Instant Natural Colic Relief

Instant Natural Colic Relief

Natural colic relief bowen refers to the steps by steps guide designed by Dr. Carlyn Goh to naturally put an end to all means of discomfort for your baby. This is a safe, gentle, easy and an effective natural guide, we mean without drugs to miraculously ease your babys discomfort. This step-by-step guide complete with videos, will teach you how to treat colic in your baby. The Bowen Technique is a very gentle, safe and simple therapy that is highly effective at easing discomfort in babies. Bowen acts to rebalance the nervous system. This is extremely important in all babies as birth is a traumatic experience for them. By re-balancing the nervous system you will feel the immediate effects of calmness and serenity in your baby and the causes of his discomfort will fade away. The result is a happy, healthy and balanced baby. More here...

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TABLE 971 Imaging Modalities in Renal Colic

Published studies indicate that emergency physicians can perform bedside ultrasound examinations in patients with renal colic and detect hydronephrosis with 97 percent sensitivity as compared with an IVP.14 The availability of ultrasound equipment for use in the ED and training of more emergency physicians has the potential to expand the use of this modality and reduce the use of IVP studies for patients with acute renal colic. Selecting IVP or ultrasound for an individual patient requires some clinical judgment. Certainly patients with contraindications to radiation and the administration of contrast should have an ultrasound. The clinician will have to further weigh the importance of ascertaining functional information about the kidney as well as the increased likelihood of identifying the location of the stone versus the added time and radiation exposure necessary to complete an IVP. One approach would be to obtain ultrasound in all patients presenting with signs and symptoms of...

Table 62 Differential diagnosis of renal colic

Palpate distant extremity pulses Mild to severe flank pain, although typically not as acute as renal colic More prolonged prodrome, with fever Urinalysis shows pyuria and bacteruria CAUTION renal obstruction with pyelonephritis is a urologic emergency requiring prompt consultation Secondary to passage of sloughed papillae down ureter Seen in patients with sickle cell disease, diabetes, NSAID abuse, or history of acute or chronic UTI UA can show hematuria and pyuria Requires urologic consultation with possible admission 1. Acute obstruction with concurrent infection. The finding of fever, pyuria, or bacteruria in a patient with renal colic requires further work-up and admission. Urine and blood cultures should be obtained and intravenous antibiotics, covering the usual urinary pathogens, should be promptly started while in the ED. Urologic consultation is required.

Transverse Mesocolon and Duodenocolic Ligament

Splenorenal Ligament Pancreas

On CT, the transverse mesocolon is identified as the fatty plane extending from the pancreas, particularly at the level of the uncinate process, to the ventrally situated transverse colon with the middle colic vessels coursing through it (Figs. 4-47 and 4-48). In cases of pancreatic carcinoma, masslike or dendritic spread through the me-socolon can be precisely localized (Figs. 4-49 through 4-51). Direct lymphatic extension along the draining chain of lymph nodes may be identified occasionally by barium studies.6,64 By its relationship to the central lymph nodes draining the colon, the duodenum may reflect changes of lymph node spread from a remote carcinoma of the colon. The lymphatic vessels draining the colon parallel the arterial supply. Those draining the right side of the colon are located near the origin of the superior mesenteric artery, in close relationship to the superior border of the horizontal (third) portion of the duodenum (Fig. 4-52). Those draining the distal...

Cholecystitis And Biliary Colic

Biliary tract emergencies result primarily from obstruction by biliary calculi in the gallbladder and bile ducts. The four major biliary tract emergencies related to gallstones include biliary colic, cholecystitis, gallstone pancreatitis, and ascending cholangitis. While gallstones are common, most are asymptomatic. The incidence of new-onset biliary pain among patients with previously asymptomatic gallstones is about 2 percent per year for the first 5 years and 15 percent at 10 years. 1 Although the classic patient with symptomatic biliary tract disease is an obese female aged 20 to 40 years, the disease occurs in all age groups and must be especially considered in diabetics and the elderly. 2 In both men and women, age over 60, right upper quadrant (RUQ) pain has the highest positive predictive value (11 to 16 percent) for gallstones.3

The Gastrocolic Ligament and the Omentum

The vascular landmarks of the gastrocolic ligament are the left and right gastroepiploic vessels that course along the greater curvature of the stomach. The left gas-troepiploic vessels are branches of the distal splenic artery and vein. They run from the splenic hilum in the gastrosplenic ligament, which continues to be the gas-trocolic ligament, and run along the greater curvature of the stomach to anastomose with the right gastroepi-ploic artery and vein. The right gastroepiploic artery is a branch of the gastroduodenal artery arising anterior to the head of the pancreas and coursing anteriorly in the fused gastrocolic ligament and transverse mesocolon, then continuing in the gastrocolic ligament along the greater curvature of the stomach. The right gastroepiploic vein joins the middle colic vein to form the gas-trocolic trunk and drain into the superior mesenteric vein anterior to the head of the pancreas5 and, in most cases, medial to the origin of the right gastroepiploic artery.

Renal Colic

The ideal imaging study in renal colic would (1) determine the size and location of the stone, (2) define the presence and degree of ureteral obstruction, and (3) identify other causes of flank pain and hematuria when renal calculi have been excluded. Some 90 percent of renal calculi are radiopaque and theoretically visible on plain radiographs. Studies in the 1930s and more recent textbooks report visualization of stones in 85 to 90 percent of cases. These studies did not specify if the visualized stone was related to the patient's symptoms or confirmed by other radiographic studies. Recent comparisons between plain-film radiography and IVP (the gold standard) found that plain radiography had a sensitivity of only 58 percent. 6 Compared with helical CT, plain radiography had a sensitivity of 45 percent and specificity of 77 percent. 7 Plain radiography alone has low utility and should not be used in the evaluation of patients with suspected renal colic it does, however, play a role...

Intestinal Colic

Colic is a paroxysm of crying for 3 h day or more for 3 days week or more over a 3-week period. The incidence of colic is about 13 percent, with no seasonal variation. Colic is a symptom complex consisting of the sudden onset of paroxysmal crying lasting several hours, a flushed face, circumoral pallor, tense abdomen, drawn up legs, cold feet, and clenched fists. It usually begins soon after birth but seldom lasts beyond 3 months of age. A careful history is important in diagnosis of colic findings upon physical examination are normal, and laboratory tests are not required. However, when the diagnosis is unclear, a careful history, physical examination, and appropriate laboratory investigations are necessary to rule out conditions listed in Tablei 112I2 . In doubtful situations, admission for observation or return for reassessment is reasonable. The cause of colic is unknown. Proposed causes include excessive intake of air, insufficient intake of fluid, allergy to protein, and...

The organism and its antigens

With the pulmonary phase and include pneumonitis, cough, dyspnea, substernal pain and sometimes a blood-stained sputum. This is known as the Loffler syndrome and has some of the characteristics of an immediate-type hypersensitivity response. There can be a dense pulmonary infiltrate at this time, and a rising eosinophilia. Pulmonary hypersensitivity can cause significant mortality among children in arid regions where high-level seasonal transmission occurs. The intestinal phase is associated with digestive disorders, nausea and colic. Villous atrophy has been demonstrated in infected children and pigs, and is probably immune-associated.

The Posterior Peritoneal Attachments

Peritoneal Attachments

Figure 3-1 shows the roots of the mesenteric attachments of the intraperitoneal segments ofbowel, and Figure 3-2 illustrates the reflections of the peritoneum from the posterior abdominal wall deep to the bowel, liver, and spleen. The transverse mesocolon constitutes the major barrier dividing the abdominal cavity into suprameso-colic and inframesocolic compartments. The obliquely oriented root of the small bowel mesentery further divides the inframesocolic compartment into two spaces of unequal size (a) the smaller right infracolic space bounded inferiorly by the junction of the mesentery with the attachment of the ascending colon, and (b) the larger left infracolic space, which is open anatomically toward the pelvis.

