Diabetes Res Clin Pract non-insulin-dependent diabetes mellitus: A randomized prospective 6-year study discount sinemet 125mg with visa. Writing Team for the Diabetes Control and Complications Trial/Epidemiology precedes stepwise deterioration of fasting with worsening diabetes purchase sinemet 300mg mastercard. Persistent effects of intensive glycemic label buy discount sinemet 300 mg on line, treat-to-target non-inferiority trial. Circulation blood glucose control and vascular outcomes in patients with type 2 diabetes. New Engl J Med 2015;372:2197 in participants with type 2 diabetes at high cardiovascular risk. Variation of fasting plasma glucose: A predictor of ment of type 2 diabetes mellitus on cardiovascular outcomes: A meta-analysis mortality in patients with type 2 diabetes. Can J Diabetes 42 (2018) S47S53 Contents lists available at ScienceDirect Canadian Journal of Diabetes journal homepage: www. In some circumstances, such as when signicant changes blood sampling (days 0 to 30) contributes 50% of the result and the are made to therapy or during pregnancy, it is appropriate to check A1C prior 90 to 120 days contributes 10% (2,3). Testing at 6-month intervals may be consid- capacity to use the information from testing to modify healthy behaviours ered in situations where glycemic targets are consistently achieved or self-adjust antihyperglycemic agents. A1C may also be used for the diagnosis of diabetes in adults (see Screening for Diabetes in Adults chapter, p. In 2007, a consensus statement from the American Diabetes Association, European Association for the Study A1C is a measurement of your average blood glucose control for the last of Diabetes and the International Diabetes Federation called for A1C 2 to 3 months. For those who wish and medication changes that will improve your blood glucose levels. Point-of-care A1C analyzers are bench-top instruments that use a nger-prick capillary blood sample. They are designed for use in a health-care providers oce, a treatment room or at a bedside. The blood is applied to a test cartridge and the sample is analyzed 1499-2671 2018 Canadian Diabetes Association. It can increase ones empowerment and adherence to potential advantages over laboratory A1C testing, including rapid treatment. It can also provide information to both the person with test results to expedite medical decision-making, convenience for diabetes and their diabetes health-care team to facilitate longer-term people with diabetes, potential improved health system eciency treatment modications and titrations as well as shorter-term treat- and improved access to testing for underserved populations (12). Care should be taken to select an appropriate meter with an Most trials in noninsulin-treated people with type 2 diabetes are alternative glucose measurement method in such situations. In the Structured Testing sites other than the ngertip (forearm, palm of the hand, thigh). At 1 year, there was a signicantly greater accurately reect glycemic status than forearm or thigh testing reduction in mean A1C in the structured testing group compared (63,64). In comparison, blood samples taken from the palm near with the active control group (0. Treatment decisions for the A1C cohort were based strictly acetoacetate through urine testing may not identify the onset and on A1C test results. For most individuals with diabetes, A1C should be measured approxi- a preset limit. A blinded (sometimes referred to as professional) mately every 3 months to ensure that glycemic goals are being met or main- tained [Grade D, Consensus]. Testing at least every 6 months should analysis by the health-care provider (typically in conjunction with be performed in adults during periods of treatment and healthy behaviour the user). Individuals with type 1 diabetes should be instructed to perform ketone up to 14 days. Blood ketone testing methods may be Novel Glucose Sensing Technology on Hypoglycaemia in Type 1 preferredoverurineketonetesting,astheyhavebeenassociatedwithearlier detection of ketosis and response to treatment [Grade B, Level 2 (67)]. S36 hypoglycemia by 54%, reduced glycemic variability and improved Targets for Glycemic Control, p. There was a statistical reduction in A1C for Glycemic Management in Adults with Type 1 Diabetes, p. Glycated hemoglobin and the risk of kidney Recommendation Tool for Health-Care Providers disease and retinopathy in adults with and without diabetes. Self-monitoring of blood glucose levels and glycemic control: The Northern California Kaiser Permanente Diabetes reg- istry. Longitudinal study of new and preva- Author Disclosures lent use of self-monitoring of blood glucose. Woo has self-monitoring on metabolic control and quality of life in type 2 diabetic patients: An urgent need for better educational strategies. Self-management education for