Although many Hepatitis hiatal hernias are asymptomatic buy panmycin 250 mg on line, if the disease con- tinues for a prolonged period generic 250 mg panmycin mastercard, it may cause gastroe- Hepatitis is an inflammatory condition of the liver best panmycin 500 mg. The usual causes include exposure to toxic sub- stances, especially alcohol; obstructions in the bile ducts; metabolic diseases; autoimmune diseases; Intestinal Obstruction and bacterial or viral infections. A growing public An intestinal obstruction is a partial or complete health concern is the increasing incidence of viral blockage in the small or large intestine that prevents hepatitis. Complete disease is easily transmitted and can cause signifi- obstruction in any part of the intestine constitutes a cant morbidity and prolonged loss of time from medical emergency and requires rapid diagnosis and school or employment. Although forms of hepatitis range from hepatitis The two forms of intestinal obstructions A through hepatitis E, the three most common include mechanical blockage, also called ileus, where forms are: hepatitis A, also called infectious hepatitis; contents of the intestine are prevented from mov- hepatitis B, also called serum hepatitis; and hepatitis ing forward due to an obstacle or barrier that C. Mechanical obstructions include tumors, scar Because of patient exposure, health-care personnel tissues (adhesions), intestinal twisting (volvolus), are at increased risk for contracting hepatitis B, intestinal “telescoping” where part of the intestine but a vaccine that provides immunity to hepatitis slips into another part just beneath it (intussus- B is available. There is no vaccine available for hep- ceptions), strangulated hernias, or the presence of atitis C. Patients with hepatitis C may remain foreign bodies, such as fruit pits and gallstones. Treatment for hepatitis abdominal surgeries or with spinal cord lesions includes antiviral drugs; however, there is no cure. Other less common causes include throm- becomes so serious that liver transplantation is the bosis or embolism of mesenteric vessels and trauma only recourse. One of the major symptoms of many liver disor- The primary medical treatment for an intestin- ders, including hepatitis and cirrhosis, is a yellowing al obstruction is insertion of an intestinal tube. If of the skin, mucous membranes, and sclerae of the intestinal tube is ineffective in relieving the the eyes (jaundice, icterus). The neoplasm nearly always develops from the epithelial or mucosal lining of the stomach in the form of a Diverticulosis cancerous glandular tumor (gastric adenocarci- Diverticulosis is a condition in which small, blis- noma). Persistent indigestion is one of the terlike pockets (diverticula) develop in the inner important warning signs of stomach cancer. These pockets occur carcinomas, hepatocellular carcinomas, and most commonly in the sigmoid colon. An obstruction that devel- for diverticulitis consists of bed rest, antibiotics, and ops suddenly may be the first symptom of cancer a soft diet. In severe cases, however, excision of the involving the colon between the cecum and the diverticulum (diverticulectomy) may be advised. In this region, where bowel contents are liquid, a slowly developing obstruction will not become evident until the lumen is almost closed. Oncology Cancer of the sigmoid and rectum causes symp- Although stomach cancer is rare in United toms of partial obstruction with constipation States, it is common in many parts of the world alternating with diarrhea, lower abdominal where food preservation is problematic. Diverticula Fat tissue Opening from inside colon to diverticulum Hardened mass inside diverticulum Figure 6-6. Pathology 119 Diagnostic, Symptomatic, and Related Terms This section introduces diagnostic, symptomatic, and related terms and their meanings. Anorexia nervosa and a similar eating disorder called bulimia nervosa are discussed in Chapter 14. Failure of the liver to produce albumin (a protein that regulates the amount of fluid in the circulatory system), combined with portal hypertension forces fluid to pass from the circulatory system and accumulate in the peritoneum. It may also be caused by toxins, infectious agents, metabolic diseases, and circulatory disorders. In this disor- der, functional hepatic cells are replaced by nonfunctioning f ibrous tissue that impairs the flow of blood and lymph within the liver, resulting in hepatic insuff iciency. It may also be due to surgery, such as gastric resection and ileal bypass, or antibiotic therapy. Obesity may be due to excessive intake of food (exogenous) or metabolic or endocrine abnormalities (endogenous). Morbid obesity is a disease with serious psychological, social, and medical rami- f ications and one that threatens necessary body functions such as respiration. After surgery in adults, a stomach tube remains in place and obser- -osis: abnormal condition; increase vation is maintained for signs of hemorrhage or blockage of the tube. Pathology 123 Diagnostic and Therapeutic Procedures This section introduces procedures used to diagnose and treat digestive system disorders. Descriptions are provided as well as pronunciations and word analyses