H 83 Clinical Presentation

Abdominal pain might be severe in patients suffering from visceral or renal ischemia. As previously mentioned, the left renal artery is more likely to be compromised, which may explain why severe left flank pain mimicking ureteral colic is often included in the reported history. One should always include questions about hypertension, cardiac disease, peripheral vascular disease, connective tissue abnormalities (such as Marfan's, Turner, and Ehlers-Danlos' syndromes), cystic media ne-

Small Bowel Obstruction

The diagnosis of small bowel obstruction is usually straightforward in the older patient (see ChapiZS). Colicky pain, distention, and vomiting that progresses from gastric contents to bile-stained to feculent are the cardinal features. Prior surgery is still the principal risk factor in this age group, and the physician should conduct a careful search for hernias. A missed hernia can lead to a fatal outcome. The mortality rate for small bowel obstruction in the elderly ranges from 14 to 45 percent. Errors in management most frequently relate to misinterpretation of radiographic studies and excessive delays in operative management. 7

Abdominal Aortic Aneurysm

The most common diagnostic mistake is to diagnose renal colic in these patients. This is understandable given the severe pain and the location of the pain. Furthermore, abdominal aortic aneurysm may present with hematuria. It should be axiomatic that aortic aneurysm be strongly considered in any patient over the age of 50 suspected of having renal colic. An episode of hypotension is often wrongly ascribed to developing sepsis or a vagal reaction in patients initially misdiagnosed as having renal colic.11

Other Conditions and Causes

The list of other conditions that can cause abdominal pain in the older patient is extensive, highlighting the need for the comprehensive evaluation of such patients. The most important disease to suspect is acute myocardial ischemia. Some 1 to 2 percent of elderly patients with abdominal pain will be having a myocardial infarction.10 Virtually all other chest diseases can cause abdominal pain, including pneumonia, pulmonary embolism, empyema, tuberculosis, congestive heart failure, esophageal rupture, and endocarditis. Genitourinary disease including renal colic, pyelonephritis, epididymitis, and testicular torsion is a possible cause of abdominal pain in the elderly. Diabetic ketoacidosis, herpes zoster, hypercalcemia, addisonian crisis, hemochromatosis, and retroperitoneal or rectus sheath hematomas secondary to anticoagulant therapy are examples of medical causes of abdominal pain in the elderly.

Diagnostic Considerations

Bedside ultrasound in capable hands can assist in rapidly securing the diagnosis of abdominal aortic aneurysm. It can also help clarify the clinical picture in acute cholecystitis and renal colic. Computed tomography is an important diagnostic modality in the older population with abdominal pain. The physician must remember that the unstable patient with a suspected abdominal aortic aneurysm belongs in the operating room and not in the computed tomography suite.

Esophageal Motility Disorders

Clinically, chest pain is the presenting symptom in the majority of patients with these disorders. The onset is usually in the fifth decade. The pain often occurs at rest and is dull or colicky in nature. Stress or ingestion of liquids at the extremes of temperature may serve as a trigger. An acute episode of pain may be followed by hours of dull, achy, residual discomfort. Thirty to sixty percent of these patients will also experience dysphagia, which is usually intermittent. Pain from spasm may respond to nitroglycerin. Calcium channel blockers and anticholinergic agents can also be employed.

Clinical Features

The major symptom of acute pancreatitis is mid-epigastric or left upper quadrant pain. It is most commonly described as a constant, boring pain that often radiates to the back as well as the flanks, chest, or lower abdomen. Although usually described as severe, the intensity can be extremely variable and does not correlate with the severity of the disease.1 The pain is exacerbated in the supine position and can be relieved when sitting with the trunk and knees flexed. Colicky discomfort is atypical and suggests another etiology. Nausea and vomiting are common, and abdominal bloating from gastric and intestinal hypomotility is a frequent complaint.

Computed Tomography

During spiral CT, the x-ray tube is in continuous rotation while the patient is moved smoothly, at a constant speed, through the scanning field. This technique improves the detection of small lesions, as scanning is performed during a single breath-hold, thus reducing the movement of intraabdominal organs and motion artifact, which occurs when imaging is performed during respiration. Data from multiple scanning planes can be used to produce three-dimensional reconstruction of lesions. In trauma, information about the extent of renal disruption, trauma to the renal pedicle, and viability of disrupted fragments can be provided. In addition, shaded surface displays allow volume surface analysis of parenchymal organs and maximal-intensity projections provide analysis of the vasculature. The selected slice thickness of a scan depends on the clinical presentation. Trauma scans are usually 8 to 10 mm thick and are obtained from the diaphragm down to the bottom of the pelvis. CT scans for...

Chapter References

Mutgi A, Williams JW, Nettleman M Renal colic Utility of plain abdominal roentgenogram. Arch Intern Med 151 1589, 1991. 8. Haddad MC, Sharif HS, Shahed M, et al Renal colic Diagnosis and outcome. Radiology 184 83, 1992. 11. Sinclair D, Wilson S, Toi A, et al The evaluation of suspected renal colic Ultrasound scan versus excretory urography. Ann Emerg Med 18 556, 1988. 12. Erwin BC, Carroll BA, Sommer GF Renal colic The role of ultrasound in initial evaluation. Radiology 152 147, 1984. 13. Andressen R, Wegner HEH Intravenous urography revisited in the age of ultrasound and computerized tomography Diagnostic yield in cases of renal colic, suspected pelvic and abdominal malignancies, suspected renal mass, and acute pyelonephritis. Urol Int 58 221, 1997. 14. Henerson SO, Hoffner RJ, Aragona JL, et al Bedside emergency department ultrasonography plus radiography of the kidneys, ureters, and bladder versus intravenous pyelography in the evaluation of suspected renal colic. Acad Emerg Med 5...

TABLE 791 Vomiting and Diarrhea The Gastroenteritis Mnemonic

Second, determine what symptoms accompany the vomiting. Is the patient febrile Fever could point toward an infectious or inflammatory source, or it could represent a toxicologic cause, such as salicylate intoxication. Is there associated abdominal pain, back pain, headache, or chest pain that may point to a specific cause Pancreatitis, cholecystitis, peptic ulcer disease, appendicitis, and pelvic inflammatory disease typically cause abdominal pain. Back pain usually accompanies aortic dissections, rupturing aortic aneurysms, pyelonephritis, and renal colic. Vomiting is one of the signs of increased intracranial or intraocular pressure and may be a foreboding sign in patients complaining of headache. Finally, the complaint of vomiting associated with chest or epigastric pain might suggest a diagnosis of myocardial ischemia. In female patients, obstetric and gynecologic causes of vomiting should always be considered. In a pregnant woman, epigastric pain and vomiting accompanying...

Nodal Metastases in the Gastrosplenic Ligament

Primary tumors from the greater curvature of the body of the stomach spread along the left gastroepiploic vessels and drain into the lymph nodes in the splenic hilum by following the left gastroepiploic vessels via the gastro-colic ligament and gastrosplenic ligament. From the posterior wall of the fundus of the stomach, they can also spread along the superior extent of the gastrosplenic ligament to the splenic hilum. From the splenic hilum, they can spread along the splenic artery to the celiac axis. This nodal group is known as the suprapancreatic nodes or the nodes in the splenorenal ligament. These nodes are also the primary site of lymphatic drainage from the spleen (Fig. 6-11).

