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Surg Rectal Dieulafoy’s is an unusual source of rectal Laparosc Endosc Percutan Tech 2008;18:398-9. Majority of Dieulafoy’s lesion Recurrent massive haematemesis from Dieulafoy occur in a lesser curvature of stomach within 6 cm of vascular malformations-a review of 101 2 the gastroesophageal junction. A 59-year-old woman presented with mucous erythema, friable mucosa with ulceration and mucosal bloody diarrhea for a year. Colonoscopy revealed diffuse improved significantly after corticosteroids treatment. Severe bridging fibrosis of the colon in a man Discussion: with inflammatory bowel disease. Indian J by bridging of regenerative mucosal tissue from one wall Gastroenterol 2012;31:39. This condition carries no malignant potential and can be found in other colitis conditions including ischemic 2 colitis, infective colitis, and colonic tuberculosis. A 52-year-old man presented with bowel habit ulcerative mass with friable mucosa and easily contacts change. He lost weight about 5 kgs Computed narrowed but scope could pass through this lesion t o m o g r a p h y o f t h e a b d o m e n d e m o n s t r a t e d (Figure 2-3). Biopsy of the lesion showed complex circumferential thickened wall of the hepatic flexure of neoplastic sheets with occasional glandular formation colon, about 5. Those lining cells pericolonic fat stranding, suggestive of carcinoma (T3) contained markedly pleomorphic nuclei. Colonoscopy revealed a circumferential was well-differentiated adenocarcinoma (Figure 4). Fuji Intelligent patients with right and left-sided colon cancer: Chromo Endoscopy and staining technique for differences in epidemiology, perioperative the diagnosis of colon tumor. He had no previous history of visible findings showed a tortuous dilated vein extending from gastrointestinal bleeding. Rectal varices are collateral vessels that connect the superior hemorrhoidal veins (inferior References mesenteric and portal circulation) with the middle and 1. Anorectal varices-their inferior hemorrhoidal veins (pudendal vein and systemic frequency in cirrhotic and non-cirrhotic portal circulation). A 46-year-old man with a history of bowel Crohn’s disease with ileocolic obstruction was clinically resection secondary to severe Crohn’s disease, entertained. C T w h o l e a b d o m e n s h o w e d with crypt distortion and crypt atrophy without any circumferential wall thickening of the ileocecal region organism (Figure 3-4). A recurrent Figure 1-2: Circumferential wall thickening of the ileocecal region (yellow arrow) Figure 3: Crypt distortion and crypt atrophy Figure 4: Fissure ulcers with transmural colitis Post operation, the patient was treated with anastomotic ulcer with normal mucosa at the neo corticosteroids and azathrioprine. Prophylaxis is recommended to be started anastomotic ulcer within two weeks after surgery, and should be continued for at least 2 years. Discussion: About 80% of patients with Crohn’s disease References required surgery at some stage of the disease. The operative recurrence was almost unavoidable in the second European evidence-based Consensus on absence of treatment. The rate of recurrence is about the diagnosis and management of Crohn’s 65-90% within 12 months, and 80 100% within 3 years disease: Special situations. Prophylactic treatment is recommended prevention of postoperative recurrence in after small intestinal resection. Am J Gastroenterol four controlled trials has shown that thiopurines were 2009;104:2089-96. Colonoscopy was performed and showed watery diarrhea and significant weight lost for 6 months. Diagnosis: Diagnosis of trichuriasis is by the demonstration Trichuris trichiura infestation of brown, barrel-shaped ova in feces. However, in some patients, stool examination could not show ova while 1,4 Discussion: colonoscopy could demonstrate whipworm infestation. Trichuris trichiura (whipworm) infestation is an Colonoscopy usually demonstrates the mobile whitish endemic in tropical and temperate countries, including worm; 30-50 mm in length with threadlike anterior end, Southeast Asia.