for selected terms. It is also used to conf irm the presence and extent of varices in the lower esophagus and stomach in patients with liver disease. When polyps are discovered in the colon, they are retrieved and tested for cancer. Colonoscopy (Examination Polyp of entire length End of of colon) sigmoidoscopy (Examination of lower third Sigmoid colon of colon) Anus Figure 6-9. Bilirubin is a breakdown product of hemo- globin and is normally excreted from the body as bile. Excessive bilirubin causes yellowing of the skin and mucous membranes, a condition called jaundice. It also helps detect colon cancer and bleeding associated with diges- tive disorders. It is used for diagnosing obstructions, tumors, or other abnormalities of the colon. It is also used to diagnose tumors, cysts, inflammation, abscesses, perforation, bleeding, and obstructions. A band is then inserted that restricts food consumption and delays its passage from the pouch, causing a feeling of fullness. Staple lines Small stomach Staple lines Esophagus pouch Pouch Esophagus Duodenum A. Duodenum Arrows show pathway of food Shortened jejunum is now connected to the small stomach pouch Connection B. Stoma Colostomy performed to Colostomy bag attach healthy attached to stoma tissue to abdomen Figure 6-12. Antacids counteract or decrease excessive drugs include agents that relieve “cramping” (anti- stomach acid, the cause of heartburn, gastric dis- spasmodics) and those that help in the movement comfort, and gastric reflux. Complete each activity and review your answers to evaluate your understanding of the chapter. Learning Activity 6-1 Identifying Digestive Structures Label the illustration on page 109 using the terms listed below. Enhance your study and reinforcement of word elements with the power of DavisPlus. We recommend you complete the flash-card activity before completing Activity 6–3 below. Learning Activities 135 Learning Activity 6-3 Building Medical Words Use esophag/o (esophagus) to build words that mean: 1. Complete the termi- nology and analysis sections for each activity to help you recognize and understand terms related to the digestive system. Use a medical dictionary such as Taber’s Cyclopedic Medical Dictionary, the appendices of this book, or other resources to define each term. Then review the pronunciations for each term and practice by reading the medical record aloud. Eventually, she was diag- nosed as having cholecystitis with cholelithiasis and underwent cholecystectomy. This pain followed a crescendo pattern and peaked several weeks ago, at a time when family stress was also at its climax. It does not cause any nausea or vomiting, does not trigger any urge to defecate, and is not alleviated by passage of flatus. While referring to Figure 6–3, describe the location of the gallbladder in relation to the liver. How does the patient’s most recent postoperative episode of discomfort (pain) differ from the initial pain she described? Use a medical dictionary such as Taber’s Cyclopedic Medical Dictionary, the appendices of this book, or other resources to define each term.

Which condition gives rise to the highest serum Answers to Questions 49–54 level of transaminases? Alcoholic hepatitis but nonhepatic sources can be ruled out by a high direct bilirubin cheap 500mg panmycin amex. Select the most sensitive marker for alcoholic liver slightly elevated in obstructive jaundice but is disease order 500mg panmycin with mastercard. Which enzyme is least useful in differentiating necrotic from obstructive jaundice? Which of the following statements about the Answers to Questions 55–59 phosphatases is true? B Phosphatases are classified as either alkaline or acid related compounds depending upon the pH needed for optimum B generic panmycin 500mg amex. The phosphatases hydrolyze a wide range needed for activity of monophosphoric acid esters. Intestinal can be achieved by incubating the serum with neuraminidase prior to electrophoresis. The enzyme Chemistry/Apply principles of special procedures/ reduces the sialic content of the bone isoenzyme, Phosphatases/1 causing it to migrate at a slower rate. The assays may be used immunochemically to monitor bone remodeling by osteoblasts in B. Some differ mainly in carbohydrate content obstruction and cannot be identified by immunologic methods. It is not increased in diseases of bone or in Chemistry/Correlate clinical and laboratory data/ pregnancy. Hyperparathyroidism and hyperthyroidism slightly increased in osteoporosis but often it is not. Osteoporosis In addition to obstructive jaundice and bone diseases, alkaline phosphatase is a tumor marker. Pancreatic disease procedures/Phosphatases/2 associated with biliary obstruction, such as cancer 64. Citrate and measures the increase in absorbance at 405 nm Chemistry/Apply principles of basic laboratory as p-nitrophenyl phosphate is hydrolyzed to procedures/Phosphatases/2 p-nitrophenol. C The Szasz modification of the Bowers–McComb method measures the hydrolysis of p-nitrophenyl phosphate, and continuously monitors the formation of p-nitrophenol at 405 nm. In which condition is the measurement of acid acid phosphatase in detecting prostatic cancer. Measuring the prostatic isoenzyme to screen