Traditional Diagnostic Imaging

Ureter, but anatomic detail of the renal parenchyma and surrounding soft tissues is poor in comparison to cross-sectional imaging techniques (Kawashima et al. 2004). EXU is also more time-consuming and labor-intensive than other imaging modalities. In addition, no-nurologic causes of urinary obstruction and flank pain are less optimally evaluated with EXU (Rucker et al. 2004). Performing EXU on patients with renal colic can also be problematic in the setting of ureteral obstruction. In the setting of ureteral obstruction, the osmotic effect of the contrast may result in a forced diuresis and subsequent fornix rupture and resultant urinoma. In the current era, emphasis has been placed on more advanced imaging techniques including ultrasonography (US), magnetic resonance imaging (MRI), and particularly computerized tomography (CT).

Gender over the Life Cycle

Bamileke prefer and actively praise a balance of male and female children. Special rituals performed by the queen mother (the mother of the chief) aim to insure a balance of male and female children in the royal family. Boy and girl infants are treated equally, and traditional given names do not distinguish among male and female children (although praise names, ndap, do distinguish among the male and female descendants of a particular village). Infants are frequently bathed, held constantly, and passed from mother to visitor to sibling and, occasionally, to father. They are encouraged to sit and to walk, and to play give-and-take games with simple objects. Small rituals, associated with bathing, are performed by caretaking adults (especially mothers and grandmothers) to prevent convulsions, colic, and witchcraft attack. Once they reach toddlerhood, both boys and girls begin to practice the tasks of adulthood (carrying bowls of water and other objects on the head, learning to handle a...

Immediate Shock Wave Lithotripsy

SWL would provide little opportunity to diagnose an unsuspected infection and thereby alter treatment plans. Nonetheless, in the absence of indications for urgent upper tract decompression, some authors have acutely utilized SWL. In a recent report, Kravchick and colleagues reported a prospective randomized trial of emergent SWL vs scheduled SWL (treatment within 30 days of diagnosis) for upper urinary tract stones associated with acute renal colic (Kravchick et al. 2005). None of the patients had presenting indications that warranted a temporary drainage procedure. Emergent SWL was associated with a higher success rate (72 ) than delayed treatment (64 ). In addition, scheduled (delayed) treatment was associated with significantly prolonged hos-pitalizations and recovery at home. Other groups have noted favorable experiences with emergency SWL. For instance, Doublet and associates found a significant relationship between stone location and stone-free...

Direct Invasion from Noncontiguous Primary Tumors

Ligament Treitz Landmark

Gastrohepatic ligament Hepatoduodenal ligament Gastrocolic ligament Transverse mesocolon Duodeno colic ligament Gastrosplenic ligament Splenorenal ligament Phrenicocolic ligament Small bowel mesentery Involvement of nodes along the lesser or greater curvature (groups 1-6) constitutes N1 disease, and the celiac axis and its three branches are N2 (7-11), N3 (12-14), and N4 (15,16). N1 1 right paracardial 2 left paracardial 3 lesser curvature 4 greater curvature 5 suprapyloric 6 infrapyloric. N2 7 left gastric artery 8 common hepatic artery 9 celiac artery 10 splenic hilus 11 splenic artery. N3 12 hepatic pedicle 13 retropancreatic 14 mesenteric root. N4 15 middle colic artery 16 paraaortic.

Normal Imaging Features

On cross-sectional imaging, the right and inferior extensions of the pancreaticoduodenal compartment are demarcated by the duodenal loop surrounding the pancreatic head (Figs. 8-108 and 8-109). Its left and mid-portion are demarcated by the pancreatic body and tail. The retroperitoneal colonic compartments are recognizable by the presence of the ascending and descending colon with mesenteric vessels on the left side the left colic vessels and the inferior mesenteric vein and side branches, and on the right side the right colic and il-eocolic vessels (Figs. 8-108 and 8-109). The continuity of the right, middle, and left colic vessels, indicating the transition between the right colonic compartment, transverse mesocolon, and left colonic compartment, can be appreciated on most CT scans156,157 (Fig. 8-109). The lower edge of the right colonic compartment is indicated by the ileocolic vessels and cecum on the left it is indicated by the junction of the fused descending colon and its...

Pathway of Nodal Metastases from Carcinoma of the Transverse Colon

Ileocolic Vessels

After the paracolic nodes, lymphatic spread from carcinoma of the transverse colon may follow along the branches of the middle colic vessels in the transverse mesocolon toward the root of the mesocolon (Figs. 617 through 6-20). From the hepatic flexure, the spread would follow the right colic vessels or right middle colic vessels to the nodal group at the gastrocolic trunk where it drains into the SMV anterior to the head of the pancreas. From the splenic flexure, the lymphatic drainage would follow along the left middle colic vessels toward Right colic vessels Middle colic vessels Left middle colic vessels Left colic vessels, IMV the IMV just caudal to the body and tail of the pancreas. On occasion, lymphatic spread may follow the left middle colic vein to the confluence of the IMV and the junction of the splenic vein and the SMV. Since the root of the transverse mesocolon is covering over the head of the pancreas and it is inserted caudal to the body and tail of the pancreas,...

TABLE 982 Nerves Carrying Painful Impulses from the Pelvic Organs

Round Ligament Pain And Relief

Ihe quality of pain can be characteristic of different etiologies. Visceral or splanchnic pain is colicky and caused by distention of a hollow viscus or stretching of a ligament. Examples include distention of the fallopian tube in ectopic pregnancy, uterine contractions in dysmenorrhea, and stretch of the round ligament with adhesions or in pregnancy. Peritoneal or somatic pain is sharp and localized to the region of inflamed tissue, as in salpingitis, appendicitis, and endometritis. Generalized peritonitis may be seen with larger degrees of inflammation, i.e., with spillage of blood, pus, or gastrointestinal (GI) contents into the peritoneal cavity.

Bleeding from Bare Area of Spleen Splenic Artery or Hepatic Artery

Pararenal Aneurysm

Bleeding from the hepatic artery is clearly shown in the following case history. A 70-year-old man was examined because of a 1 -month history of colicky right upper quadrant pain. His past medical history included acute rheumatic fever at the age of 5 and an episode of acute staphylococcal endocarditis at the age of 56. Oral cholecystography revealed moderate opacification of the gallbladder, and the hepatic angle, flank fat, and psoas muscle were clearly visualized (Fig. 8-99a) at this time. However, 24 hours later, the patient's colicky right upper quadrant pain increased suddenly, with abdominal distention. Initial diagnostic considerations included acute cholecystitis, acute pancreatitis, and penetrating peptic ulcer. An abdominal radiograph now showed a density throughout the right abdomen, with loss of the

CT Anatomy of the Pancreatic Head

Pancreatic Vascular Anatomy

At the midlevel of the head of the pancreas, the anatomic landmark is the gastrocolic trunk where it enters into the SMV.15 Although the branching patterns that form the gastrocolic trunk may vary, the site where it enters into the SMV and the position of the SMV in relationship to the head of the pancreas are constant. The gastrocolic trunk enters into the SMV anteriorly, and the SMV is usually anterior and medial to the head. The position of the posterior SPDV and the bile duct remains the same at the posterolateral surface of the head of the pancreas. The anterior SPDA continues the same course of the gastroduodenal artery at the anterolateral surface of the head, but the anterior SPDV can be seen draining into the gastrocolic trunk. The anterior SPDV is a small vein that is closely approximated to the head. Its course can be similar to a larger right colic vein that is located at the root of the transverse mesocolon and also drains into the gastrocolic trunk. This may explain the...

