Differences between Crohn’s Disease with Ulcerative Colitis

Crohn’s disease:

• affecting colon and ileum
• affecting mucosa, submucosa and muscularis
• skip lesion distribution
• deep linear ulcers
• granulomas present (50%)
• fistula present
• there are fat and vitamins malabsorption
• responses to surgery is poor

Ulcerative colitis

• affecting colon
• affecting mucosa and submucosa
• diffuse distribution
• superficial ulcers
• no granuloma
• no fistula
• no fat and vitamins malabsorption
• response to surgery is good

Bowel sound and mechanical bowel obstruction

• Mechanical bowel obstruction causes proximal part to the obstructed area to distend.
• This compromises blood flow
• Causing venous obstruction
• Which leads to shortage of arterial supply
• Ischemia happens and leads to infarct
• Infarction means no peristalsis
• No peristalsis, no bowel sound

Smoking and peptic ulcer

Smoking impairs blood flow to mucosa. Impairs healing process. Leads to or worsen the ulcer.

Pathophysiology of colicky pain

• obstruction / blockage of a tube
• increase in peristalsis in order to remove the cause of ibstruction
• leads to vigorous muscular contraction
• cause ischemia
• lactic acid accumulation and spasm
• irritate nerve endings
• pain

Hepatorenal syndrome (HRS)

Definitions

Renal failure
- situation in which the kidneys fail to function adequately

Hepatorenal syndrome
- acute renal failure
- that occurs in the setting of cirrhosis or fulminant liver failure
- sometimes also associated with portal hypertension
- usually in the absence of other disease of the kidney

Pathophysiology

2 Theories

1.

• cirrhosis or fulminant liver failure
• cause portal hypertension
• renal perfusion is maintained by vasodilatory systems
• as liver disease progresses in severity, renal vasodilatory systems are unable to counteract the maximal activation of the endogenous vasoconstrictors and/or intrarenal vasoconstrictors
• leads to uncontrolled renal vasoconstriction.

2.
- unrelated to systemic hemodynamics but is due to either a

• deficiency in the synthesis of a vasodilatory factor OR
• hepatorenal reflex that leads to renal vasoconstriction.

Coombs’ test

What is this test for?
Looks for antibodies that act against your red blood cells.

Types
Direct antiglobulin test; Indirect antiglobulin test

Direct Coombs test

The Concept

• IgG antibodies that specifically bind to antigens on the red blood cell (RBC) surface membrane
• Red blood cells (RBCs) become coated with IgG alloantibodies (an antibody that occurs naturally against foreign tissues from a person of the same species) and/or IgG autoantibodies (An antibody that reacts with the cells, tissues, or native proteins of the individual in which it is produced)
• Complement proteins may subsequently bind to the bound antibodies

So,
- Coombs test is used to detect these antibodies or complement protein
- Red blood cells are taken
- Coombs reagent (antihuman globulin) incubated with the red blood cells
- if there are antibodies or complement proteins bound to red blood cells, agglutination occurs

Indirect Coombs test
- Used in pregnant women, and to test blood in blood tranfusion
- Detects antibodies which are not bound to red blood cells of patients
- If agglutination occurs, the indirect Coombs test is positive.
- rarely used to diagnose a medical condition


Examples

Alloimmune hemolysis

o Rhesus hemolytic diseases of the newborn
o Systemic lupus erythematosus
o Evans' syndrome (antiplatelet antibodies and hemolytic antibodies)
o Etc

Drug-induced immune-mediated hemolysis

o Methyldopa (IgG mediated type II hypersensitivity)
o Penicillin (high dose)
o Quinidine
o Etc

Antistreptolysin O titer (ASOT)

• Group A streptococci produce the enzyme streptolysin O, which can destroy red blood cells.
• Body reacts by producing antistreptolysin O to neutralize it.
• A high titer indicates there isor has been a streptococcal infection or has been present.
• ASO appears in the blood serum one week to one month after the onset of a strep infection.
• Normal value : < 200 Todd units
  

Titer : standard of strength of a volumetric test solution; the assay value of an unknown measure by volumetric means

Jones criteria for Rheumatic Fever (mnemonics included)

