors and patient support groups are valuable adjuncts in a disease that is typically lifelong. Drug treatment is aimed at settling the acute phase and preventing relapses. CORTICOSTEROIDS, given locally to the affected gut or orally, are used initially and the effects must be carefully monitored. If steroids do not work, the immunosuppressant agent AZATHIOPRINE should be considered. Antidiarrhoeal drugs may occasionally be helpful but should not be taken during an acute phase. The anti-in?ammatory drug SULFASALAZINE can be bene?cial in mild colitis. A new generation of genetically engineered anti-in?ammatory drugs is now available, and these selective immunosuppressants may prove of value in the treatment of Crohn’s disease.
Diet is important and professional guidance is advisable. Some patients respond to milk- or wheat-free diets, but the best course for most patients is to eat a well-balanced diet, avoiding items that the sufferer knows from experience are poorly tolerated. Of those patients with extensive disease, as many as 80 per cent may require surgery to alleviate symptoms: a section of affected gut may be removed or, as a lifesaving measure, a bowel perforation dealt with.
(See APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELFHELP – Colitis; Crohn’s disease.)... crohn’s disease
Dialysis is available as either haemodialysis or peritoneal dialysis.
Haemodialysis Blood is removed from the circulation either through an arti?cial arteriovenous ?stula (junction) or a temporary or permanent internal catheter in the jugular vein (see CATHETERS). It then passes through an arti?cial kidney (‘dialyser’) to remove toxins (e.g. potassium and urea) by di?usion and excess salt and water by ultra?ltration from the blood into dialysis ?uid prepared in a ‘proportionator’ (often referred to as a ‘kidney machine’). Dialysers vary in design and performance but all work on the principle of a semi-permeable membrane separating blood from dialysis ?uid. Haemodialysis is undertaken two to three times a week for 4–6 hours a session.
Peritoneal dialysis uses the peritoneal lining (see PERITONEUM) as a semi-permeable membrane. Approximately 2 litres of sterile ?uid is run into the peritoneum through the permanent indwelling catheter; the ?uid is left for 3–4 hours; and the cycle is repeated 3–4 times per day. Most patients undertake continuous ambulatory peritoneal dialysis (CAPD), although a few use a machine overnight (continuous cycling peritoneal dialysis, CCPD) which allows greater clearance of toxins.
Disadvantages of haemodialysis include cardiovascular instability, HYPERTENSION, bone disease, ANAEMIA and development of periarticular AMYLOIDOSIS. Disadvantages of peritoneal dialysis include peritonitis, poor drainage of ?uid, and gradual loss of overall e?ciency as endogenous renal function declines. Haemodialysis is usually done in outpatient dialysis clinics by skilled nurses, but some patients can carry out the procedure at home. Both haemodialysis and peritoneal dialysis carry a relatively high morbidity and the ideal treatment for patients with end-stage renal failure is successful renal TRANSPLANTATION.... dialysis
The embryo develops upon one side of the ovum, its ?rst appearance consisting of a groove, the edges of which grow up and join to form a tube, which in turn develops into the brain and spinal cord. At the same time, a part of the ovum beneath this is becoming pinched o? to form the body, and within this the endoderm forms a second tube, which in time is changed in shape and lengthened to form the digestive canal. From the gut there grows out very early a process called the allantois, which attaches itself to the wall of the uterus, developing into the PLACENTA (afterbirth), a structure well supplied with blood vessels which draws nourishment from the mother’s circulation via the wall of the womb.
The remainder of the ovum – which within two weeks of conception has increased to about 2 mm (1/12 inch) in size – splits into an outer and inner shell, from the outer of which are developed two covering membranes, the chorion and amnion; while the inner constitutes the yolk sac, attached by a pedicle to the developing gut of the embryo. From two weeks after conception onwards, the various organs and limbs appear and grow. The human embryo at this stage is almost indistinguishable in appearance from the embryo of other animals. After around the middle of the second month, it begins to show a distinctly human form and then is called the fetus. The property of ‘life’ is present from the very beginning, although the movements of the fetus are not usually felt by the mother until the ?fth month.
During the ?rst few days after conception the eye begins to be formed, beginning as a cup-shaped outgrowth from the mid-brain, its lens being formed as a thickening in the skin. It is very soon followed by the beginnings of the nose and ear, both of which arise as pits on the surface, which increase in complexity and are joined by nerves that grow outward from the brain. These three organs of sense have practically their ?nal appearance as early as the beginning of the second month.
The body closes in from behind forwards, the sides growing forwards from the spinal region. In the neck, the growth takes the form of ?ve arches, similar to those which bear gills in ?shes. From the ?rst of these the lower jaw is formed; from the second the hyoid bone, all the arches uniting, and the gaps between them closing up by the end of the second month. At this time the head and neck have assumed quite a human appearance.
The digestive canal begins as a simple tube running from end to end of the embryo, but it grows in length and becomes twisted in various directions to form the stomach and bowels. The lungs and the liver arise from this tube as two little buds, which quickly increase in size and complexity. The kidneys also appear very early, but go through several changes before their ?nal form is reached.