for confined to the investigation of sexual assault. Measuring the enzyme in a vaginal swab extract presence of seminal fluid in the vaginal sample. Te diagnosis of hemolytic anemia Tartrate-resistant acid phosphatase is used as a D. As a marker for bone regeneration cytochemical marker for hairy-cell leukemia, and Chemistry/Apply knowledge to identify sources of may be measured in serum to identify diseases with error/Phosphatases/3 increased osteoclast activity, particularly malignancies 67. Hydrolyzes second α 1–4 glycosidic linkages of second α 1-4 glycosidic bonds of polyglucans starch, glycogen, and other polyglucans forming maltose. Hydrolyzes all polyglucans completely to amylase: P-type derived from the pancreas and produce glucose S-type derived from the salivary glands. Oxidatively degrades polysaccharides containing be differentiated by both electrophoresis and glucose immunoassay. Splits polysaccharides and disaccharides by form in plasma is the salivary isoenzyme. There are addition of water several genetic variants of the salivary isoenzyme, Chemistry/Apply knowledge of fundamental biological which in part accounts for the broad reference characteristics/Enzymes/1 range. Amylase hydrolyzes Chemistry/Apply knowledge of basic laboratory the substrate from both ends producing fragments procedures/Enzymes/1 of 2, 3, and 4 glucose subunits. How soon following acute abdominal pain due to groups, forming glucose and p-nitrophenol. Urinary amylase peaks concurrently Enzymes/2 with serum but rises higher and remains elevated for up to 1 week. Which of the following statements regarding the Answers to Questions 70–72 diagnosis of pancreatitis is correct? B Amylase is not increased in all persons with in acute pancreatitis pancreatitis and can be increased in several B. Lipase adds both both amylase and lipase sensitivity and specificity to the diagnosis of acute C. Plasma or serum lipase becomes useful only when patients have renal failure abnormal within 6 hours, peaks at approximately D. Serum lipase peaks several hours before amylase 24 hours, and remains abnormal for about 1 week after an episode of acute pancreatitis following an episode of acute pancreatitis. In acute pancreatitis, the rate of urinary amylase excretion Chemistry/Correlate clinical and laboratory data/ increases, and the amylase:creatinine clearance ratio Enzymes/2 is helpful in diagnosing some cases of pancreatitis. Which of the following conditions is associated The normal A:C clearance ratio is 1%–4%. Peptic ulcers sensitivity of amylase and lipase in detecting chronic Chemistry/Correlate clinical and laboratory data/ disease to below 50%. Patients with chronic disease Enzymes/2 have pancreatic insufficiency giving rise to increased fecal fat, and decreased pancreatic digestive enzymes 72. Which of the following statements regarding such as trypsin, chymotrypsin, and elastin. Activity will vary depending on the method used S-type and P-type, respectively, are present in C. High amylase occurs in mumps, glucose ectopic pregnancy, biliary obstruction, peptic D. Overrange samples are diluted in deionized water ulcers, alcoholism, malignancies, and other nonpancreatic diseases. Isoenzymes can be Chemistry/Apply knowledge of basic laboratory separated by electrophoresis (S-type is faster than procedures/Enzymes/2 P-type), but more commonly immunoinhibition of S-type amylase is used to rule out mumps, malignancy, and ectopic pregnancy, which give rise to high S-type amylase. Saccharogenic methods measure the production of glucose, while amyloclastic methods measure the degradation of starch. Starch is a polymer of α-D glucose subunits linked together by both α 1-4 and α 1-6 glycosidic bonds. Different lots may have more or less branching owing to the number of α 1-6 bonds. Since amylase hydrolyzes at the α 1-4 sites only, the amount of product measured is influenced by the extent of branching. Which of the following statements regarding Answers to Questions 73–76 amylase methods is true? C Many endogenous inhibitors of amylase, such as expected activity wheat germ, are found in serum. Te reference range is consistent from method or 4-nitrophenyl maltohepatoside can be used for to method kinetic assays. Maltotetrose is hydrolyzed to maltose by amylase, and the maltose hydrolyzed by Chemistry/Apply knowledge to identify sources of α-glucosidase or maltose phosphorylase, forming error/Enzymes/2 glucose or glucose-1-phosphate, respectively. Other esterases can hydrolyze triglyceride and be added to synthetic substrate assays to inhibit synthetic diglycerides S-type amylase. A Triglycerides may be hydrolyzed by nonspecific generating reactions esterases in serum as well as lipase. Synthetic substrates are less soluble than olive oil at an interface of oil and H2O and requires bile salts in aqueous reagents and colipase for activity. A Lipase elevation is of greater magnitude (2-50 × N) and duration than amylase in acute pancreatitis. Which statement about the clinical utility of When the lipase method is optimized by inclusion of plasma or serum lipase is true? Lipase is not increased in mumps, malignancy, specific than serum amylase for detection of acute or ectopic pregnancy pancreatitis.