Major criteria

Joints : polyarthritis
O : heart-shaped O due to carditis
Nodules : subcutaneous nodules
Erythema marginatum
Sydenham's chorea (St. Vitus' dance)

OR

C : Carditis
A : Arthritis, poly
N : Nodules, subcutaneous
C : Chorea, Sydenham's
ER : ERythema Marginatum

Minor Criteria

- Fever
- Arthralgia (joint pain without swelling)
- Laboratory abnormalities:

increased Erythrocyte sedimentation rate,

increased C reactive protein,

leukocytosis

- prolonged PR interval
- elevated or rising Antistreptolysin O titre, or DNAase (evidence of Group A Strep infection)
- previous rheumatic fever or inactive heart disease

Don't get confused with rheumatic fever with rheumatic heart disease

Rheumatic fever
inflammatory disease
which may develop after a Group A streptococcal infection

Rheumatic heart disease
disease of the heart resulting from rheumatic fever

Acute VS Chronic Heart Failure Presentations

Acute heart failure

• severe dyspnoea
• orthopnea
• fronthy pinkish sputum (pulmonary oedema)
• hypotension
• pallor
• cyanosis

Chronic heart failure

• reduce exercise tolerance
• fatique
• exertional dyspnoea
• peripheral oedema
• JVP distension
• hepatomegaly
• serous effusion

Is reperfusion after myocardial infarction beneficial to all patients?

Myocardial reperfusion may not benefit all patients and may actually be harmful to some. Components of reperfusion injury may occur not only in isolation but also in combination--when more profound consequences might be expected. The exact mechanisms of reperfusion injury are uncertain, but they probably include cellular overload of calcium, osmotic cell swelling, and myocyte or microvascular damage from cytotoxic free radicals derived from oxygen

http://www.bmj.com/cgi/content/full/310/6978/477

Although reperfusion is essential for salvage of the ischemic heart, reperfusion beyond a certain period of ischemia may cause injury to the myocardium. Dramatic changes in contractile function, arrhythmias, and ultrastructure occur in the ischemic-reperfused heart as a consequence of the generation of oxyradicals, loss of cation homeostasis, depletion of energy stores, and changes in subcellular activities. These acute effects of reperfusion appear to be the result of the occurrence of oxidative stress and intracellular Calcium overload in the heart. Alterations in cardiac gene expression may account for delayed recovery of subcellular organelles in the ischemic myocardium.

http://www.heartandmetabolism.org/pdf/37/8.pdf

Necrotizing arteriolitis and malignant hypertension

necrotizing arteriolitis
- necrosis in the media of arterioles
- characteristic of malignant hypertension

malignant hypertension
- a complication of hypertension
- characterized by

• very elevated blood pressure (usually greater than 220/120)
• organ damage in the eyes, brain, lung and/or kidneys

MacConkey agar / McConkey agar concept

What is this for?
designed to grow Gram-negative bacteria and stain them for lactose fermentation.
distinguishes those Gram-negative bacteria that can ferment the sugar lactose from those that cannot

Contents
It contains :

• bile salts and crystal violet dye to inhibit most Gram-positive bacteria
• neutral red dye to stains microbes fermenting lactose
• lactose and peptone.

The concept :

• bacteria that can ferment sugar lactose will produce acid
• lowers the pH
• appearance of red/pink colonies.

• bacteria that cannot ferment sugar lactose will use peptone
• producing ammonia
• raise pH
• appearance of white / colourless colonies

Macconkey agar with lactose (left) and non-lactose (right) fermenters

Why do we use Ziehl-Neelsen stain, not gram stain for mycobacterium tuberculosis?

Ziehl-Neelsen stain, also known as the acid-fast stain, is a special bacteriological stain used to identify acid-fast organisms, mainly Mycobacteria. Acid fast bacteria are stained bright red and other organism and background will be blue. Acid-fast bacteria are bacteria that resistance to decolorization by acids during staining procedures.

Why do we use Ziehl-Neelsen stain, not gram stain?
Acid fast bacteria cell walls contain peptidoglycan but they have a waxy coat on their cell wall too. Gram stain (crystal violet nor the counterstain (safranin)) can not penetrate the waxy layer. Therefore they will not be visible able to see under the microscrope.