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Nursing Assessments for Electrolyte Imbalance Knowledge of the common causes of electrolyte imbalances indicates the patient who is at risk and who should be observed most closely for signs of an electrolyte imbalance. Many symptoms and observations may result from one or a combination of electrolyte imbalances. Symptoms noted may indicate a need for laboratory testing to determine the exact imbalance and provide additional data to support the diagnosis. Intracellular potassium accounts for 98 percent of the potassium in the body, whereas the remaining 2 percent is found in extracellular fluid. Potassium is critical to neuromuscular function because it plays an important role in action potentials, nerve polarization/depolarization, and excitability. Some drugs may cause an increase or decrease in potassium levels and should be noted when levels are analyzed. Deficient dietary intake of potassium and magnesium (which causes potassium to move into the cells) could contribute to the development of hypokalemia. In addition, deficient aldosterone levels, that is, Addison’s disease, or aldosterone-inhibiting diuretics may cause hyperkalemia. Acidosis also can cause hyperkalemia by causing a shift of hydrogen ions into the cell and potassium ions out of the cell and into the blood. Leukemic patients may demonstrate hyperkalemia owing to leukocytosis that occurs with the condition. False increases can occur owing to situational increases in potassium in the specimen: Potassium is released when blood cells are destroyed (thus any crush injury or hemolysis). Most (95 percent) of the sodium in the body is found in the extracellular spaces and 5 percent in the intracellular space. The concentration of sodium across the cellular membrane plays an important part in neuromuscular cell activity. Nursing assessments may reveal symptoms whose severity will vary depending on the degree and speed of onset of the hyponatremia. Elderly hospitalized patients should be watched most carefully because many have chronic diseases that may be fatal in combination with excessive sodium and fluid loss. Symptoms the nurse may note that indicate sodium elevation, or hypernatremia, include. Death Chloride the level of chloride usually follows the sodium level, except in cases of acid–base imbalance, when chloride levels are associated with bicarbonate levels. Most of the chloride in the body comes from the salt (sodium chloride) ingested and absorbed in the intestines as food is digested. Urine chloride levels may be measured to determine if the cause of hypochloremia is a loss of sodium and excess of base, such as occurs with vomiting, diuretics that show a low urine chloride level, or hormones such as cortisol or aldosterone that show a high urine chloride level. Hyperchloremia also results from metabolic acidosis owing to the loss of base and respiratory alkalosis that occurs with hyperventilation. Total calcium levels are determined during a general admissions panel of blood work. This is particularly true when a protein deficiency exist because 50 percent of the calcium found in the body is bound to protein. Kidney transplant Urine calcium levels will indicate the amount of calcium being excreted in the urine. Additionally, an ionized calcium test may be performed to measure the amount of calcium that is not bound to protein in the blood. The level of ionized calcium in the blood is not affected by the amount of protein in the blood. Elevated magnesium levels cause sedation and depressed neuromuscular activity, whereas low levels of magnesium cause neuromuscular excitability. Hypomagnesemia also can 52 Fluids and Electrolytes Demystified result from conditions resulting in chronic malabsorption such as occurs with diarrhea and fat malabsorption (which usually occurs after intestinal surgery or infection) or problems such as Crohn’s disease, gluten-sensitive enteropathy, and regional enteritis. Conditions that cause frequent or severe vomiting may result in a loss of magnesium as well, and toxemia in pregnancy has been associated with hypomagnesemia. Irregular heartbeat Phosphate Phosphate values are assessed to determine the amount of phosphorus in the body.