Lymphatic Drainage of the Colon and Pathways of Lymph Node Metastasis

Regional nodal metastasis is one of the most common modes of tumor spread in carcinoma of the colon. The lymph nodes draining lymphatics from the colon can be classified into four groups the epicolic nodes, the para-colic nodes, the intermediate mesocolic nodes, and the principal nodes.16,17 The epicolic nodes lie on the wall of the colon beneath the peritoneum covering the colon, generally on the antimesocolic side of the colonic wall. The paracolic nodes lie along the marginal vessels along the mesocolic side of the colon. The intermediate mesocolic nodes lie in the mesocolon accompanying the vessels in the mesocolon and draining into the principal nodes at the root of the mesocolon. In general, the pathway of lymphatic drainage follows these groups ofnodes from the epicolic to paracolic, intermediate, and principal nodes, respectively.

Clinical Features And Spectrum

It is followed by a general malabsorption resulting in weight loss and anorexia. Weight loss can be found in about 90 of the patients. Gastrointestinal symptoms, which lead to the diagnosis, consist of episodic and watery diarrhea and steatorrhea accompanied by colicky abdominal pain and, in one-third, by occult blood in stool. 13 Endoscopic investigation reveals a pale yellow mucosa alternating with erythematous, erosive parts in the duodenum or jejunum, and duodenal biopsies are positive in the PAS stain.

Internal Abdominal Hernias

Transmesenteric Internal Hernia

The majority of internal hernias result from congenital anomalies of intestinal rotation and peritoneal at-tachment.6-9 Acquired defects of the mesentery or peritoneum secondary to abdominal surgery or trauma may also serve as the hernial ring.10-13 The retroperitoneal group of internal hernias is more frequently encountered in adults, whereas the transmesenteric types are more commonly present in the pediatric age group.6,8,14 The autopsy incidence of internal hernia has been reported to be between 0.2 and 0.9 .6,15 Many are small and easily reducible, so that they may remain relatively asymptomatic during life.16,17 In other cases, the patients present with a history of intermittent attacks of vague epigastric discomfort, colicky periumbilical pain, nausea, vomiting especially after intake of a large meal and recurrent intestinal obstruction. The discomfort may be altered or relieved by change in position. Internal hernias account for 0.5-3 of all cases of intestinal...

Anatomic Considerations

Mesenterico Parietal Fossa Waldeyer

And fossae have been classically described, there is only one fossa to the left of the duodenum capable of developing into the sac of a hernia, termed the paraduodenal fossa (fossa of Landzert)26 (Fig. 16-2). This fossa, present in about 2 of autopsy cases,20 is situated at some distance to the left of the ascending or fourth portion of the duodenum and is caused by the raising up of a peritoneal fold by the inferior mesenteric vein as it runs along the lateral side of the fossa and then above it. Small intestine may herniate through the orifice posteriorly and downward toward the left, lateral to the ascending limb of the duodenum, extending into the descending mesocolon and left portion of the transverse mesocolon. The free edge of the hernia thus contains the inferior mesenteric vein and the ascending left colic artery. Confusion can be minimized if it is understood that the her-nial orifice is in a paraduodenal location but the her-niated loops present at a distance more clearly,...

The Evolution of Disease

Similar analyses have been applied to infant colic, a mysterious condition of prolonged crying that seems to peak at two months and then gradually dissipates. In an evolutionary sense, crying represents an infant's communication to elicit feeding and care. Because care-givers and infants are often spatially separated in contemporary households, infant crying may be prolonged and fretful because of the difficulty of securing feeding and comfort. Rather than treating the infant, the implications of this perspective is that parental care-giving patterns could be modified (Barr, 1999).

Differential Diagnosis

A number of diagnoses can be confused with renal colic. The history and physical examination can help to narrow the differential. However, this may be difficult, since the patient's discomfort can interfere with the usual history and physical examination. Crucial to the evaluation of these patients is to ensure that a catastrophe mimicking renal colic is not missed. The most critical alternative diagnosis to consider is an aortic dissection or ruptured AAA. Renal colic and AAA may have a similar presentation. Focal abdominal tenderness, abdominal distention, pulse disparity, and hemodynamic instability are not found in renal colic. These findings suggest a leaking or ruptured AAA. If a dissection or rupture is suspected, an emergency vascular surgical consultation should be obtained. If an AAA has not been excluded from the differential diagnosis, appropriate monitoring equipment, intravenous access, and professional staff should be sent from the emergency department with the patient...

The History of Diverticular Disease

The physiology of the colon related to the pathology of diverticular disease, which covers the fifth phase of Painter and Burkitt's (1975) discussion when they and Arfwidsson (1964) investigated colonic pressure in relation to the pathogenesis of the disease, and in 1964 Painter had suggested that the pain, often termed colic, that patients experience in diverticular disease may be caused by 'excessive segmentation leading to an intermittent functional colonic obstruction'.

Nutrient Requirements Nonruminant Herbivores

Energy). 4 Structural carbohydrates, such as cellulose and hemicellulose, often make up the majority of their diet 3 and are fermented by microbes in the cecum and colon to provide much of the energy required by a horse at maintenance. 4 A minimum of 12 to 15 fiber is presumed necessary to minimize incidence of colic and laminitis, but forages alone do not generally provide sufficient energy for growing, working, or lactating horses, so cereal grains are added to their diets. Cereal grains provide digestible nonstructural carbohydrate (starch). 4 Lipids may also be supplemented, providing 2.25 times the energy value of carbohydrates, 5 and 20 added fat can be included in the diet without adverse effects. 4 Diets supplemented with fat should be monitored closely for rancidity, because spoiled feed is not accepted. Supplementation with fat improves work output, reproductive performance, milk production, and foal growth, but it must be monitored closely to avoid obesity and insulin...

General Considerations

CHOLECYSTITIS Patients may present during the postoperative period with biliary colic, acute calculous cholecystitis, or acute acalculous cholecystitis. The etiology of these disorders in the postoperative period is not clear. Ultrasound studies of the gallbladder and pancreas should be performed to aid in the diagnosis.

Clinical Manifestations and Diagnosis of Gall Stone Disease

Pain related to the gall bladder is usually felt in the right upper quadrant or in the epigastrium. It may radiate to the back, going around the right flank. In some cases, it may radiate to the shoulder area or be felt in the chest. In acute cholecystitis, the pain is steady, as opposed to cramping or colicky. It typically occurs after a meal and may be accompanied by nausea and vomiting. Continuous obstruction of the cystic duct causes gall bladder distention and inflammation. Extension of the inflammation into the common bile duct area may cause edema and obstruction of the duct, resulting in jaundice. The

Folklore and Evidence Fact or Fiction Totality of the Evidence

Prevents scurvy helps to heal ulcers causes constipation unpasteurized milk has more nutrients than pasteurized a glass of milk before bed causes drowsiness mothers who drink a lot of milk have colicky babies milk and other dairy products are fattening and should be avoided on a low-fat diet the calcium in milk and other foods causes kidney stones Prevents vaginal yeast infections cures vaginitis, constipation, and diarrhea yoghurt applied topically heals a sunburn Causes tooth decay causes hyperactivity eating too much causes diabetes and heart disease Is natural and will not raise blood-sugar levels a mix of honey and water is a good cure for colic Causes acne eating chocolate helps to prevent heart disease

TABLE 238 Etiology of Hyperkalemia

Vaginal Cuff Cellulitis

Ventricular fibrillation, complete heart block, and asystole may occur. Death from hyperkalemia is usually the result of diastolic arrest or ventricular fibrillation. Neuromuscular manifestations include weakness, paresthesias, areflexia, and ascending paralysis. The gastrointestinal symptoms include nausea, vomiting, intermittent intestinal colic, and diarrhea. Patients with slowly developing hyperkalemia often tolerate serum K + of 7 to 8 meq L, whereas, with acute elevations, significant problems, including cardiac arrest, can occur at most lower levels.