Per-rectal examination and prostate enlargement characteristics

Benign (nonmalignant character of a neoplasm) enlargment
- smooth and firm

Prostatic carcinoma
- hard and irregular

Colorectal cancer / colon cancer / large bowel cancer staging systems

Normally used
o Dukes system
o TNM system
o AJCC stage groupings (not covered here)


TNM Classification of Malignant Tumours (TNM)

Common tumors have their own TNM classification.
Not all tumors have TNM classifications, e.g., brain tumors.

Mandatory parameters ('T', 'N', and 'M')

* T : size or direct extent of the primary tumor
o T0 - no evidence of tumor
o Tis- cancer in situ (tumor present, but no invasion)
o T1 - invasion through submucosa into lamina propria (basement membrane invaded)
o T2 - invasion into the muscularis propria (i.e. proper muscle of the bowel wall)
o T3 - invasion through the subserosa
o T4 - invasion of surrounding structures (e.g. bladder) or with tumour cells on the free external surface of the bowel

* N : degree of spread to regional lymph nodes
o N0: tumor cells absent from regional lymph nodes
o N1: tumor cells spread to closest or small number of regional lymph nodes
o N2: tumor cells spread to an extent between N1 and N3.
o N3: tumor cells spread to most distant or numerous regional lymph nodes

* M : presence of metastasis
o M0: no distant metastasis
o M1: metastasis to distant organs (beyond regional lymph nodes)

If a parameter is not accessed, an 'x' will be used.

Other parameters

* G (1-4): the grade of the cancer cells (i.e. they are "low grade" if they appear similar to normal cells, and "high grade" if they appear poorly differentiated)
* R (0/1/2): the completeness of the operation (resection-boundaries free of cancer cells or not)
* L (0/1): invasion into lymphatic vessels
* V (0/1): invasion into vein
* C (1-4): a modifier of the certainty (quality) of the last mentioned parameter

further reading : http://en.wikipedia.org/wiki/TNM


Dukes classification
by British pathologist Dr Cuthbert Dukes

o Dukes A: Invasion into but not through the bowel wall

o Dukes B: Invasion through the bowel wall but not involving lymph nodes
* B1 : extend but note penetrating muscularis propria
* B2 : extend and penetrating muscularis propria

o Dukes C: Involvement of lymph nodes
* C2 : extend but note penetrating muscularis propria
* C2 : extend and penetrating muscularis propria

o Dukes D: Widespread metastases

A sign that you are going to have a wet dream tonight

Talking about prostate, I remember this interesting thing but I have not found any scientific findings proving this but yet, it is still good to know.

So what is it? As a women will experience mood swings etc which could alarm her the next period, a man will fell weirdly-tired before or on the night of the wet dream.

I wrote weirdly tired because a man will get puzzled to find out the causes of this tired feeling, if he did not do any different physical activities than he normally does that day.

This tired feeling will cause him to go bed earlier (if he can).

So if you (men only) feel weirdly tired and try to think the causes, don't forget to include this as one of the causes.

Why our prostates enlarge?

Actually, the reason why prostate enlarges is still a mystery. Several hypothesis were made.

Normal growth process
The prostate gland is highly unusual because it undergoes an increase in size at several stages during most of a man's life. It grows at before or at birth, early and during puberty, mid-20s and in 50s (urinary problems usually occur here). When a man is in his 70s, the prostate gland has reached a maximum weight.

Abnormally high level of dihydrotestosterone (DHT)
DHT, biologically active metabolite of the hormone testosterone promotes prostate cells growth.

Warts what?

What is wart?

• a small, rough tumor
• caused by a viral infection, specifically by the human papillomavirus (HPV)
• contagious when in contact with the skin of an infected person
• typically disappear after a few months but can last for years and can recur
• also known as verruca

Types of wart

1. Common wart (Verruca vulgaris),

• a raised wart with roughened surface

2. Flat wart

• a small
• smooth flattened wart
• tan or flesh coloured
• which can occur in large numbers

3. Filiform or digitate wart

• a thread- or finger-like wart
• most common on the face
• especially near the eyelids and lips

4. Plantar wart

• a hard sometimes painful lump
• often with multiple black specks in the center
• usually only found on pressure points on the soles of the feet