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If you break this criticism down generic 250 mg panmycin with visa, it’s interesting to view the chain of events that occurs panmycin 500mg cheap. A value judgment is placed on whatever you do by measuring it against your inner belief system cheap panmycin 500 mg line, which in this circumstance states that it’s important to always pay bills on time. You adopted these values as a child to help guide your behaviour so that you would continue to be cared for and would not get into trouble. As a child you were very vulnerable and fundamentally feared abandonment or being overwhelmed. The inner critic, triggered by a violation of your belief system, quickly takes control to go from “this is bad” to “I am bad. It determines that the action was bad and generalizes, with the creation of the identity “I” that “I am bad. The “I” is created when there is a perceived threat to the integrity of your internalized belief system. It reflects how you think you should behave in the world to maintain a feeling of being loved and accepted. The inner child feels threatened and those fears become expressed Where Does the “I” Come From? The inner child places itself in the situation of not having paid the bill and reacts to it. In other words, if you’re using the word “I,” as part of a conversation that’s taking place in your mind, watch out! A pattern of response from your early childhood has likely been triggered and you should be very wary about what it has to say! The “I” is the inner child who believes it has not acted in a manner that follows its belief system in order to maintain things in a safe fashion. The system needs to act defensively and the internal criticism reflects a child’s attempt to guide his or her behaviour in the right way. The harsh and critical words of your own inner voice may even reflect things that were said to you as a child by your caregivers in previous situations. How Understanding the “I” Creation Helps You Deal With Stress It’s important for you to understand the relationship between the judgment of your action by your belief system and the subsequent personalization and creation of the “I”. In understanding that not paying the bill is perceived as bad and that that action has triggered the creation of the “I”, it allows you to more easily separate the action from the commentary. Your actions may be viewed as wrong according to your belief system but that doesn’t make you a bad human being. All of this evaluating and judging occurs spontaneously and automatically, again reflecting the fact that much of your mental functioning is beyond your conscious control. Ultimately, it’s this referencing of how an event compares with your established patterns of belief that then creates the “self. What are the circumstances that lead to the formation of the “I” for you personally? By paying attention to what tends to happen just before you notice an internal conversation where you’re using the word “I” a lot, you can identify the patterns that lead to “I” formation. When you hear your inner voice using the word “I”, (or for some people “you” in reference to themselves, e. They’re probably coming to you straight from your inner child and you know so much more now than you did when you were four! This should give you some perspective and allow you to calm down a bit, be less critical and judgmental and therefore reduce your stress. A sensation (or if you prefer, think of it as a perception, stimulus, experience, or event) leads to a story about the sensation based on your belief system, which recruits your inner child, who then defines the self. Instead you’ll be more likely to be able to step back and say, “Wait a second, you’re the inner child my doctor warned me about! You believe your story to be one hundred percent real and true, even though most of it was created as a coping mechanism when you could scarcely walk. So you know that your own story can’t be the whole truth and nothing but the truth, but when you first hear it, it sure feels like the truth. If you let yourself get caught up in your own story and the belief that there is the “I” that is fundamentally bad, good, angry, sad, etc. Be present to what arises from a position of separation, as the witness or observer of the story and its process, without identification or attachment. This isn’t to say that you don’t need to pay your bills, or that there are no consequences to your actions. A little stress can be an excellent motivator, but when your stories start to suck the life out of you and you really start suffering, it’s good to know how your mind really works so that you can put a stop to it. Your identification with your thoughts, emotions and physical sensations determines your own suffering. If you understand that sensations, stories and even the self (that pops up as a star in your own melodrama), are all just mental states and conditioned patterns of reaction, then you can use all that you’ve learned about mindfulness to experience them without the pain of ownership. The next time you catch your inner voice with something critical to say, see if you can clearly pinpoint what it’s trying to tell you about 154 • Mindfulness Medication who you are as a person. If it’s saying, “I am a bad person,” for example, ask yourself: Am I truly a bad person or is this just a mental state? In asking these questions, you will start to stand back a bit and give yourself some vital perspective. The union of Eastern mindfulness and the Western-based inquiry into the processes of the mind is a powerful one-two punch to your habitual stress