Unilateral Upper Urinary Tract Obstruction

The underlying etiology is often urinary calculi, but the diagnostic possibilities are extensive (Ko-bayashi et al. 2003). In general, acute obstruction is most commonly associated with intermittent, severe flank pain that can radiate into the groin, external genitalia, and or ipsilateral thigh (i.e., classic renal colic). Gross hematuria can also be associated with the colicky symptoms. Not uncommonly, gastrointestinal complaints including nausea and vomiting will also accompany the symptoms. In addition, patients can also experience fever and chills, especially if the obstruction is associated with infection (Nickel 2002). In some instances, patients can present with partial unilateral obstruction in the absence of flank pain. In this scenario, an urgent evaluation is often prompted by other associated symptoms including nausea and vomiting, abdominal pain, new onset of irritative voiding symptoms, or gross hematuria. In other instances, the finding of a partial...

Large Bowel Obstruction

A carcinoma is the leading cause of large bowel obstruction, while volvulus and diverticulitis account for most of the remaining cases. All of these precipitating conditions are more common in the elderly. The overall mortality rate approximates 40 percent. Distention is common, vomiting and constipation are reported in about half the patients. Importantly, a significant percentage (up to 20 percent) will report diarrhea. A history of rectal bleeding, altered bowel habits, or weight loss may be present with underlying carcinoma.12 The pain is usually gradual in onset however, cecal volvulus can present with the acute onset of severe, colicky pain. 17 Sigmoid volvulus is two to three times more frequent than cecal volvulus and more commonly presents with a gradual onset of pain.18 Fever or the presence of peritoneal irritation suggests a perforation or gangrenous bowel.

Heavy Metal Intoxication

Ingestions of one of several heavy metals can lead to systemic manifestations. Lead poisoning, or plumbism, is the most common heavy metal poisoning. Systemic signs of lead poisoning are highly variable depending on the age of the patient and the amount of lead ingested. Symptoms range from colic, iritability, fatigue, and anemia to encephalopathy. Intraorally, lead poisoning presents as an ulcerative stomatitis or a bluish hue to the buccal mucosa. The classic bluish lead line on the ginigiva, secondary to subepithelial deposits of lead sulfide, also may be seen. In addition, a tremor on tongue thrusting, excessive saliva production, metallic taste, and severe periodontal disease may occur. Treatment is chelation therapy.40

Pathway of Nodal Metastases from Carcinoma of the Cecum and Ascending Colon

The primary nodal group draining lymphatics from tumors of the cecum and the ascending colon is the para-colic nodes along the marginal vessels of the cecum and ascending colon (Figs. 6-14 and 6-15). Further spread would follow along the ileocolic vessels toward the root of the SMA. Progression of nodal disease along the base of the mesentery may cause obstruction of the right ureter because of their close proximity and nodal spread could progress to the paraaortic nodal group. The principal nodes of this segment of the colon are the nodes at the root of the SMA.

Natural Infections

Although infection may be asymptomatic, symptomatic disease typically follows a predictable course. Clinical signs at the onset of disease in horses and sheep are nonspecific excited or depressed behavior, hyper-thermia, anorexia, jaundice, constipation, and colic. Classical disease becomes apparent within 1 or 2 weeks. Animals maintain an upright, wide-based stance with their heads extended. Repetitive behaviors are common and may include vacuous chewing, circular ambulation, and running into obstacles. Horses become paretic in the terminal phases of disease. A distinctive decubitus posture associated with paddling movements of the legs has been described. Frequently, in late disease, the virus migrates centrifugally along the optic nerve to cause retinopathy and visual impairment. Acute mortality may be as high as 80-100 in horses and 50 in sheep. Sheep that survive may have permanent neurologic deficits. Recurrence of acute disease has been described in sheep. Natural symptomatic...

Disorders associated with food allergens

There are no gastrointestinal symptoms due to food allergy which are specific to teenage and adult patients, despite some characteristic differences. For instance, food-induced enteropathy is unusual at this age on the other hand, gastric and colic symptoms are very frequent. Cow's milk allergy is less prominent as a major allergen. According to large epidemiologic studies, celery, fish, seafood and eggs are the most frequently responsible food allergens among these age groups.

Diagnostic Studies

Results of laboratory studies in patients with biliary colic are frequently normal. The hemogram may reveal chronic anemia with or without evidence of hemolysis in patients with pigment stones. The white blood cell count, serum bilirubin level, alkaline phosphatase level, and aminotransferase levels are often normal. The serum lipase level should be obtained to rule out pancreatitis. The urine must be examined to exclude other causes of abdominal pain. In females, serum or urine pregnancy testing should be performed to rule out obstetric causes of abdominal pain. A negative pregnancy test result also enables one to proceed safely with radiologic studies, if indicated. Additional studies in patients with biliary colic may be performed to support the diagnosis and rule out other causes of upper abdominal pain with nausea. Plain film radiographs of the abdomen demonstrate gallstones in only 10 to 20 percent of cases. The majority of stones are cholesterol and therefore radiolucent....

TABLE 684 Diagnostic Tests for Appendicitis

Recent work has concluded that plain films continue to be markedly overutilized. One study concluded that restriction of the PAR to patients with suspected obstruction, perforation, ischemia, peritonitis, or renal colic would have had no impact on management, and the use of PARs would have been reduced by 80 percent.13 The authors go on to suggest that more liberal use of ultrasound would decrease unnecessary utilization of plain films. There is evidence that ultrasound is superior to plain chest abdominal films in the detection of free air,14 which may be one of the principal uses for the PAR and upright chest film. Still other authors note the superior performance of computed tomography (CT) in identifying virtually any abnormality that can be seen on plain films, particularly SBO and renal colic, in addition to many other findings that can only be seen when the technology of computerized, collimated-beam, tomographic imaging is utilized. Although ultrasound can be extremely...

Gallbladder and Biliary Tract Disease

Gallstones are the most common cause of biliary tract disease in the United States. Gallstones occur in 20 to 35 percent of the population by age 75 years but in the majority are asymptomatic. Acute colicky pain localizing to the right upper quadrant accompanied by nausea and vomiting, sometimes with a finding of a palpable and tender gallbladder, characterizes gallstone obstruction of the cholecystic duct. The acutely ill patient frequently will give a history of past episodes of postprandial

Right Upper Quadrant Pain

Right upper quadrant pain can be caused by gallbladder disease including acute cholecystitis, biliary colic, biliary dyskinesia, cholangitis, and bile duct obstruction. Other sources of right upper quadrant pain include hepatic dysfunction or abscess, leaking duodenal ulcer, as well as processes outside of the peritoneal cavity, such as a right lower lobe pneumonia.

Upper Gi Emergencies Acute cholecystitis

Acute cholecystitis is an inflammatory condition of the gallbladder, often, but not always, associated with the presence of gallstones. It is a common surgical cause of emergency admission to hospital, and is more common in women than men in keeping with the distribution of stone disease. The symptoms will initially resemble biliary colic, with right upper quadrant pain, and nausea, but symptoms persist and patients become systemically unwell. Fever, tachycardia, and mild jaundice may develop, and the pain may radiate to the scapula. An initial chemical inflammation is often superceded by bacterial infection with a deterioration in systemic symptoms. Clinical examination demonstrates localised tenderness in the right upper quadrant over the fundus of the gallbladder. Pain on inspiration while palpating in the right

Breast Feeding Difficulties

Sometimes breast-feeding babies react to certain foods eaten by their mothers. You may notice after you eat spicy or gas-producing foods that your baby cries, fusses, or nurses more often. Babies with colic often have similar symptoms. The best way to tell the difference between a food reaction and colic is by how long the symptoms last. The symptoms of a reaction to food are usually short-lived, lasting less than 24 hours. Symptoms caused by colic occur daily, and often last for days or weeks at a time. If your baby gets symptoms every time you eat a certain type of food, stop eating that particular item.