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The prognosis is particularly However, not all studies agree that stro vival rate was 44% compared with a 30% bad in children and young adults, in mal response and pushing margins pre survival rate in patients with 7-15 lymph whom the diagnosis is often delayed dict a better prognosis {1788, 1177}. However, others have not rogeneous disease biologically and involved by metastatic tumour (pN3) had found the Laurén classification to predict genetically, and a clear working model of an even worse 5-year survival of 11% prognosis {1788, 1177}. Arnold Definition observed mainly in male patients (M:F Most endocrine tumours of the stomach ratio, 2. Three distinct types 6% of gastric endocrine tumours and pre have are recognized: (1) Type I, associ vails in men (M:F ratio, 2:1) at a mean age ated with autoimmune chronic atrophic of 63 years (range 41-61 years) . It all located in the mucosa of the body niques and increased awareness of such leads to chronic atrophic gastritis (with or fundus of the stomach, whereas the rare lesions, have shown a much higher inci without pernicious anaemia) which leads G-cell tumours are located in the antro dence of gastric carcinoids, which may to an increase in gastrin production. Small cell carcinomas now account for 11-41% of all gastroin prevail in the body/fundus, but some are testinal carcinoids {1588, 1764, 1782}. Type may be involved as an additional growths are frequently observed . Of 152 cases stud which, though larger than those of type I, ied by endoscopy, 57% had more than are generally smaller than 1. Infiltration of the muscu thy and high levels of circulating gastrin laris propria is found in 76%, and of the are critical diagnostic findings. Carcinoid – denal gastrinomas) or with Cushing syn the absence of reactivity for the well differentiated endocrine neoplasm drome due to secretion of adrenocorti argentaffin or diazonium tests for sero 1. Small cell carcinoma – poorly differentiated endocrine neoplasm circumscribed in the mucosa or, more of tumours . Tumour-like lesions (77%) are < 1 cm in maximum diameter 5-hydroxy-tryptophan; these lesions, Hyperplasia and 97% of tumours are < 1. In addition, rosette-like and palisading patterns that whole tumour cell population. They are deeply invasive tumours are associated suggest endocrine differentiation, and in relatively rare in the stomach, despite the with local and/or distant metastases in which the last can be confirmed by frequent occurrence of minor endocrine most cases. This is a very rare tumour in the stomach nuclei are more vesicular and nucleoli are . The tumour cells are argentaffin, well documented in histopathological intensely argyrophilic and reactive with studies . The successive stages of chromogranin A and anti-serotonin anti hyperplasia are termed simple, linear, bodies. Analysing six type I gastric carci this rare dominantly inherited disorder is same stomach, the deletion size in the noids, Debelenko et al. The tumour suppressor function tumour invades muscularis propria or of the gene has been proposed based on beyond, is > 1 cm in size, angioinvasive, the results of combined tumour deletion functioning, with high mitotic activity and and pedigree analysis {107, 271, 394}. On 56 Tumours of the stomach death from the tumour occurs in 27% of more than on the behaviour of gastric patients with a mean survival of 28 tumours, although some aggressive months . If larg > 1 cm generally require surgical resec er than 1 cm or more than 3-5 lesions are tion even when they are histologically Fig. Today, stomach lym the neoplastic nature of lesions previous Primary gastric lymphomas are defined phomas are considered primary if the ly termed ‘pseudolymphoma’ . Recognition of morphological tribution; somewhat higher incidences Lymphomas at this site are considered features characteristic of primary extra have been reported for some Western primary if the main bulk of disease is nodal lymphomas of mucosa-associated communities with a high prevalence of located in the stomach. The majority of lymphoid tissue-type helps in defining Helicobacter pylori infection . The low Epidemiology Incidence rates are similar in men and grade lesions are almost exclusively Approximately 40% of all non-Hodgkin women. Within the gastrointestinal phoma suggested that the tumour was this excludes cases of secondary tract, the stomach is the most frequent associated with H. High-grade lesions to be present in 90% of cases limited to may appear as a palpable mass in the the mucosa and submucosa, falling to epigastrium and can cause severe 76% when deep submucosa is involved, symptoms, including weight loss. The two larger lesions are centrally ulcer There is some controversy surrounding by water. In some cases, the tration of the epithelium by B-lympho {1492, 384} to a strong association . Recently, a truncated form of an extent of lymphoma infiltration through cells has been studied in detail. In these cases the surrounding nor the proliferative response appeared to truncation in the protein and antibodies mal appearing gastric mucosa may har be strain specific for individual tumours to this truncated protein could be detect bour lymphoma, and accurate mapping but varied between tumours from differ ed in 70% of the patients studied with of the lesion requires multiple biopsies ent patients . In a proportion liferative response was not seen and this of cases, endoscopic examination shows could not be induced if the T-cells were Immunosuppression very minor changes such as hyperaemia replaced by supernatant from other cul Lymphomas may arise or involve the and in a few cases random biopsies of tures containing unseparated tumour stomach in patients with both congenital apparently entirely normal mucosa may derived cells .