responses. As you have discovered, anxiety and stress come from the fact that everything you experience is examined to determine how it impacts your created sense of self or “I”. You might feel hurt that someone didn’t call you, that he or she ignored you, yelled at you, didn’t include you, couldn’t read your mind to know exactly what you wanted, etc. You’ll find that it’s very calming to just consider whatever is happening as a straightforward event, without having to self-reference it. For example, Larry bought his suit and his mind started to criticize him and say, “How could I have bought such an expensive suit? It can be tricky to let go of the “I” who is feeling hurt, but try to think about only the simple facts of a stressful situation. Give yourself the opportunity to look at what’s happening objectively, without the emotional torment. You can then deal more effectively with the issue and will have a much better shot at solving the problem. The only true measure of your experience is whether it’s ethically right, compassionate and wise. When you catch yourself doing something mundane or routine and are relaxed, drop in on your mind and see what it’s doing. Compare this state to what you experienced when you weren’t thinking any “I”-related thoughts. Pay attention to how your mind relates to the stories and the “I” that is created in response to a stress-inducing situation, action, event or sensation. Ask the question, “Does the belief that there is an “I” that is bad (or whatever judgment is present for you at that moment) define my essence? You begin to use the word “I” in an inner commentary in response to a sensation or stimulus that causes you stress. A mental dialogue that includes the phrase “I” and is typically highly judgmental reveals this sense of self. Consider for a moment whether or not your inner voice is usually saying nice or negative things. Think about whether you consciously determine what the voice is going to say next or not and for that matter, would you ever say the type of things your inner voice sometimes says to you, to another person? The voice pops up in response to an external or internal sensation (experience, event, action, stimulus… you get the idea), comments on what has happened and directs the action to be taken next. In the last chapter you learned that this voice is actually a pattern of response that you learned in childhood and is known as the inner child. It would be very helpful to have an understanding of the nature of this little captain of your mind. I think you’ll find that eavesdropping on someone else’s inner voice will help to illustrate the nature of the voice itself. His inner voice started to become stronger and it sounded something like this: 157 158 • Mindfulness Medication I’m going to be late. Accompanying the dialogue, Larry also began to notice that he was starting to sweat, his pulse was becoming faster, his breathing shallower, he was shaking his head back and forth and he felt a familiar tightness in his abdomen.

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Therefore Pasteur proved that micro-organisms entered to substrates through the air and micro-organisms did not evolve spontaneously purchase panmycin 500 mg mastercard. Discovery of streptococci The germ theory of disease The complete establishment of the germ theory of disease depended on the work of a German scientist buy generic panmycin 500 mg on-line, Robert Koch (1843- 1910) buy panmycin 500mg visa. Koch’s postulates Koch’s postulates: proof of germ theory of disease A micro-organism can be accepted as a causative agent of an infectious disease only if the following conditions are satisfied. The micro-organism should be found in every case of the disease and under conditions which explain the pathological changes and clinical features. It should be possible to isolate the causative agent in pure culture from the lesion. When such pure culture is inoculated into appropriate laboratory animal, the lesion of the disease should be reproduced. It should be possible to reisolate the bacterium in pure culture from the lesion produced in the experimental animal. It has not been possible to fulfil every one of Koch’s postulates, but by adhering to them as closely as possible, serious errors have been prevented. Some microbes are very difficult or impossible to grow in vitro(in the laboratory) in artificial media. Certain diseases develop only when an opportunistic pathogen invades immunocompromised host. Classification is the assignment of organisms (species) into anorganised scheme of naming. The establishment of criteria for identifying organisms & assignment to groups (what belongs where) 5 2. At what level of diversity should a single species be split in to two or more species? Species) are more similar to each other than are members of higher level taxa (eg. Thus once you know that two individuals are member of the same taxon, you can inter certain similarities between the two organisms. Strain is the level below the species b) Two members of the same strain are more similar to each other than either is to an individual that is a member of a different strain, even if all three organisms are members of the same species Bacterial species - A bacterial species is defined by the similarities found among its members. Properties such as biochemical reactions, chemical composition, cellular structures, genetic characteristics, and immunological features are used in defining a bacterial species. Identifying a species and determining its limits presents the most challenging aspects of biological classification for any type of