Physical Examination 231

After vital signs and the initial assessment, the secondary assessment is conducted. If possible, the physical examination should be conducted in a systematic way in a fully exposed patient. In trauma patients, the risk of hypothermia must be considered even in the warmer months nevertheless, it should not hinder complete exposure for examination and it will be reduced bywarm infusions and by covering with external warming devices after assessment (ATLS Manual 2004a). With the exception of life-threatening emergencies requiring immediate evaluation and therapy, the secondary assessment should include organ systems other than those assumed to be affected. This will allow the discovery of physical signs not necessarily linked to the working hypothesis, as well as those arising from any additional disease (e.g., discovering a melanoma in a patient presenting with renal colic).

Gastrointestinal symptoms

Diarrhoea, vomiting and abdominal colic are common manifestations of food intolerance but may also be due to infective or other causes. The cause should be established by appropriate investigations. Food intolerance causing gastrointestinal symptoms could be due to enzyme deficiency and immunological and non-immunological reactions to foods. Cow's milk intolerance is a common problem during infancy that can be treated by excluding cow's milk from the diet. Replacement with soya milk or hydrolysed formula is given. Secondary lactose deficiency is relatively common following gastroenteritis, which is self-limiting. Avoidance of milk and milk products is essential during this period. In adults, some cases of irritable bowel syndrome may be due to food intolerance. If one or more foods is suspected this can be excluded from the diet and the response observed.

TABLE 1783 Adverse Effects of Chelating Agents

PROGNOSIS Approximately 85 percent of patients who suffer encephalopathy develop permanent CNS damage, including seizures, mental retardation in children, and cognitive deficits in adults. Abdominal colic usually subsides within days after beginning chelation therapy, and other acute manifestations clear within 1 to 16 weeks with therapy. Lead-induced nephropathy may be partially reversible with chelation therapy.

History

The importance of history taking in urologic emergency is illustrated by a prospective study (Eskelinen et al. 1998) addressing its accuracy in acute renal colic. The combination of gross hematuria, loin tenderness, pain lasting less than 12 h, and decreased appetite-all information easily available from history-detected renal colic with a sensitivity of 84 and a specificity of 98 .

The dark reactions

Returning to synthesis of carbohydrate by the Calvin cycle, as mentioned above, the first step is the carboxylation of the five-carbon sugar, ribulose diphosphate catalysed by rubisco. As mentioned in the preceding section, this enzyme may also function as an oxidase indicated by its full name ribulose diphosphate car-boxylase oxidase. When this occurs and oxygen replaces carbon dioxide, the ensuing reaction produces phosphoglycolate in addition to 3-phosphoglycerate. Since, as a result of illumination, oxygen is consumed and carbon dioxide is released during the reactions of the glycolate pathway, this process is termed photorespiration and occurs alongside photosynthesis. The higher the ambient temperature in which the organism is growing, and the higher the oxygen concentration relative to carbon dioxide, the more pronounced the oxidase activity becomes and consequently the less efficient rubisco is at introducing carbon dioxide into carbohydrate synthesis. The phosphoglycolate...

Mesenteric Ischemia

The hallmark of mesenteric ischemia is pain out of proportion to physical examination findings. The pain will be moderate to severe, nonlocalized, colicky, and constant. Patients may have a history of abdominal angina including pain while during eating, weight loss, and anorexia. Acute arterial embolus is usually marked by an abrupt onset of sharp abdominal pain, vomiting, and diarrhea. Acute arterial and venous mesenteric thrombosis occurs over a longer period of time with acute and subacute abdominal symptoms spanning a longer period of time. These are typically the patients who complain of abdominal angina or intermittent colicky abdominal pain. Nonocclusive mesenteric ischemia can be accompanied with a prodrome of malaise and nonspecific abdominal pain, which then progresses to increased pain and nausea and even peritoneal signs with the progression of ischemia.

Doppler Ultrasound

Doppler ultrasound is the first-line examination to perform when there is suspicion of renal colic in the pregnant woman. However, it does not differentiate physiological dilatation of pregnancy from pathological dilatation related, for example, to a kidney calculus. Since it only explores the high lumbar ureter or pelvic ureter, it misjudges many cases of calculi. With a sensitivity of 34 and a specificity of 86 (Mauroy et al. 1996 Sto-thers and Lee 1992), this exam is often flawed as a diagnostic procedure. Different devices have been developed in an attempt to improve its performance

Barium Enema

Children with signs and symptoms suggestive of intussusception, such as colicky abdominal pain, vomiting, and passage of stool mixed with blood, require stabilization and a barium enema. Plain films may demonstrate signs of intestinal obstruction, such as distended loops, air-fluid levels, and a paucity of bowel gas in the right lower quadrant, the so-called Dance's sign. A barium enema is indicated, and a hydrostatic reduction of the intussusceptum is successful in 50 to 90 percent of cases.17 A barium enema may be useful for the diagnosis of bowel obstruction, volvulus, appendicitis, and diverticulitis, usually in consultation with surgical colleagues.

Other symptoms

Stomatitis and mucositis due to infection with Candida albicans is improved by an antifungal antibiotic such as keto-conazole or fluclonazole. Gastric distension can be relieved by metoclopramide and intestinal colic or an irritable bowel by anticholinergic antispasmodics such as dicyclomine. Corticosteroids may improve appetite and well-being.

Lithotripsy ESWL

Extracorporeal shock wave lithotripsy (ESWL) involves the use of high-intensity sound waves to break up calculi within the genitourinary system. Ihe main advantage with this technique in dealing with nephrolithiasis is its noninvasive nature. Overall morbidity with ESWL is quite low. Iypically, patients with post-ESWL complications may come to the emergency department with the following signs and symptoms nausea, vomiting (especially 48 h after the procedure), skin ecchymosis, pain, or ureteral colic and fever.5,6,7 and 8

Patient Presentation

The patient presentation associated with upper urinary tract obstruction is varied. In addition, the differential diagnosis of upper urinary obstruction is extensive (Table 10.1). Many patients seen on an emergent basis will have classic symptoms of renal colic however, an urgent evaluation may be requested for a totally asymptomatic patient with incidentally discovered unilateral or bilateral upper urinary tract obstruction.

Analgesia

In the urgent care setting, pain control is another consideration when evaluating a patient with upper urinary tract obstruction. The cornerstone of pain control for patients with renal colic and upper urinary tract function has traditionally been parenteral narcotics (Gulmi et al. 2002). Nonsteroidal anti-inflammatory drugs (NSAIDs) have recently gained popularity in the urgent care setting (Larkin et al. 1999). NSAIDs provide effective analgesia in the absence of significant sedation or exacerbation of associated nausea and vomiting. In a prospective, randomized, double-blind trial, Larkin and colleagues compared efficacy of the NSAID, ketorolac, to meperidine among 70 patients evaluated for acute renal colic. They noted that ketorolac provided superior analgesia and facilitated quicker discharges from the emergency room setting (Larkin et al. 1999). Despite the analgesic benefits of NSAIDs, associated physiologic effects in the kidney can be detrimental especially for patients with...

Bacillus cereus

The diarrheal form of B. cereus FP is similar to that caused by C. perfringens. The toxin, unlike the emetic type, is an enterotoxin formed in the intestine and is heat labile. The predominant symptoms are diarrhea and abdominal colic. The incubation period, as expected for an organism that multiplies in the intestine and then produces its toxin, is also longer (8-16h). This type of B. cereus FP can be caused by a wide variety of foods, including meat, vegetables, and dairy products.