adults with type 2 diabetes: A meta-analysis of the effect on glycemic control. Integrating medical management with diabetes self-management training: A randomized control trial of the Diabe- 1. Mean blood glucose and biological varia- tes Outpatient Intensive Treatment program. Diabetes Care 2003;26:3048 tion have greater inuence on HbA1c levels than glucose instability: An analy- 53. Diabe- treated type 2 diabetes: Results from the Structured Testing Program study. Guidelines and recommendations for improves glycemic control in stable, insulin-treated veterans with type 2 laboratory analysis in the diagnosis and management of diabetes mellitus. The effect of intensive treatment of diabetes on the development and national Diabetes Federation. Consensus statement on the worldwide progression of long-term complications in insulin-dependent diabetes melli- standardisation of the HbA1c measurement. Epidemiology of severe hypoglycemia in the hemoglobin, HbA1c, is associated with deteriorating diabetes control. Nocturnal blood glucose proles tion, European Association for the Study of Diabetes, International Federation in patients with type 1 diabetes mellitus on multiple (> or = 4) daily insulin injec- of Clinical Chemistry and Laboratory Medicine, and the International Diabetes tion regimens. Measurement of hemoglobin A(1c): A new twist on the path to hypoglycemia during sleep. Frequency of blood glucose monitoring in relation to glycemic control les/reports-and-resources/horizon-scanning-report0044-poc-hba1c-in in patients with type 2 diabetes. Differences in A1C by race and ethnicity taking insulin: A blinded, randomized trial. Impact of self monitoring of blood glucose A cross-sectional analysis of community-based data. Ann Intern Med in the management of patients with non-insulin treated diabetes: Open par- 2011;154:3039. Self-monitoring of blood glucose in non- HbA1c and blood glucose: Implications for the diagnosis of diabetes. J Clin insulin treated patients with type 2 diabetes: A systematic review and meta- Endocrinol Metab 2012;97:106772. Improved glycemic control in poorly con- meta-analysis of direct and indirect comparisons. Curr Med Res Opin trolled patients with type 1 diabetes using real-time continuous glucose moni- 2006;22:67181. Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study diabetes: What is the evidence? Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study An update. Self-monitoring of blood glucose levels toring on A1C, glucose proles, and hypoglycemia in adults with type 1 diabe- in patients with type 2 diabetes mellitus not taking insulin: A meta-analysis. Systematic of sensor-guided pump therapy in type 1 diabetes: A randomised controlled trial. Self-monitoring of blood glucose in type 1 monitoring when starting pump therapy in patients with poorly controlled type 1 diabetes patients with insucient metabolic control: Focused self-monitoring diabetes: The RealTrend study. Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Sci Technol 2009;3:838. Self-monitoring of blood glucose environment: Evidence from the Juvenile Diabetes Research Foundation con- in patients with type 2 diabetes mellitus who are not using insulin. Effect of continuous glucose the management of new-onset Type 2 diabetes mellitus: The St Carlos Study, monitoring on glycemic control in adults with type 1 diabetes using insulin injec- a prospective randomized clinic-based interventional study with parallel groups. Notice: New requirements for medical device licence applications for type 1 diabetes: 12-month follow-up of the Juvenile Diabetes Research Foun- lancing devices and blood glucose monitoring systems [press release]. Use of a real time continuous glucose monitoring ing in type 2 diabetes: A systematic review of randomized controlled trials.
The condition may take one to six months to resolve even with complete abstinence cheap 300mg sinemet. Long-term survival in patients with alcoholic hepatitis who discontinue alcohol is significantly better than in those who continue to drink purchase sinemet 125 mg visa, although it remains considerably below that of an age- matched population buy 300 mg sinemet otc. Three-year survival approaches 90% in abstainers, whereas it is less than 70% in active drinkers. Comparison of viral hepatitis and alcoholic hepatitis based on history and physical examination, laboratory tests and liver histology. Alcoholic Cirrhosis Established cirrhosis is usually a disease of middle age after the patient has had many years of drinking. Although there may be a history of alcoholic hepatitis, cirrhosis can develop in apparently well-nourished, asymptomatic patients. Occasionally, the patient may present with end-stage liver disease with malnutrition, ascites, encephalopathy and a bleeding tendency. Hepatomegaly is often present, affecting