organism. Monera ( the prokaryotes) Kingdom of Monera Three categories: - Eubacteria Are our common, everyday bacteria, some of which are disease – causing; also the taxon from which mitochondria originated. Distinctively, however, the members of Kingdom Protista are all eukaryotic while the mebers of kingdom Monera are all prokaryotic. Some members of protista are multicellular, however Kingdom protista represents a grab bag, essentially the place where the species are classified when they are not classified as either fungi, animals or plants. Kingdom Fungi Unlike pprotists, the eukaryotic fungi are typically non – aquatic species. They traditionally are nutrients absorbers plus have additional distinctive features. The domain system contains three members 9 ¾ Eukaryotes ( domain Eukarya ) ¾ Eubacteria ( domain Bacteria) ¾ Archaebacteria ( domain Archaea) Viral classification Classification of viruses is not nearly as well developed as the classification of cellular organisms. Today viruses tend to be classified by their chemical, morphological and physiological attributes (e. Binomial nomenclature is not employed to name viruses; instead viruses are named by their common names (e. The distinguishing features between Eukaryotic cell and Prokaryotic cell Features Prokaryotic cell Eukaryotic cell. Cellular element enclosed with in the cell envelope: Mesosomes, ribosomes, nuclear apparatus, polyamies and cytoplasmic granules. Cell wall Multi layered structure and constitutes about 20% of the bacterial dry weight. Young and rapidly growing bacteria has thin cell wall but old and slowly dividing bacteria has thick cell wall. It is composed of N-acetyl Muramic acid and N-acetyl Glucosamine back bones cross linked with peptide chain and pentaglycine bridge. Contains toxic components to host Bacteria with defective cell walls Bacteria with out cell wall can be induced by growth in the presence of antibiotics and a hypertonic environment to prevent lysis. Protoplasts: Derived from Gram-positive bacteria and totally lacking cell walls; unstable and osmotically fragile; produced artificially by lysozyme and hypertonic medium: require hypertonic conditions for maintenance. Spheroplast: Derived from Gram-negative bacteria; retain some residual but non-functional cellwall material; osmotically fragile;produced by growth with penicillin and must be maintained in hypertonic medium. L- forms: Cell wall-deficient forms of bacteria usually produced in the laboratory but sometimes spontaneously formed in the body of patients treated with penicillin; more stable than protoplasts or spheroplasts, they can replicate in ordinary media. Cell membrane Also named as cell membrane or cytoplasmic membrane It is a delicate trilaminar unit membrane. Mesosomes Convoluted invagination of cytoplasmic membrane often at sites of septum formation. Nuclear apparatus Well defined nucleus and nuclear membrane, discrete chromosome and mitotic apparatus are not present in bacteria ; so nuclear region of bacteria is named as nuclear body, nuclear apparatus and nucleoid. Besides nuclear apparatus, bacteria may have extra chromosomal genetic material named as plasmids. Plasmids do not play any role in the normal function of the bacterial cell but may confer certain additional properties(Eg. Virulence, drug resistance) which may facilitate survival and propagation of the micro- organism. Glycocalyx (capsule and slime layer) Capsule is gel firmly adherent to cell envelope. Capsule is composed of polysaccharide and protein(D-Glutamate of Bacillus anthracis) Features of capsule 1. Flagellum It is the organ of locomotion in bacterial cell and consists of thee parts. The basal body The basal body and hook are embedded in the cell surface while the filament is free on the surface of bacterial cell. Pili (fimbriae) It is hair like structure composed of protein (pilin) Two types (Based on function). Sex pili: The structure for transfer of genetic material from the donor to the recipient during the process of conjugation. Spores Resting cells which are capable of surviving under adverse environmental conditions like heat, drying, freezing, action of toxic chemicals and radiation. Classification of bacteria Bacterial classification depends on the following characteristics. Morphology of bacteria When bacteria are visualized under light microscope, the following morphology are seen. Bacilli (singular bacillus): Stick-like bacteria with rounded, tepered, square or swollen ends; with a size measuring 1-10μm in length by 0. Spiral: Spiral shaped bacteria with regular or irregular distance between twisting. Staining of bacteria Bacterial staining is the process of coloring of colorless bacterial structural components using stains (dyes). The principle of staining is to identify microorganisms selectively by using dyes, fluorescence and radioisotope emission. Staining reactions are made possible because of the physical phenomena of capillary osmosis, solubility, adsorption, and absorption of stains or dyes by cells of microorganisms. Individual variation in the cell wall constituents among different groups of bacteria will consequently produce variations in colors during microscopic examination. Whereas, cytoplasm is basic in character and has greater affinity for acidic dyes. Because dyes absorb radiation energy in visible region of electromagnetic spectrum i. Direct staining Is the process by which microorganisms are stained with simple dyes. A mordant is the substance which, when taken up by the microbial cells helps make dye in return, serving as a link or bridge to make the staining recline possible.