Breast Metastases

Talis Lesion

Its embolic nature is revealed by the two large submucosal masses of approximately equal size on the antimesenteric border in the field of distribution of the right colic artery. (Reproduced from Meyers and McSweeney.1) Its embolic nature is revealed by the two large submucosal masses of approximately equal size on the antimesenteric border in the field of distribution of the right colic artery. (Reproduced from Meyers and McSweeney.1)

Info

Adults, acute lead poisoning is characterized by colic, vomiting, and diarrhea coma and convulsions are rare. Chronic lead poisoning in adults causes toxic anemia (microcytic anemia) with constipation, gas-trocolic symptoms, and blisters and or renal tubular destruction or chronic interstitial nephropathy with headache, nausea, and impaired renal function. Terminal chronic lead poisoning is associated with a severe organic psychosyndrome. In addition to the CNS, the PNS also suffers damage apparent in the neuromuscular syndrome, also known as lead palsy, especially prominent in the muscles of the upper limbs. In children, the clinical picture is dominated by severe brain edema with symptoms of intracra-nial pressure indicative of encephalopathy seizures, hemiplegia, and other neurological sequelae.

Digestive Function

A horse fed a hay diet is likely to have a pH greater than 7 in the hindgut. Carbohydrate overload can decrease the pH to below 6. A pH of 6 is considered to be subclinical acidosis and a pH below 6 can greatly increase the risk of clinical conditions such as colic and founder. 2

Value Of Pasture

Good quality pasture is an excellent basis for a feeding program. The old saying that ''Dr. Green is an excellent veterinarian'' is still true. Proper use of pasture provides a much higher level of such antioxidants as vitamin E and carotene than are present in hay. Pasture can reduce the incidence of colic, ulcers, signs of respiratory diseases (due to decreased mold and dust), and abnormal behaviors.

Grazing

(usually at speed), depending on the recreational purpose of the owner. The most valuable horses are kept in this manner and their welfare is probably the poorest as indicated by the rate of stereotypic behavior displayed and the rate of gastrointestinal problems (colic) and lamenesses reported. The stalled horse will spend 20 or less of his time eating. He may compensate somewhat for the absence of grazing by foraging through the bedding of his stall, sometimes eating the wood shavings that are typical bedding for horses. If wooden surfaces are available, he may chew them. This behavior is not a response to confinement, but rather a response to lack of dietary roughage, i.e., chewing time. Provision of free-choice hay, a bale a day for a 500-kilogram horse, increases the eating time of a stalled horse to approximately that of the grazing horse. The hay-fed horse may chew enough, but he does not move as frequently, nor does he have equine companions.

Abnormal Behaviors

The behavior is displayed by 5 of horses, especially certain breeds and during certain activities. Thoroughbreds are the breed most likely to crib. Risk factors are being used as a dressage horse, as a three-day event performer, as a jumper, or as a race horse. The behavior is not learned by observing other horses, but there is a familial factor relatives of cribbers are more likely to crib. Various methods are used to eliminate cribbing, but a collar that prevents the horse from arching his neck to crib is the most effective. Surgical treatment is not very effective, and muzzles seem more frustrating than the collars. Nothing needs be done to prevent the horse from cribbing unless he experiences gas colic as a result. The behavior may help the horse cope with its unnatural environment or may even add buffering substances to his stomach and intestines by adding some saliva with every cribbing bite. Provision of a chest-high cribbing bar prevents damage to fences or...

Evaluation

At the time of presentation, a thorough history, physical examination, and determination of hemodynamic stability should ensue. Given that flank pain arising from SPH is commonly confused with renal colic, a noncontrast CT of the abdomen and pelvis is often performed. In fact, a contrast-enhanced CT is the first-line study and should be obtained in the event that a non-contrast CT or US suggests the presence of a retroperi-toneal hematoma. Laboratory studies should include a complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), creatinine, and a coagulation profile.

Management

This is a laparotomy via a subumbilical midline incision and a total abdominal hysterectomy, bilateral salpingo-oophorectomy, infra-colic omentectomy, washings and selected biopsies. In cases where there is extensive peritoneal spread of disease, surgically removing the majority bulk of the disease appears to provide some benefits to the patient as regards response to subsequent chemotherapy and possibly a small survival benefit (Griffiths, 1975 Griffiths et al., 1979 Hacker et al., 1983 Goodman et al., 1992 Hoskins et al., 1992 Hunter et al., 1992 Curtin et al., 1997). During the past two decades, maximum cytoreductive surgery (also called debulking surgery) has been the recommended surgical approach for advanced stages of ovarian carcinoma. The residual tumour volume after surgery is one of the strongest prognostic factors, and only patients who undergo complete or optimal surgery are likely to be long-term survivors (Allen et al., 1995 Munkarah et al., 1997). A well-trained surgeon...

Kidney and ureter

Pain and tenderness in the kidney, because of their retroperi-toneal location, are felt posteriorly in the loin and renal angle. Pain from a stone passing from the renal pelvis down the ureter may be felt initially posteriorly. The pain then radiates around the loin into the iliac fossa and scrotum. Renal colic produces an intense, severe colicky type pain where the patient can find no relief by either movement or rest. In contrast, pain from a renal tumour or pyelonephritis is likely to be constant, but less intense.

Carcinoid tumors

Carcinoid tumors are classified according to their embryologic origin foregut (bronchial, thymic, gastroduodenal, and pancreatic), midgut (jejunal, ileal, appendiceal, and right colic), and hindgut (distal colic and rectal). Depending on the site of origin, carcinoids secrete hormones differently and have different clinical features. Carcinoid tumors most frequently occur in the gastrointestinal tract. Bronchial and thymic carcinoids occur less commonly. In general, the diagnosis of carcinoid rests on the finding of elevated circulating serotonin or urinary metabolites (5-hydroxyindoleacetic acid 5-HIAA ) and localizing studies. The single best biochemical test is an elevated urinary 5-HIAA (normal 2-8 mg 24 h). Rectal or jejunoileal tumors may be visualized by contrast studies, whereas bronchial carcinoids can be identified on chest x-rays, CT scans, or bronchoscopy. Abdominal or hepatic metastases are best identified by CT scanning, ultrasonography, or angiog-raphy. As with other...

Stones

Ureteric colic due to a stone passing down the ureter is one of the commonest urological emergencies. The severe pain must be distinguished from the pain of biliary colic or a ruptured abdominal aortic aneurysm (AAA) and therefore an IVU, or CT urogram, is needed to confirm the diagnosis and establish the level the stone has reached. Pain relief using NSAIDS or opiates is usually effective.

Vascular Involvement

Of the SMA (Fig. 12-8) or into the jejunal mesentery where the IPDA originates from. Tumors arising from the head of the pancreas near the confluence of the gastrocolic trunk where it drains into the SMV may infiltrate into the base of the transverse mesocolon along the middle colic artery or vein (Fig. 12-6). Knowledge of this anatomy and of the potential pathways of local tumor invasion is important for surgical planning when an aggressive surgical approach is planned.

Intussusception

The majority of cases (90 ) are idiopathic. The commonest (> 90 ) site of involvement is the ileocaecal region ileo-colic intussusception usually begins several centimeters proximal to the ileocaecal valve and advances into varying lengths of the colon, occasionally presenting at the rectum. Ileo-ileal and jejuno-jejunal intussusception may be secondary to a pathological lead point or previous surgery. In Africa, there is an increased incidence of colo-colic intussusception which tends to affect older children. The risk of intussusception lies in delayed diagnosis and treatment, which can result in bowel strangulation and perforation.

Foreign Bodies

Penetrating injuries following blast or gunshot injuries result in multiple life-threatening injuries. Renal foreign bodies maybe metallic particles, bullets, or pellets entrapped in the parenchyma or the collecting system. In stable patients, penetrating injuries are no longer absolute indications for exploration (Sofer et al. 2001). Foreign bodies maybe removed endoscopically or surgically in cases of migration causing buckshot colic or infection (Harrington and Kandel 1997).