predominantly the left lobe due to marked hypertrophy and there are signs of portal hypertension including splenomegaly, ascites and distended abdominal wall veins. There may be signs of alcohol damage in other organ systems such as peripheral neuropathy and memory loss from cerebral atrophy. These include lgA nephropathy, renal tubular acidosis and the development of hepatorenal syndrome. The diagnosis of alcoholic cirrhosis rests on finding the classical signs and symptoms of end-stage liver disease in a patient with a history of significant alcohol intake. Liver biopsy is encouraged, especially when the diagnosis is in question, since patients usually under report the amount of alcohol consumed. The degree of steatosis is variable and alcoholic hepatitis may or may not be present. When marked, genetic hemochromatosis has to be First Principles of Gastroenterology and Hepatology A. With continued cell necrosis and regeneration, the cirrhosis may progress to a macronodular pattern. Biochemical abnormalities include a low serum albumin, elevated bilirubin and aminotransferases. Portal hypertension results in hypersplenism leading to thrombocytopenia, anemia and leukopenia. The prognosis of alcoholic cirrhosis depends on whether the patient can abstain from alcohol, this in turn is related to family support, financial resources and socio-economic state. Patients who abstain have a five-year survival rate of 60 to 70%, which falls to 40% in those who continue to drink. Complete abstinence may not improve prognosis when portal hypertension is severe, although at the earlier stage of cirrhosis, the portal pressure may actually fall with abstinence. Hepatocellular carcinoma occurs in 10% of stable cirrhotics and the incidence is higher in patients who also have viral hepatitis infection. This usually develops after a period of abstinence and macronodular cirrhosis is present. Treatment strategies can be instituted if detected early (see below), therefore long-term follow- up and periodic screening is advisable. As patients can rarely achieve complete and durable abstinence from alcohol without assistance, support groups and regular follow-up is needed to reinforce the need for abstinence. In general, enteral nutrition is preferable over parenteral supplementation, and protein should be supplied to provide positive nitrogen balance. Nutritional supplementation is generally associated with an improvement in liver test results, but only rarely with a mortality benefit. Shaffer 433 Alcoholic fatty liver responds to alcohol withdrawal and a nutritious diet. However, with long- term follow-up, patients with fatty liver disease may develop fibrosis or even cirrhosis as the liver heals. Patients with severe alcoholic hepatitis should be admitted to hospital and complications of liver failure treated appropriately. Specific treatments for alcoholic hepatitis include the use of corticosteroid (40 mg/day for 4 weeks and then taper). There is reduction of the short- term mortality of about 50% in patients with severe alcoholic hepatitis. A discriminant function of >32 is a predictor of poor prognosis and favorable response to corticosteroid therapy. Patients with gastrointestinal hemorrhage, active infection, diabetes and acute pancreatitis tend to do worse with corticosteroid, and therefore should not be considered for it in the setting of severe alcoholic hepatitis. A liver biopsy is needed to confirm the presence of severe alcoholic hepatitis before corticosteroid administration. Propylthiouracil has been used to dampen the hepatic hypermetabolic state in alcoholic hepatitis. In one long-term randomized controlled trial, there was a significantly reduced two- year mortality rate in patients who continued to drink moderately. However, other investigators have not been able to reproduce these positive results. Therefore, current evidence cannot support the routine use of propylthiouracil in acute alcoholic hepatitis. Testosterone and anabolic androgenic steroids have been tried with conflicting results, Intravenous amino acid supplements have been given to the severely protein malnourished with varying degrees of success. Two recent trials showed that the patients with alcoholic hepatitis treated with infliximab had more infectious complications without any benefit in liver function or Maddrey scores. The only randomized controlled study to date has demonstrated a higher probability of death at 2 months in those patients randomized to steroids and infliximab. Pentoxifylline is safe and cheap, and could be used despite the lack of a confirmatory study. Their use in alcoholic hepatitis could theoretically improve hepatic regeneration. However, patients treated with both agents have had complications and even deaths from hypoglycemia. Therefore, these agents should not be used except in the