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No Hydrometrocolpos Obtain contrast enema Yes Ovarian cyst Pyloric atresia Duodenal atresia Meconium peritonitis Ileal atresia Malrotation with volvulus Perforation from: Meconium ileus Jejunal atresia Volvulus Meconium plug syndrome Atresia Small l colon syndrome Meconium ileus Hirschsprung’s disease Colorectal atresia Algorithm 36 buy cheap panmycin 500 mg. Burd Low obstruction Small bowel No polyhydramnios High obstruction Small bowel Normal-caliber polyhydramnios coion Figure 36 discount panmycin 500 mg visa. Calcifications can form when the peritoneal cavity is exposed to meconium safe panmycin 500mg, and their presence suggests an antenatal intestinal perforation. Morphologic abnormalities suggesting a chromosomal defect also may have been observed, prompting amniocentesis and chromosomal testing. Chro- mosomal defects are found in about 5% of infants with esophageal atresia (most frequently trisomy 18 and 21) and about 30% of infants with duodenal atresia (most commonly trisomy 21). Family and maternal history may provide additional insight into the cause of neonatal intestinal obstruction. Because a familial association has been reported for most causes, a family history of newborn or child- hood surgery for intestinal obstruction should be sought, and the cause should be determined, if possible. Family members with disorders and anomalies outside of the gastrointestinal tract also may suggest an eti- ology of neonatal intestinal obstruction. Almost half of neonates with small left colon syndrome are infants of diabetic mothers. Physical Examination A complete examination is mandatory for all neonates with suspected intestinal obstruction. Particular attention should be focused on the abdominal examination, on the perineal inspection, and on identifying other anomalies, including features suggesting a chromosomal disor- der. In the case presented at the beginning of the chapter, the presence of trisomy 21 provides indirect evidence supporting the diagnosis of duodenal atresia. Although difficult to observe in most cases, gastroduodenal or high jejunal obstruction may result in epigastric distention with a scaphoid lower abdomen, as described in the case presented. As discussed pre- viously, mechanically ventilated neonates with esophageal atresia and 36. Neonatal Intestinal Obstruction 651 a tracheoesophageal fistula also may exhibit abdominal distention. The abdomen should be examined for tenderness and masses, and the inguinal region should be inspected for hernia. The main features to evaluate are the general perineal appear- ance and anal position and patency. The anal canal normally is posi- tioned about halfway between the coccyx and base of the scrotum in males or the vestibule in females, and it is within a perineal depression surrounded by slightly pigmented skin. Variations from this standard suggest that a variant of imperforate anus may be present. Neonates with a short distance from the distal colon to the perineum (low imper- forate anus) may have a perineal depression with pigmentation without a patent anal canal. With observation during the first 24 hours of life, meconium eventually may pass through a rectoperineal fistula and be seen exiting on the perineum anterior to the normal anal posi- tion or at midline raphe of the scrotum or penis in males or vestibule in females. Because meconium may be seen exiting on the perineum in patients with low imperforate anus, the examination should be per- formed carefully, since a normal anal canal may be confused by inex- perienced observers with a low imperforate anus with a rectoperineal fistula. Neonates with a long distance from the distal colon to the per- ineum (high imperforate anus) have more remarkable perineal find- ings, including the absence of an anal opening, absence of a perineal depression (“flat bottom”), and lack of pigmented skin. Additional screening maneuvers may be used to supplement the physical examination. To screen for esophageal atresia, a tube gently is passed through the mouth into the esophagus. In term infants with esophageal atresia, passage of the tube usually stops at about 10cm (Fig. If the tube successfully passes into the stomach, the gastric Pass 10-Fr tube through mouth Tube 10cm Dilated esophageal pouch Fistula Trachea Figure 36. Aspiration of more than 10 to 15cc of bilious material suggests an intestinal obstruction and provides further support for pursuing additional workup for the cause. Diagnostic Studies At this point in the workup, the range of possible diagnoses may have been narrowed substantially, and minimal additional diagnostic studies may be required. When the clinical history, presentation, and examination suggest esophageal atresia, posteroanterior