S. Zarkos. Saint Francis College, Loretto, Pennsylvania.
Oropharyngeal and neck lesions glyburide 5mg lowest price diabetes type 1 unconscious, in smokers buy glyburide 5mg low cost blood glucose values, are especially worrisome because of the greatly increased risk of cancer in these individuals discount glyburide 2.5mg fast delivery blood glucose higher in morning. Abnormalities of the thyroid cause most lumps of the neck that trigger a visit to a physician’s ofﬁce purchase glyburide 2.5 mg amex diabetes in dogs breath. Relative contribution of tech- netium-99m sestamibi scintigraphy generic glyburide 5mg with mastercard diabetes in large dogs, intraoperative gamma probe detection, and the rapid parathyroid hormone assay to the surgical management of hyperparathyroidism. Thyroid carcinoma: biological implications of age, method of detection, and site and extent of recurrence. To discuss the anatomy and physiology of the swallowing structures and mechanism, including the physiologic lower esophageal sphincter. To discuss pertinent clinical history and physical examination ﬁndings as they relate to structural and functional pathology. To describe various therapeutic options for patients with neurologic, neoplastic, reﬂex- mediated, and dysmotility-mediated disorders. Cases Case 1 A 58-year-old man presents to your ofﬁce complaining of difﬁculty in swallowing. Case 2 A 39-year-old woman presents to your ofﬁce with burning chest pain, rapidly worsening over 3 years. Case 3 A 72-year-old woman presents to your ofﬁce with difﬁculty in swal- lowing for decades. Swallowing Difﬁculty and Pain 201 Introduction The swallowing mechanism is a complex interaction of pharyngeal and esophageal structures designed for the seemingly simple purpose of propelling food to the stomach and of allowing the expulsion of excess gas or potentially toxic food out of the stomach. Initial evaluation of a patient complaining of difﬁculty (dysphagia) or pain (odynophagia) with swallowing involves a thorough, focused history and a physical examination. The advent of esophageal motility and pH studies has permitted correla- tion of physiologic data to the anatomic information obtained through radiographic and endoscopic studies. Others may only confuse the diagnosis, having no relationship to the patient’s complaints. In evaluating swallowing difﬁculty and pain, it is extremely important to relate symptoms to diagnosis, as inappropri- ate therapy actually may worsen the patient’s symptoms or initiate new complications. Anatomic Considerations The esophagus is a muscular tube extending from the cricoid to the stomach. It is composed of a mucosal layer, a submucosa, and a double outer muscular layer (Fig. No serosa is present on the esopha- gus, resulting in a structure that has less resistance to perforation, inﬁltration of malignant cells, and anastomotic breakdown follow- Ganglia of myentetric plexus [Auerbach] Ganglia of submucosal plexus (Meissner) Epithelium Submucosa Muscularis mucosa Lamina propria Muscularis externa Esophageal gland Longitudinal muscle layer Figure 12. Three layers compose the esophageal mucosa: a stratiﬁed, nonkeratinizing squamous epithelial lining; the lamina propria (a matrix of collagen and elastic ﬁbers); and the muscularis mucosae. The squamous epithelium of the esophagus meets the junctional columnar epithelium of the gastric cardia in a sharp transition called the Z-line, typically located at or near the lower esophageal sphincter (Fig. Although the upper third of esophageal muscle is skeletal and the distal portion is smooth, the entire esophagus functions as one coordi- nated structure. Contraction of the longitudinal muscle ﬁbers of the esophageal body produces esophageal shortening. The inner circular muscle is arranged in incomplete rings, producing a helical pattern that, on contraction, produces a corkscrew-type propulsion. Muscle layers are of uniform thickness until the distal 3 to 4cm, where the inner circular layer thickens and divides into incomplete horizontal muscu- lar bands on the lesser gastric curve and oblique ﬁbers that become the gastric sling ﬁbers on the greater curve. In an adult, the cricopharyngeal muscle is located approximately 15cm from the incisors, and the gastroesophageal junction is located approximately 45cm from the incisors. Because the lymphatic system is not segmental, lymph can travel a long distance in the plexus before traversing the muscle layer and entering regional lymph nodes.