setting of a clinical trial. Finally, it must be stressed that a good nutritional intake is necessary to hasten recovery and improve survival. At 1 year from the time of diagnosis of alcoholic hepatitis, patients with First Principles of Gastroenterology and Hepatology A. Shaffer 434 mild malnutrition have a 14% mortality rate, compared with a 76% mortality rate in those with severe malnutrition. Patients who have established alcoholic cirrhosis need to be monitored for complications of cirrhosis in the same way that any other patient with cirrhosis is being monitored. Periodic assessments should include a surveillance gastroscopy to check for the presence of esophageal varices and prophylactic -blocker therapy instituted for those with large esophageal varices. Hepatic encephalopathy remains a complication, but usually can be controlled with prophylactic lactulose. Ascites frequently settles down in those patients who abstain from alcohol for more than 6 months. Every effort should be made to exclude spontaneous bacterial peritonitis and prevent hepatorenal syndrome, two life threatening complications of ascites. Periodic screening for the presence of hepatoma should be made, since effective treatments are available if hepatomas are detected early. Surgical resection in the stable compensated cirrhotic patient or local ablative therapy such as intra-lesional radiofrequency ablation in the mildly decompensated patient should be offered. Those patients who are also infected with viral hepatitis B or C should be assessed for their suitability to receive anti-viral therapy. It is preferable that patients totally abstain from alcohol during the treatment period. Untreated viral hepatitis can certainly accelerate the fibrotic process in alcoholic cirrhosis. Colchicine has been tried as an antifibrotic agent to reduce the extent of cirrhosis and hence portal pressure without much success. Liver transplantation is a treatment option for patients with end stage alcoholic cirrhosis and this is the treatment of choice in the patient with decompensated alcoholic cirrhosis. Ethical issues surrounding the use of such a scarce resource for a self inflicted disease still need to be settled, especially when it relates to liver transplantation for patients who have active alcoholic hepatitis.
Some men never Why is it important to look after the regain erectile function but can still have fulflling relationship when treating erectile dysfunction? Couples having erectile problems Relationship problems can cause erectile dysfunction are encouraged to explore ways of touching each and erectile dysfunction can cause relationship other to bring about sexual satisfaction buy cheap sinemet 110mg online. Relationship problems need to be men and women can orgasm without an erection recognised and attempts made to resolve them as part or penetration happening purchase sinemet 125 mg with visa. For that websites some men it can be helpful to also talk with others who have Andrology Australia developed overseas similar problems generic sinemet 300 mg, or to speak with trained therapists who www. Specialist counsellors ofer individuals and couples support and therapy for sexual problems. Phone: 1300 364 277 Online support groups for partners of men with erectile dysfunction can give access to chat groups, fles, messages and links to share experiences and information of the partners experiences of the problem. The groups can be found by searching the Internet, although users must usually become members of these websites before being given access to these online services. Associate Professor Lording is a Board Member of Andrology Australia and an Andrology Australias resources and information are provided Honorary Clinical Associate Professor in the Department of at no cost and are available to be downloaded or ordered Medicine at Alfred Hospital, Melbourne. Do not stop taking your medicine About one half of American men over age 40 have erection or change any meds without talking to your health care problems. Young men who have had injuries to the pelvis or The good news is that there are many safe penis are most likely to be helped by this treatment. Penile prostheses, which provide frm erections, are good treatment choices a treatment that works for you and your for some men. The rods fll with fuid when a pump hidden in the To improve erection problems, your health care provider body is pressed. However, once a prosthesis cuidadores/preguntas-y-respuestas/2012/erectile-dysfunction is placed, other non-surgical treatments will no longer work if the prosthesis is removed. You may download this fact sheet and print it yourself at If so, how can I fnd the right one for me? The article will also to the design, development, and use of specific phar- review new medications that may be available in the