Parathyroid Cancer

Patients with parathyroid cancer present with a much higher incidence of bone pain, proximal muscle weakness, hematuria, and renal colic than patients with benign parathyroid pathology. Also, patients who present in hypercalcemic crisis, sometimes referred to as parathyroid storm, are more likely to harbor a parathyroid carcinoma than a benign adenoma as a cause for their hyperparathyroidism.3

Complications

Arteriovenous fistulas usually present with delayed onset of significant hematuria, hypertension, heart failure, and progressive renal failure, most often after penetrating trauma. Percutaneous embolization or stenting of the renal artery is often effective for symptomatic arteriovenous fistulas, but larger ones may require surgery (Wang et al. 1998 Kavic et al. 2002). The development of pseudoaneurysm is a rare complication following blunt renal trauma. In numerous case reports, transcatheter embolization appears to be a reliable minimally invasive solution (Franco de Castro et al. 2001 Miller et al. 2002). Acute renal colic from a retained missile has been reported and may be managed endoscopically if possible (Harrington and Kandel 1997). Other unusual late complications, such as duodenal obstruction, may result from retroperitoneal hematoma following blunt renal trauma (Park et al. 2001).

Visceral Pain

Visceral abdominal pain is usually caused by stretching of fibers innervating the walls or capsules of hollow or solid organs, respectively. Less commonly, it is caused by early ischemia or inflammation. Severity ranges from a steady ache or vague discomfort to excruciating or colicky pain. Because the visceral afferents follow a segmental distribution, visceral pain can be localized by the sensory cortex to an approximate spinal cord level determined by the embryologic origin of the organ involved. For example, foregut organs (stomach, duodenum, and biliary tract) produce pain in the epigastric region midgut organs (most of the small bowel, appendix, and cecum) cause periumbilical pain and hindgut organs (most of colon, including the sigmoid) as well as the intraperitoneal portions of the genitourinary system tend to cause pain initially in the suprapubic or hypogastric area.

Initial Evaluation

In addition to past medical history, a complete description of the patient's current problem should be elicited. This includes a description of the pain and symptoms. The time of onset, the length and duration of the pain, and whether it is constant or intermittent should all be recorded. One should inquire about the quality of the pain whether it is sharp and stabbing or more colicky. When initially asked about location of pain, patients may describe that their abdomen hurts diffusely. However, when probed further patients often can locate a single point where the pain is worst. Pain may also radiate to a different area, such as in cholecystitis, which can start in the right upper quadrant and then radiate up to the right shoulder, caused by diaphragmatic irritation from the inflamed gallbladder. It is also important to look at the vital signs and the overall state of the patient. Before beginning the directed physical examination, look at the patient. Are they lying still because...

Gallstones

Gallstones may cause a variety of symptoms depending on which part of the body they are in. The commonest problems arise from stones in the gallbladder, and present as biliary colic or cholecystitis. Biliary colic is a self-limiting condition characterised by right upper quadrant pain, often severe, caused by temporary cystic duct obstruction. The pain is associated with nausea, and occasional vomiting, and may radiate to the back. If the pain does not settle within a few hours, and a fever and raised white cell count develop, then a diagnosis of acute cholecystitis is more likely (see Acute Cholecystitis). Unrelieved obstruction of the cystic duct may lead to formation of a muco-cele, as mucus secretions collect and produce a tense swollen gallbladder. Infection within an obstructed gallbladder results in an empyema. Stones in the CBD may cause obstructive jaundice (see Jaundice), as may stones impacted in Hartmann's pouch (Mirizzi's syndrome). Infection can occur within an...

Physical Examination

The general appearance of the patient is one of the most important factors to consider when examining the patient. The diagnostic possibilities for a patient with ca-chexia are different than a well-nourished patient complaining of flank pain. Patients with classic colic will appear uncomfortable however, the diagnosis is not always stone disease. A similar appearance can be seen in patients with other urologic problems such as UPJ obstruction or less commonly ureteral tumors. Completely nonurologic problems such as acute appendicitis, gynecologic disorders, or dissecting aortic aneurysms can also present with symptoms of renal colic (Rucker et al. 2004). In all patients, vital signs should be documented. In addition to blood pressure, heart rate, and respirations, the presence of fever is a very important finding. Fever suggests the presence of renal parenchy-mal infection or abscess and overall increases the urgency of the diagnostic evaluation, especially among diabetic patients or...

General surgery

A leaking AAA is occasionally misdiagnosed as ureteric colic. Any patient over the age of 50 years with sudden onset of abdominal loin pain must not be diagnosed as having a symptomatic renal stone until radiological confirmation has been obtained, or an AAA excluded by ultrasonography.

Tumour

This uncommon tumour may be associated with an existing bladder TCC. The condition may present as haematuria, 'clot colic' or be found incidentally, or during surveillance of a patient with known bladder cancer. Treatment for a localized tumour is nephroureterectomy. Metastatic disease is incurable and treated symptomatically.

Imaging

Emergency indications for formal renal ultrasound include renal colic, renal failure, acute renal infection, urinary retention, and the detection of complications in renal transplant patients, as well as the exclusion of important nonurologic differential diagnoses such as spleen or liver rupture. However, because of the overwhelming diagnostic advantages of CT (Fowler et al. 2002 Sheafor et al. 2000), renal ultrasound is likely the second best choice for imaging calculi in suspected colic, except in children and pregnant women. Intravenous pyelography (IVP) allows additional qualitative analysis over KUB. It can determine the secretory function of each kidney, the presence of delay in filling of the renal pelvis (found in urinary obstruction), the post-void residual volume, and can describe the genitourinary anatomic pathology. Until 1995, IVP was the mainstay in the diagnosis of renal colic, but it has since been supplanted by helical CT. Its drawbacks are its generally lower...

Diagnosis 211

The first step in the management of urologic emergencies is to recognize the clinical significance. One must distinguish among genuinely life-threatening problems such as urosepsis or kidney rupture, urgent problems such as testicular torsion, and merely troublesome conditions such as cystitis in a healthy young woman. This maybe more easily said than done. The practitioner is challenged both by the broad spectrum of urologic emergencies and by the even more numerous possible diagnoses mimicking urologic symptoms. For example, a patient with a long history of renal colic may present with acute flank pain, tachycardia, tachypnea, and hypotension. If renal ultrasound is normal (lack of upper tract dilatation) and urinalysis reveals no microhematuria, abdominal ultrasonography and or computed tomography (CT), as indicated in a diagnostic algorithm, will lead to the correct diagnosis of ruptured abdominal aneurysm.

Infections

About 50 percent of patients who develop renal papillary necrosis have diabetes. Patients may be asymptomatic and not notice the sloughed papillary tissue excreted in their urine, or they may present with symptoms similar to acute pyelonephritis. Renal infection with ureteral obstruction may develop into sepsis and septic shock in these diabetic patients. Necrotic tissue fragments, red and white blood cells, and bacteria may be seen in the urine. Ureteral obstruction can be detected with ultrasound, computed tomography, and retrograde pyelography. Intravenous pyelogram should be avoided, especially if preexisting renal disease exists. Patients presumed to have pyelonephritis, but who appear to fail to respond to parenteral antibiotics, should be evaluated for renal papillary necrosis and perinephric abscess. Likewise, symptoms of flank pain suggesting renal colic should always be evaluated fully to exclude infection or papillary necrosis. Treatment still consists of aggressive...

Baby Sleeping

Baby Sleeping

Everything You Need To Know About Baby Sleeping. Your baby is going to be sleeping a lot. During the first few months, your baby will sleep for most of theday. You may not get any real interaction, or reactions other than sleep and crying.

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