5. Mosaic wart

• a group of tightly clustered plantar-type warts
• commonly on the hands or soles of the feet

6. Genital wart

• a wart that occurs on the genitalia

Ketuat in Medical

Ketuat = wart

Some causes of sudden pallor

• Fainting / Syncope (temporary loss of consciousness due to a sudden decline in blood flow to the brain)
• Shock (Severe condition from reduced blood circulation)
• Motion sickness (condition in which a disagreement exists between visually perceived movement and the vestibular system's sense of movement causing nausea)
• Heart attack
• Arrhythmia
• Hypoglycemic attack
• Severe gastroenteritis (severe inflammation of the gastrointestinal tract)
• Stomach upset
• Acute blood disorder
• Leukemia (cancer of the blood cells, usually white blood cells)
• Clotting disorder

Functions of Prostaglandin

• cause constriction or dilation in vascular smooth muscle cells
• cause aggregation or disaggregation of platelets
• sensitize spinal neurons to pain
• decrease intraocular pressure
• regulate inflammatory mediation
• regulate calcium movement
• control hormone regulation
• control cell growth

NSAIDs and Cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) inhibitions

Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) inhibit cyclooxygenase to inhibit prostaglandin synthesis.

Cyclooxygenase-1 inhibition
- reduce platelet aggregation
- unwanted effects mainly on gastrointestinal and kidney
- associated with gastrointestinal toxicity

Cyclooxygenase-2 inhibition
- anti-inflammatory, analgesic and antipyretic effects

• Thus, using NSAIDs with specific Cyclooxygenase-2 inhibition will decrease gastrointestinal irritation.
• But it is better to avoid the usage of NSAIDs (if possible).

Colicky pain, biliary colic and renal colic

Colicky pain

• any pain that comes in waves
• usually for organs with lumens and have peristaltic movement

Biliary colic*

• right upper quadrant pain, right flank pain, or even mid chest pain with cholelithiasis
• pain is steady, starts rapidly and lasts at least 30 minutes
• associated with irritation of the viscera secondary.

Renal colic*

• pain commonly caused by kidney stones.
• radiates through the flank until it reaches the bladder
• remain constant

*are not colicky pain, different things

Signs and symptoms of hypercalcaemia

• fatigue
• depression
• confusion
• anorexia
• nausea
• vomiting

• constipation
• pancreatitis
• increased urination

Causes of mucous in stool

Abdominal Cancer

Andrade's syndrome
- a hereditary form of amyloidosis with accumulation of amyloid in organs and tissues of the body

Bowel Obstruction

Colitis
- a chronic digestive disease characterized by inflammation of the colon
- auto-immune affecting the tissue that lines the gastrointestinal system.
- classed as an inflammatory bowel disease (IBD)

Cystic Fibrosis
- a hereditary disease affecting the exocrine (mucus) glands of the lungs, liver, pancreas, and intestines

Dysentery
- an infection of the digestive system that results in severe diarrhea containing mucus and blood in the feces

Shigellosis
- known as bacillary dysentery

Hemorrhagic proctocolitis
- inflammation of the rectum and colon

Irritable bowel syndrome
- a functional bowel disorder characterized by mild to severe abdominal pain, discomfort, bloating and alteration of bowel habits
- caused by psychosomatic illness, immune reaction, active infections
- not to be confused with inflammatory bowel disease.

Pelvic abscess
- caused by infections, appendicitis, diverticulitis etc
- commonly follows acute appendicitis or after gynaecological infections.

Pelvic lipomatosis
- a benign overgrowth of adipose tissue with a small amount of inflammatory and fibrotic component

Proctitis
- inflammation of the anus and the lining of the rectum

Pseudomembranous Colitis
- infection of the colon

Cyclooxygenase / COX enzyme / prostaglandin synthase / rostaglandin synthetase

• an enzyme for formation prostanoids (including prostaglandins, prostacyclin and thromboxane).