macological agents to recreate the normal physiology future to supplement treatment with sildenafil. All of these erectaid treatments can central cavernosal arteries of the corpora cavernosa potentially work and can have excellent compliance in must dilate to increase blood flow to the penis. Nitric oxide is produced from ination, a psychosocial evaluation, and basic labora- the precursor L-arginine through the enzyme nitric tory studies. Nitric oxide subsequently helpful but should not be a substitute for the inter- diffuses into smooth muscle cells and activates the view. Based polypeptide and prostaglandins that act through the on these facts, the goal-directed approach is com- adenylate cyclase pathway and its secondary neuro- monly followed nowadays. Inadequate response suggests Smooth muscle relaxation is counterbalanced by underlying organic vascular disease. Levels of these agents, pharmaco-penile duplex ultrasonography, cavernosog- which are present in the healthy corpus cavernosum, raphy. Primary care physicians and other medical may be increased by high sympathetic tone caused by specialists have gradually replaced urologists and physical and psychological stressors. Norepinephrine is released from the sympathetic nerve endings in the Standard Treatments for Erectile corpora cavernosa and activates the alpha-1 adreno- DysfunctionPre-Sildenafil Era ceptors, which raise intracellular calcium and produce smooth muscle contraction (Kim & Ooh, 1992). The band can advantage to this form of therapy (Blackard, Borkon, remain for a maximum of 30 minutes. Although the published reports describe efficacy Numerous published reports exist that describe rates of 60% to 80%, the compliance after 1 year of this treatment as very effective. Cookson ing of the base of the penis with erection, and the and Nadig reported long-term follow-up results in laborious mechanics of just using the vacuum device. Early satisfaction in this subset of patients, the overall sexual rehabilitation after pelvic surgery may enhance dropout rate was 30% to 40%. Of this series, 59% of the patients rates, and impact on patients sexual and psycholog- at 6 months reported having sexual activity (vaginal ical functioning. There were no differences between the two between the couples that existed preoperatively. At a treatments in sexual or psychological impact (Turner mean interval of 9 months, the early (daily) use of et al. This to a 40% to 60% noncompliance rate after 1 year potency rate (defined as vaginal penetration) of 16% Treatment of Erectile Dysfunction / Raina et al. Answers were scored: 0 = no intercourse, 1 = never/almost never, 3 = sometimes, 5 = always/almost always. Because topical activity and interest in patients (and partners) who pre- nitroglycerine is rapidly absorbed through the vaginal viously were inactive for a year or more, waiting for mucosa, patients using transcutaneous or ointment- the period of neuropraxia to resolve. A study conducted by Nehra and colleagues firm these initially favorable results and reported sig- (2000) demonstrated that a combination of silde- nificant urethral pain and burning. Whereas phentolamine is a direct adrenocep- decreased because comparative studies reported that tor blocker, alprostadil and papaverine modulate sildenafil has better efficacy and compliance. Recently, levels of cyclic 3,5-adenosine monophosphatase Treatment of Erectile Dysfunction / Raina et al. This increases safety and decreases morbidity patients rated their erections as being good to excel- (McMahon, 1996). In addition, about 10% to 20% lack of interest, there is some evidence that early of patients have difficulty reproducing a successful rehabilitation of the penis is necessary to prevent injection (Evans, 1999). This These authors reported an attrition rate of 31% over a concept is supported by a recent report by Montorsi 38-month period; cost, penile discomfort, and patient- et al. Lack of efficacy was the primary reason for resulted in a normal erection recovery rate at 6 discontinuation in only one of seven (14. These subjective results were also confirmed (which included all etiologies) were fully or partially by hemodynamic and nocturnal testing. Inadequate rigidity or better than those of age-matched controls who have lack of efficacy was the primary reason for discontinu- undergone similar operations (stage of disease and ation in 18% of the patients. All eligible men had a complete Promising results have been reported for patients history and physical to exclude any contraindications treated with prostate cancer and in patients with end- to the drug. The patients operative reports Accounts of sildenafil use in clinical practice and post- were reviewed, and the patients were stratified as to marketing data reflect clinical trial results that report the type of nerve-sparing