Ultimately glyburide 5 mg visa diabetes type 2 vertigo, 50% of patients who undergo curative resection develop local order 2.5mg glyburide mastercard blood glucose 4 hours after meal, regional purchase 2.5 mg glyburide with amex treatment diabetes elderly, or widespread recurrence generic glyburide 2.5 mg with mastercard diabetes in dogs facts. Operative management is discussed brieﬂy below buy 2.5 mg glyburide diabetes januvia, and additional ther- apies, based on pathologic ﬁndings, are outlined in Algorithm 25. Cancer of the Cecum, Ascending Colon, or Hepatic Flexure For lesions located in the cecum or ascending colon, a right hemi- colectomy to encompass the bowel served by the ilii-colic, right colic, and right branch of the middle colic vessels is recommended. For lesions involving the hepatic ﬂexure, a more extended resection is indi- cated, including the right colon and proximal and midtransverse colon, including both branches of the middle colic artery. Cancer of the Splenic Flexure Splenic ﬂexure lesions require removal of the distal half of the trans- verse colon and the descending colon. Cancer of the Sigmoid Colon Sigmoid lesions are treated by removal of the sigmoid colon. Subtotal colectomy is the treatment of choice for patients with syn- chronous lesions at different sites. If synchronous lesions are located in the same anatomic region, a conventional resection may be performed. Colon and Rectum 465 Cancer of the Rectum Rectal cancer has traditionally been treated with abdominal perineal resection, which removes the whole rectum and anus. More recently, the low anterior resection and local excision with and without radi- ation have gained popularity. Both preserve continence and can result in equal 5-year survival rates in properly selected patients. Cancer Arising in a Colon Polyp A colorectal polyp is deﬁned as a mass that protrudes into the lumen of the colon. Nonneoplastic polyps are without dysplastic features and include mucosal, hyperplastic, inﬂammatory, and hamartomatous (including juvenile) polyps. There is now a general consensus that most colon cancers arise from preexisting polyps. The lifetime risk of an adenoma transforming into a malignancy is estimated to be 5% to 10%, and the time for trans- forming is estimated to be 5 to 15 years. Less than 2% of adenomas smaller than 1cm harbor a carcinoma, whereas the percentage increases to about 10% in adenomas between 1 and 2cm and 50% in adenomas larger than 2cm. Colonoscopy and complete polypectomy are cura- tive in patients with carcinoma in situ, as these lesions appear to have no potential for metastases. Sessile and pedunculated polyps illustrating Haggitt’s classi- ﬁcation of levels of invasion. Eisenstat Therapy for Metastatic Colorectal Cancer Of 100 patients with colorectal cancer, roughly 50 are cured by surgery, 15 develop local recurrence, and 35 develop blood-borne distant metas- tases. The organs most frequently involved with metastases are the liver, the lung, the bone, and the brain. Up to 15% of patients present with liver metastases at their initial operation, and 30% of patients undergoing apparently curative resection already have hepatic metas- tases that are not evident to the surgeon at the time of operation. Patients with disseminated disease beyond the scope of surgical resection are eligible for chemotherapy. Therapy for Local Recurrent Colorectal Cancer Of all colorectal cancer recurrences, 70% occur within 2 years of oper- ation. Local recurrences vary between 1% and 20% for colon cancer and between 3% and 32% for rectal cancer. Many patients are eligible for surgical therapy of localized recurrence, but this should always be considered in conjunction with options for chemotherapy.