• prostanoids; most are pro-inflammatory
• but prostaglandins have a protective role in preventing acid-insult to the mucosa (COX converts arachidonic acid to prostaglandin H2)

• The two major isoenzyme are COX-1 and COX-2
• Different tissues express varying levels of COX-1 and COX-2

• inhibition of COX can provide relief from the symptoms of inflammation and pain but since it also inhibits prostaglandin, it can causes gastric ulcer

Dressler's syndrome / postpericardiotomy syndrome / postmyocardial infarction syndrome

Dressler's syndrome is
- secondary form of pericarditis that occurs in the setting of injury to the heart or the pericardium
- a complication that can occur after

• a heart attack
• heart surgery
• pericardium becomes inflamed

- thought to develop as an immune system response following a heart attack or heart surgery reaction to myocardial neo-antigens
- easily treated with medications that reduce inflammation
- repeated episodes of Dressler's syndrome can lead to a condition called constrictive pericarditis

sign and symptoms

• fever
• chest pain
• shortness of breath
• fever

*feels like another heart attack

Keloids

• is an overgrowth of tissue at the site of a healed skin injury
• consisting mainly type I and some type III collagen
• form within scar tissue
• benign, non-contagious

characterized by a

• collection of atypical fibroblasts with excessive deposition of extracellular matrix components
• especially collagen
  

1. type I collagen - the most abundant collagen of the human body. It is present in scar tissue, the end product when tissue heals by repair. It is found in tendons, skin, artery walls, the endomysium of myofibrils, fibrocartilage, and the organic part of bones and teeth.
2. type III collagen - the collagen of granulation tissue, and is produced quickly by young fibroblasts before the tougher type I collagen is synthesized

Types of inflammation at a glance

Granulomatous inflammation
Formation of granulomas (a ball-like collection of immune cells trying to destroy a foreign substance)


Fibrinous inflammation
large increase in vascular permeability allows the blood vessels to pass through fibrin


Purulent inflammation
Inflammation resulting in large amount of pus, which consists of neutrophils, dead cells, and fluid


Serous inflammation
Characterized by the copious effusion of non-viscous serous fluid


Ulcerative inflammation
Necrosis of the tissue from the surface, exposing lower layers

Laxatives at a glance

There are 4 types

Bulk forming agents
- swell when mix with water
- adding bulk in stool
- bran, methylcellulose

Stool softeners
- there are two mechanisms of action

stimulate the gut muscle to contract faster so that there will be less water reabsorbed at large intestine, making stool soft. example, docusate sodium

or lining up the faeces (oil based) so that water could not be absorbed. example, paraffin oil

Stimulants
- three ways of action

stimulate intestinal motility

increase fluid secretion

reduce water absorption

- example : senna, bisacodyl

Osmotic laxatives
- draws water into the colon
- example : lactulose

Painless jaundice and pain jaundice

Jaundice caused by extrahepatic obsctruction due to malignant usuallt painless and progressive.

Jaundice caused by intraluminal obstruction by a gall stone may cause severe pain.

Findings suggesting chronic alcohol ingestion

Raised plasma gamma-glutamyltransferase (GGT) activity
- GGT is liver enzyme
- involved in the secretion and absorption of bile
- marker as an indicator of early liver cell damage or cholestatic disease

macrocytosis
- erythrocytes that are larger than normal

hyperuricaemia
- presence of high levels of uric acid in the blood

hypertriglyceridaemia
- increased hypertriglyceride

*non of these findings is diagnostic of alcoholism

Immunoglobulin G and M and relationship with acute and chronic infections

This is what I learned from my colleague.

Acute or 'just now' infections
- IgM is high
- IgM involved in primary response

IgM structure

Chronic infections
- IgG is high
- IgG predominately involved in the secondary antibody response

IgG structure

Steatorrhea

Steat_orr_hea (for memorizing purpose)

- presence of excess fat in feces
- usually due to :

• reduced or no bile secretion
• bacteria
• Abetalipoproteinemia, or Bassen-Kornzweig syndrome (rare autosomal recessive disorder that interferes with the normal absorption of fat and fat-soluble vitamins from food)
• coeliac disease (an autoimmune disorder of the small intestine)
• inflammatory bowel disease
• short bowel syndrome
• cystic fibrosis (hereditary disease affecting the exocrine (mucus) glands of the lungs, liver, pancreas, and intestines)
• abuse of slimming pills.