procedure they underwent. Patients were started on 50 mg a day; the ences a mans ability to achieve vaginal intercourse. After surgery, 22 series, sildenafil was ineffective in the first 9 months of the patients (24. After surgery but before sildenafil use, of sildenafil is the use of nitroglycerine or nitrate- none of the patients was able to achieve vaginal pen- containing compounds, which may cause hypoten- etration. The drug is generally prescribed in either 50 or was roughly greater than 1 year in all 3 subgroups. The drug requires sexual stim- patients responded to the drug: 38 of the 53 patients ulation to be effective (Jarow, Burnett, & Geringer, (71. It was unclear controlled studies and reported that 16% of patients whether the 15% response rate in the non-nerve- experienced headache, 10% experienced flushing, and sparing group was due to placebo effect, unrecognized 7% experienced dyspepsia. However, in the 56- to 65-year-old group, the The authors study identified that sildenafil citrate response rate dropped to 45% in the group with two could salvage erectile function in roughly 70% of impo- nerves spared and to 0% in those with one nerve pre- tent, motivated patients if a bilateral nerve-sparing served. In the older age group (>65 years old), 33% procedure is performed and in 50% of patients if a uni- of the patients responded when two bundles were lateral nerve-sparing procedure is done. The dropout rate was 29%, with 50% sildenafil at any time after surgery and that they (6/12) discontinuing because of the return of natural should not be hesitant to increase the dose to 100 mg. A study conducted by Nehra and col- patient discontinued the drug at 3 years because of leagues (2000) reported that a combination of silde- side effects. New Oral Therapies Three-Year Update of Sildenafil Myriad new therapeutic agents are emerging for the treatment of sexual dysfunction. Apomorphine Citrate Efficacy and Safety: sublingual has a central mechanism of action; it is Cleveland Clinic Series administered sublingually 20 min prior to expected Data from 41 patients who responded to sildenafil sexual activity. Sildenafil was prescribed at a dose of 50 mg inhibitors with increased potency and selectivity. The drug significantly improved partner satisfaction, and side effects were assessed.
If ascitic fluid reaccumulates despite these measures purchase sinemet 110mg with mastercard, aspiration of large quantities of ascites fluid or large volume paracentesis may be First Principles of Gastroenterology and Hepatology A cheap sinemet 300mg on-line. The black colour of melena is the result of degradation of blood by intestinal bacteria buy 110 mg sinemet with visa. Obscure bleeding is defined as bleeding of unknown origin that persists or recurs after negative initial endoscopies (colonoscopy and upper endoscopy). Another risk factor for some patients is a reduced level of consciousness due to shock or hepatic encephalopathy. Some patients may require supplemental oxygen or even intubation for airway protection and/or assisted breathing. It is important to remember that, hemoglobin (Hb) and hematocrit (Hct) may not be low at presentation. Over the ensuing 3648 hours, most of the volume deficit will be repaired by the movement of fluid from the extravascular into the intravascular space. Only at these later times will the Hb and Hct reflect the true degree of blood loss. In a predisposed individual, anemia can lead to congestive heart failure or angina. Other important data includes a prior history of peptic ulcer disease, history of abdominal surgery (e. The hemodynamic status should be interpreted in light of the patients abilities to compensate for hypovolemia. In a young and fit adult, the presence of a resting or orthostatic tachycardia should be interpreted as a sign of significant volume loss, while the loss of an equivalent blood volume in an elderly or debilitated subject would more likely be manifested by hypotension or shock. Once supportive measures have been undertaken, the patient should be assessed with a view towards identifying the source of bleeding (ie. The pigmentation of the stool will depend on the length of time in transit along the bowel. In determining the likely source of bleeding, the clinician needs to interpret the patients manifestations of bleeding in conjunction with the hemodynamic status. In the absence of spontaneous passage of stools, a digital rectal examination to determine the stool color will be most informative. If the bleed is due to a peptic ulcer, upper endoscopy allows stratification of rebleed risk based on the appearance of the ulcer. Early upper endoscopy is done if there are signs of a brisk bleed, a variceal bleed is suspected, the patient is older or has numerous comorbidities. Wireless capsule endoscopy involves ingestion