Many patients with colonic disease also have small-bowel ﬁndings glyburide 5mg lowest price diabetes mellitus monitoring, which distinguishes Crohn’s from ulcerative colitis buy glyburide 5 mg online diabetes diet log book. Multiple subcutaneous nodules that are tender glyburide 2.5mg fast delivery diabetes type 1 causes and symptoms, red purchase 2.5mg glyburide with mastercard diabetes symptoms blurred vision one eye, raised buy glyburide 5 mg low price diabetic diet knowledge questionnaire, and microscopically composed of lymphocytes and histio- cytes characterize erythematous lesions that may form a tender necro- tizing ulcer. Most of these occur in the pretibial area, but they also can occur anywhere on the body. Ocular manifestations include uveitis, iritis, episcleritis, vasculitis, and conjunctivitis. These ﬁndings are asso- ciated more commonly with colonic disease and infrequently precede any intestinal symptoms. The incidence of carcinoma is increased in the setting of Crohn’s disease and should be suspected in patients with a severe or chronic stricture. Colon and Rectum 451 Sulfasalazine and mesalamine are the two aminosalicylates used for Crohn’s disease. For patients with exacerbations leading to moderate or severe Crohn’s disease, steroids are the primary therapy. As increasing evidence points to an immunologic etiology of inﬂam- matory bowel disease, efforts have been made to utilize various immunotherapies. Methotrexate is a folate analogue that inhibits purine and pyrimidine synthesis and has been shown in a number of trials to be effective in treating Crohn’s disease. However, this drug has signiﬁcant side effects including hepatotoxic- ity and bone marrow suppression and thus is reserved for patients with severe Crohn’s that is refractory to other therapies. Surgical Therapy: As previously noted, the primary treatment of Crohn’s disease is medical, and surgery is considered for patients with speciﬁc complications of the disease. Crohn’s disease cannot be cured by an operation, but surgery can help ameliorate certain situations (Table 25. Small intestinal or ileocolic stenotic disease is treated by resection with primary anastomosis. Only grossly involved intestine should be resected, because wide resection or microscopically negative margins of resection have no impact on the recurrence rate of the Resection Small-bowel Bypass disease Stricturoplasty Indications for surgery Total proctocolectomy with ileostomy • Failed medical therapy • Obstruction • Complicated fistulas Abdominal colectomy with Colonic • Perforation ileorectal anastomosis disease • Cancer • Hemorrhage • Abscess Subtotal colectomy with ileostomy Segmental resection Abscess drainage Anal Fistulotomy disease Seton Algorithm 25. Failure of medical treatment Persistence of symptoms despite corticosteroid therapy for longer than 6 months Recurrence of symptoms when high-dose corticosteroids tapered Worsening symptoms or new onset of complications with maximal medical therapy Occurrence of steroid-induced complications (cushingoid features, cataracts, glaucoma, systemic hypertension, aseptic necrosis of the head of the femur, myopathy, or vertebral body fractures) Obstruction Intestinal obstruction (partial or complete) Septic complications Inﬂammatory mass or abscess (intraabdominal, pelvic, perineal) Fistula if Drainage causes personal embarrassment (e. Patients who present with ﬁstulizing disease with either estab- lished ﬁstulas or undrained sepsis require the greatest amount of judgment and caution. However, percutaneous drainage, parenteral nutrition, and bowel rest usually control sepsis and allow the inﬂammation of the uninvolved bowel and surrounding structures to resolve. For isolated Crohn’s colitis, a total proctocolectomy with ileostomy or total abdominal colectomy with ileorectal anastomosis or ileostomy and rectal stump are the primary therapies. The manifestations of perianal Crohn’s disease are multiple, includ- ing abscesses, ﬁstulas, ﬁssures, ulcers, strictures, and incontinence. Estimates of the number of Crohn’s patients who develop peri- anal manifestations at some time range from 10% to 80%. As with Crohn’s disease proximally, palliation of symptoms and preservation of functional bowel are the priorities guiding surgical intervention. Likewise, the aim of therapy is the treatment of complications of disease rather than the disease itself. Two mandates clarify these prin- ciples with respect to perianal disease: (1) the management of a septic focus is an indication for surgery, and (2) the sphincter should be pre- served as long as the patient is coping well.
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