Caseating (necrosis) and non-caseating granulomas

Granulomas
- nodular inflammatory lesions
- ball-like collection of immune cells trying to destroy a foreign substance
- containing compactly grouped modified phagocytes
- such as epithelioid cells, giant cells, and other macrophages


Caseating granulomas
- necrosis present
- appears cheese-like to unaided eye (don't expect to see this on microscope)
- typically a feature of the granulomas of tuberculosis
- tend to have infectious causes

Caseating lung due to TB

Caseating granulomas microscopic

Non-caseating granulomas
- necrosis not present
- does not appear cheese-like to unaided eye

Non-caseating granulomas microscopic

Hypersensitivity I, II, III, IV and V

Hypersensitivity definition

• undesirable reactions produced by the normal immune system

Hypersensitivity Type I

• Allergy (immediate)
• IgE

Hypersensitivity Type II

• Cytotoxic, antibody-dependent
• Bind to cell surface components
• and to cell receptors (if you do not use Hypersensitivity Type V classification)
• IgM or IgG
• Complement

Hypersensitivity Type III

• Immune complex disease
• IgG
• Complement

Hypersensitivity Type IV

• Delayed-type hypersensitivity, Cell-mediated immune memory response, antibody-independent
• T-cells

Hypersensitivity Type V

• *Additional, some do not use this classification and combine it with Hypersensitivity Type II
• Cytotoxic, antibody-dependent
• Bind to cell receptors
• IgM or IgG
• Complement

od om on bd tds qid prn acronyms in drug prescriptions

• od : omni die / once a day
• om : omni mane / on morning
• on : on nocte / on night
• bd : bis in die / twice a day
• tds : die sumendus / three times daily
• qid : quater in die / four times per day
• prn : pro re nata / when required

Gay Bowel Syndrome

What is this?

• Gastrointestinal discomfort
• occur with unusual frequency in homosexual patients (not gays only)
• includes abdominal pain, cramps, bloating, flatulence, nausea, vomiting, or diarrhoea
• caused by enteric bacteria, viruses, fungi, zooparasites, or trauma.

The clinical diagnoses in decreasing order of frequency :

• condyloma acuminata : a contagious projecting warty growth on the external genitals or at the anus
• hemorrhoids : a varicose condition of the external hemorrhoidal veins causing painful swellings at the anus
• nonspecific proctitis : inflammation of the mucous membrane of the rectum
• anal fistula (an abnormal passage from one epithelial surface to another epithelial surface)
• perirectal abscess
• anal fissure
• amebiasis : infection with the protozoon Entamoeba histolytica.
• benign polyps (any mass of tissue that bulges or projects outward or upward from the normal surface level)
• viral hepatitis
• gonorrhea : a contagious catarrhal inflammation of the genital mucous membrane, transmitted chiefly by coitus and due to Neisseria gonorrhoeae
• syphilis
• anorectal trauma and foreign bodies
• shigellosis : Bacillary dysentery (a disease marked by frequent watery stools, often with blood and mucus, and characterized clinically by pain, tenesmus, fever, and dehydration.) caused by bacteria of the genus Shigella
• rectal ulcers
• lymphogranuloma venereum : a venereal (relating to or resulting from sexual intercourse) infection usually caused by Chlamydia trachomati

*since not only gays get this syndrome, some are against this term

The systole and diastole (arteries) concepts

- arteries are elastic

- when heart pumps, it generates a strong force and cause bulging of the arteries
- the bulging (coincide with peak of force) is what forms the systolic pressure

- since arteries are elastic, they will come back to their original shapes
- during the process, they will squeeze out the extra blood (bulging creates extra spaces for the blood to fill in) and this process generates a force
- the force is what forms the diastolic pressure

How antacids cause Vitamin B12 deficiency

Normally

- vitamin B12 binds to salivary R-binders first
- it needs acidic condition to separate them

- stomach secretes intrinsic factor
- intrinsic factor binds to vitamin B12, which protects vitamin B12 from being degraded by the enzymes and facilitate vitamin B12 absorption in the ileum

When you have chronic gastritis
- your gastric mucosa already atrophied
- causing decrease in intrinsic factor production and decrease in acid production

When you take antacids
- you further decrease the acidic level
- worsen the vitamin B12 absorption
- causing vitamin B12 deficiency