and lateral chest radiographs should be obtained while gently pushing an oro- gastric tube against the blind ending esophagus. The presence of a prominent esophageal air pouch containing a curled tube is observed in most cases of esophageal atresia. The chest radiograph also should be examined for an abnormal cardiac silhouette that may suggest con- comitant congenital cardiac disease and for infiltrates attributable to aspiration of oropharyngeal secretions. Posteroanterior and lateral decubitus abdominal radiographs should be obtained in all neonates with suspected intestinal obstruc- tion. In the case presented at the beginning of the chapter, the next step is to obtain plain abdominal radiographs. In patients with esophageal atresia, the presence of air in the stomach confirms the presence of a tracheoesophageal fistula. A “double bubble” corresponding to a dilated stomach and duodenum is characteristic of a duodenal obstruction and likely would be observed in the case pre- sented. When duodenal obstruction is suspected but insufficient air has been swallowed to reveal this finding, it is useful to place 50cc of air via a nasogastric tube and immediately obtain a prone abdominal radiograph. When few dilated loops of bowel are observed beyond the duodenum, jejunal atresia is most likely. When multiple loops of dilated bowel are observed, particularly at more than 24 hours of life, a more distal obstruction is likely (Fig. Abdominal films demon- strating dilated loops of intestine without air-fluid levels and a ground- glass appearance, particularly in the right lower quadrant, produced by a mixture of air with thick meconium, is characteristic of meconium ileus. Scattered intraabdominal calcifications suggest antenatal per- foration and possible obstruction related to meconium peritonitis. Among infants with imperforate anus, the frequency of vertebral anomalies, including lumbar hemivertebrae or absent vertebra and a deficient sacrum, increases as the distance from the perineum to the distal end of the rectum increases. Plain radiographs together with the history and examination are suf- ficient to establish the likely diagnosis in most cases of proximal intesti- nal obstruction. Upper gastrointestinal contrast studies usually are not required before laparotomy. Characteristic abdominal film findings with high intestinal obstruction at the level of the duodenum (A), high obstruction at the level of the jejunum (B), and low obstruction at and distal to the ileum (C). An important use of this study is to distinguish duodenal atresia from malrotation and midgut volvulus when surgery is delayed because of the need to eval- uate and manage suspected cardiac or other anomalies. In all cases of midgut volvulus, exploratory laparotomy should proceed expedi- tiously. Repair of duodenal atresia, however, may be delayed when it is likely that additional medical management will improve the post- operative course. An upper gastrointestinal contrast study performed to rule out malrotation is mandatory before discharge in all neonates with unexplained bilious vomiting and abdominal distention, since the failure to recognize malrotation before volvulus ensues can lead to midgut necrosis. Neonates with abdominal distention at birth usually should undergo abdominal sonography in addition to plain abdomi- nal radiographs to evaluate for the previously mentioned intraperi- toneal and retroperitoneal lesions. A contrast enema is the most useful test to distinguish the varied causes of intestinal obstruction distal to the jejunum. The passage of intraluminal contents produced by antenatal mucosal shedding deter- mines the degree of intestinal dilatation at birth. For this reason, a normal-caliber colon is observed in patients with proximal intestinal obstructions, and a microcolon is observed with complete obstruction at a point more distal to the jejunum. When meconium ileus is sus- pected, the contrast study should be performed with Gastrografin, which serves to draw fluid into the intestinal lumen and dislodge thick meconium because of its hyperosmolarity. The contrast study typically demonstrates an empty microcolon with meconium plugs within a narrow-caliber terminal ileum. Meconium plug syndrome is suggested by an obstructing intraluminal mass (usually inspissated meconium) with proximal intestinal dilatation. In small left colon syndrome, a narrow-caliber left colon and dilated proximal colon are observed. Burd Colorectal atresia may be demonstrated by failure to reflux contrast proximally past a point of obstruction. The barium enema in a typical case of Hirschsprung’s disease shows an undilated rectum or distal colon with flow into a dilated proximal colon.

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