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A solid black Color slides are best obtained with a 35-mm background also has the advantage of hiding single-lens-reflex camera with through-the-lens liquids that have seeped out from a specimen. The best results are achieved with this makes a cleaner presentation in the final fine-grain films. Most gross specimen photography is done with tungsten Lighting halogen lamps (3200 K) as opposed to an elec tronic flash (5500 K). Unlike the transient illumi Important features of a specimen may be hidden nation of the electronic flash, tungsten lamps when the lighting is too dim or obscured when the provide constant illumination so that the lighting lighting is too bright. Appropriate lighting, on can be critically evaluated before the photograph the other hand, will actually enhance the photo is taken. This will provide Standardized Exposure Determination shadows that will help suggest a relief or distin guish a form from its background. This posi the amount of light that reaches the film or digital tioning of the light source can help show texture camera can be controlled in two ways. The aperture refers to the made listing the correct aperture that matches diameter of the lens diaphragm, and this can be each magnification (Fig. Each f-stop set is easy to use, it may be necessary to modify the ting changes the amount of light passing through exposure for very dark blood-red specimens or the lens by a factor of 2. For example, an f-stop of 2 will let Scale more light into the camera than an f-stop of 22. The aperture also controls the depth of field, which While many find scales and labels unnecessary refers to the zone of sharpness in front of and distracters in an otherwise aesthetic photograph, behind the point of focus. With large apertures at least one of the specimen photographs should (smaller f-stop numbers), everything outside the include a scale along with the specimen identifi plane of focus abruptly becomes blurred. A scale helps the viewer orient small apertures (such as an f-stop of 22), objects the specimen and provides a benchmark for the remain in focus over a greater depth of field. Commercially prepared plas the amount of light hitting the film is also tic rulers are available that can be made into vari controlled by the shutter speed. Small adhesive labels with the specimen identifi Each shutter speed, like the f-stop, doubles or cation number can be attached directly to the halves the exposure at the next setting. When placing the scale in a photograph, speeds on modern shutters are 1, /2, /4, /8, 1 1 1 1 be sure to place it in the anatomical inferior posi /15, /30, /60, /125 second, etc. The scale should be positioned at the level both the aperture and shutter control the of the specimen so that it is in plane of focus. You need to identify the best f-stops and shut ter speeds for your particular system by running Digital Photography a series of exposure tests for each different speci men magnification. An incident light meter works best because mens, digital images offer several advantages it measures the light falling on the specimen. First and the reflected light meters that are found in most foremost is the ease with which an image, once cameras can be ‘‘fooled’’ and give incorrect read captured in digital format, can be edited, orga ings because of the light coming from the back nized, catalogued, and stored. For example, reflected light meters may system permits immediate review of the image read too much of the background and not enough captured. Most digital cameras have a video of the specimen when a lightly colored specimen ‘‘out’’ port that allows for the image to be cap on a black background is being photographed. Some digital cameras are also equipped hand-held incident light meter, a series of test with small screens for reviewing the image cap exposures should be made at different magnifi tured. Most manufactured laboratories that routinely use photography as lenses have reproduction ratios listed on the a component of their gross dissections, digital lens barrel for each magnification. In making this image photography can reduce film and pro test run, choose a standard exposure such as 1/4 cessing costs. Each month seems to bring an this exposure time will enable you to use small updated digital camera that is less costly and of apertures, which result in a better depth of field higher quality than the previous model. The are literally hundreds of digital cameras now on best aperture then can be determined for a spe the market, and choosing the best one is a formi cific image magnification, and a chart can be dable task. When selecting a digital camera, one 30 Surgical Pathology Dissection of the most important features to keep in mind one of the two halves.

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