The genital organs appear late. The swellings, which form the ovary in the female and the testicle (or testis) in the male, are produced in the region of the loins, and gradually descend to their ?nal positions. The external genitals are similar in the two sexes till the end of the third month, and the sex is not clearly distinguishable till late in the fourth month.
The blood vessels appear in the ovum even before the embryo. The heart, originally double, forms as a dilatation upon the arteries which later produce the aorta. These two hearts later fuse into one.
The limbs appear at about the end of the third week, as buds which increase quickly in length and split at their ends into ?ve parts, for ?ngers or toes. The bones at ?rst are formed of cartilage, in which true bone begins to appear during the third month. The average period of human gestation is 266 days – or 280 days from the ?rst day of the last menstrual period. The average birth weight of an infant born of a healthy mother (in the UK) is 3,200 g (see table).
The following table gives the average size and weight of the fetus at di?erent periods:
(See also PREGNANCY AND LABOUR.)... fetus
The gums become sore and bleed at the slightest pressure. Crater-like ulcers develop on the gum tips between teeth, and there may be a foul taste in the mouth, bad breath, and swollen lymph nodes. Sometimes, the infection spreads to the lips and cheek lining (see noma).
A hydrogen peroxide mouthwash can relieve the inflammation.
Scaling is then performed to remove plaque.
In severe cases, the antibacterial drug metronidazole may be given to control infection.... gingivitis, acute ulcerative
Glue ear is sometimes first detected by hearing tests. Examination with an otoscope can confirm the diagnosis. In mild cases, the condition often clears up without specific treatment. If the condition persists, it may be necessary to insert grommets, which allow air into the middle ear and encourage fluid to drain.
Adenoidectomy may also be required.... glue ear
It occurs about 6 days after fertilization, when the blastocyst (early embryo) comes into contact with the wall of the uterus.
As the cells of the developing embryo continue to divide, the outer cell layer penetrates the lining of the uterus to obtain oxygen and nutrients from the mother’s blood; later, this layer develops into the placenta.
The embryo usually implants in the upper part of the uterus; if it implants low down near the cervix, placenta praevia may develop.
Rarely, implantation occurs outside the uterus, possibly in a fallopian tube, resulting in an ectopic pregnancy.... implantation, egg
joint The junction between 2 or more bones. Many joints are highly mobile, while others are fixed or allow only a small amount of movement.
Joints in the skull are fixed joints firmly secured by fibrous tissue. The bone surfaces of mobile joints are coated with smooth cartilage to reduce friction. The joint is sealed within a tough fibrous capsule lined with synovial membrane (see synovium), which produces a lubricating fluid. Each joint is surrounded by strong ligaments that support it and prevent excessive movement. Movement is controlled by muscles that are attached to bone by tendons on either side of the joint. Most mobile joints have at least one bursa nearby, which cushions a pressure point.
There are several types of mobile joint. The hinge joint is the simplest, allowing bending and straightening, as in the fingers. The knee and elbow joints are modified hinge joints that allow some rotation as well. Pivot joints, such as the joint between the 1st and 2nd vertebrae (see vertebra), allow rotation only. Ellipsoidal joints, such as the wrist, allow all types of movement except pivotal. Ball-and-socket joints include the hip and shoulder joints. These allow the widest range of movement (backwards or forwards, sideways, and rotation).
Common joint injuries include sprains, damage to the cartilage, torn ligaments, and tearing of the joint capsule.
Joint dislocation is usually caused by injury but is occasionally congenital.
A less severe injury may cause subluxation (partial dislocation).
Rarely, the bone ends are fractured, which may cause bleeding into the joint (haemarthrosis) or effusion (build-up of fluid in a joint) due to synovitis (inflammation of the joint lining).
Joints are commonly affected by arthritis.
Bursitis may occur as a result of local irritation or strain.... jogger’s nipple
The discoloration is most common in elderly people and is usually symptomless, clearing up when the laxatives are stopped.
Rarely, it is associated with colon cancer (see colon, cancer of).... melanosis coli
Treatment may include nonsteroidal anti-inflammatory drugs, drugs that affect blood clotting, hormones, or the fitting of an IUD (intrauterine device) that releases small amounts of progestogen. Menorrhagia may also be treated by endometrial ablation.... menorrhagia
Gastro-oesophageal disease should be diagnosed in those patients who are at risk of physical complications from the re?ux. Diagnosis is usually based on the symptoms present or by monitoring the production of acid using a pH probe inserted into the oesophagus through the mouth, since lesions are not usually visible on ENDOSCOPY. Severe heartburn, caused by the lining of the oesophagus being damaged by acid and PEPSIN from the stomach, is commonly confused with DYSPEPSIA. Treatment should start with graded doses of one of the PROTON PUMP INHIBITORS; if this is not e?ective after several months, surgery to remedy the re?ux may be required, but the effects are not easily predictable.... gastro-oesophageal reflux
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