of a pill sized camera to take pictures of the small bowel. Enteroscopy involves a long scope inserted from the mouth to examine the proximal small bowel. Balloon enteroscopy is a newer endoscopic technique in which total endoscopic examination of the small bowel is possible. Description When an abdominal mass is discovered on physical examination, one must define its nature. Using a systematic approach often permits the identification of the mass before the use of sophisticated tests. Important Points in History and Physical Examination Important clues in the history and general physical examination may help to identify the enlarged viscus. For example, in a young patient presenting with diarrhea, weight loss and abdominal pain, finding a right lower quadrant mass would suggest inflammatory bowel disease. However, an abdominal mass may be discovered during physical examination of an asymptomatic individual. Certain observations made during the abdominal examination may be helpful (See also Section 20). A practical approach is to divide the abdomen into four quadrants (See Section 20. Starting from the principle that an abdominal mass originates from an organ, surface anatomy may suggest which one is enlarged. In the upper abdomen a mobile intraabdominal mass will move downward with inspiration, while a more fixed organ (e. Auscultation Careful auscultation for bowel sounds, bruit or rub over an abdominal mass is part of the systematic approach. Defining the Contour and Surface of the Mass This is achieved by inspection, percussion and palpation. In the absence of ascites, ballottement of an organ situated in either upper quadrant more likely identifies an enlarged kidney (more posterior structure) than hepatomegaly or splenomegaly. Differential Diagnosis The following suggests an approach to the differential diagnosis of an abdominal mass located in each quadrant: 18. This anterior organ has an easily palpable lower border, which permits assessment of its consistency. Right kidney: The kidney may protrude anteriorly when enlarged and be difficult to differentiate from a Riedels lobe of the liver. Gallbladder: This oval-shaped organ moves downward with inspiration and is usually smooth and regular. Left Upper Quadrant Location in the left upper quadrant suggests spleen or left kidney. Since it has an oblique longitudinal axis, it extends toward the right lower quadrant when enlarged. Shaffer 29 Left kidney: Its more posterior position and the presence of ballottement helps distinguish the left kidney from the spleen. Colon, pancreas, stomach: It is practically impossible to differentiate masses in these organs by physical examination. Inflammatory bowel disease usually would be associated with pain on palpation but carcinoma of the cecum would be painless. Approach to Diagnosis To complete the assessment of an abdominal mass, one may choose among several different investigational tools. This noninvasive, safe, cheap and widely available method identifies the mass and provides information on its origin and nature. Hollow organs may be demonstrated radiographically through the use of contrast media (e. Description Proctalgia fugax is a sudden severe pain in the anus lasting several seconds or minutes and then disappearing completely. Although some observations suggest a rectal motility disorder, the symptom appears more likely to result from spasm of the skeletal muscle of the pelvic floor (specifically, the puborectalis). History and Physical Examination Proctalgia fugax occurs in about 14% of adults and is somewhat more common in females than males. The pain may be excruciating, but since it is so short-lived patients seldom report it to their physician. In 90% of instances it lasts less than five minutes and in many cases less than a minute. Differential Diagnosis Perianal disease may cause pain but it usually accompanies, rather than follows, defecation. One should be particularly careful to exclude the presence of an anal fissure, which may be difficult to see on anal inspection. Pain originating from the coccyx may be accompanied by coccygeal tenderness both externally and from within the rectum. An acute attack of anal pain lasting several hours may indicate a thrombosed hemorrhoid. Saloojee Examination of the abdomen is an important component of the clinical assessment of anyone presenting with suspected disease of the gastrointestinal tract. As in all other parts of the examination, care must be taken to show respect and concern for the patient while ensuring an appropriate and thorough examination. While performing the examination it is useful to keep in mind the concepts of sensitivity and specificity. How confident can we be that a suspected physical finding is in fact present and has clinical significance?
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