Inflammatory Bowel Disease - A Holistic Perspective
The most frequent surgically treated causes of acute abdomen are appendicitis, intussusception, adhesions causing bowel obstruction, incarcerated hernia, midgut volvulus and complicated Meckel's diverticulum. Non-surgically treated conditions frequently have a digestive origin including gastroenteritis, severe constipation, mesenteric lymphadenitis, ileocecitis, Schonlein-Henoch purpura, inflammatory bowel disease, or paralytic ileus.
In regard to the RNA-binding function of apobec-1, recent studies have demonstrated that apobec-1 binds with high affinity 50 nM) to an AU-rich element (ARE) with a consensus sequence UUUN(A U)U (Fig. 2) (36). This sequence is part of a consensus ARE, present in the (3'UTR) region of many rapidly degraded mRNAs that encode cytokines and protooncogenes. AREs have been demonstrated to be essential for rapid degradation of certain mRNAs as evidenced by targeting studies in mice, where the AREs were deleted from both alleles of tumor necrosis factor (TNF)-a gene resulting in augmented expression of TNF-a, which in turn led to a clinical phenotype resembling inflammatory bowel disease (82). Recombinant apobec-1 was demonstrated to bind to AREs in c-myc, interleukin-2, TNF-a, and granulocyte-macrophage colony-stimulating factor with high affinity (50-100 nM) (36). Furthermore, transient apobec-1 overexpression led to increased stability of endogenous c-myc mRNA in F442A cells, a function...
Dysentery colitis are the major complications of infection with this parasite. In a patient with dysentery (diarrhea that contains visible or microscopic blood), it is vital to differentiate amongst infectious causes (including amebiasis, Shigella, Salmonella, Campylobacter and entero-invasive and enterohemorrhagic E. coli) and noninfectious causes (including inflammatory bowel disease, ischemic colitis and gastrointestinal bleeding secondary to AV malformations or diverticulosis). At times it is difficult to make the diagnosis of amebic colitis, as the presentation of the illness may be atypical, with non-bloody diarrhea and lack of systemic symptoms, such as fever. In such patients laboratory diagnosis is problematic, since a single stool exam for parasites is insensitive, histopathologic confirmation of infection on biopsy specimens may be difficult, and serologic tests for anti-amebic antibodies are not always positive in the acute setting (Table 9.4).
This is a fascinating area of investigation, because apoptosis of immune cells has been linked to both beneficial and deleterious effects. When immune cells undergo apoptosis this can be a necessary event for the host to prevent propagation of inflammation. As an example, it has been argued that Crohn's disease, a chronic relapsing form of inflammatory bowel disease, results in part from a failure of activated T-helper cells to undergo apoptosis (4). Similarly, apoptosis and consumption of infected cells by neutrophils may represent an important mechanism for elimination of pathogens. In contrast, apoptosis of infected cells has been hypothesized as a major cause for both proliferation of invasive organisms such as Shigella, and release of proinflammatory mediators (5). Additionally, death of immune cells is potentially an important feature of the immune escape of pathogens and tumor cells.
Increased permeability of the mucosal lining, allowing entry of microbial or dietary antigens, has been proposed as a possible cause in the pathophysiology of chronic inflammatory bowel disease. Interestingly, in Crohn's disease of the colon, there is abnormal permeability in apparently uninvolved proximal small intestine as well as in the colon110. Patients with Crohn's disease are subject to gastrointestinal strictures where a controlled release matrix may lodge and cause epithelial damage due to the release of concentrated drug at one site over a prolonged period of time111.
Wound healing, pyogenic infection, organising haematoma, oesophagitis, inflammatory bowel disease, lymphadenopathy associated with granulomatous disorders, viral and atypical infections, chronic pancreatitis, retroperitoneal fibrosis, radiation fibrosis (early), bursitis.
(ICOS), X-linked lymphoproliferative syndrome (XLP), BAFF-R and TAC-I , but the majority appear to have a complex genetic disorder associated with increased production of inflammatory cytokines, particularly IFN-y This helps to explain the high incidence of inflammatory bowel disease and granulomatous infiltration of organs such as the spleen, liver and lungs, and the splenomegaly that often prompts a search for lymphoma. The incidence of stomach cancer and lymphoma is raised in CVID, the former probably due to Helicobacter pylori gastritis. There are some similarities between CVID and XLP, in that both are associated with a relative expansion in numbers of circulating CD8+ T cells with restricted clonality, which in XLP are mainly committed to EBV peptides. Although XLP is a very rare disorder, the diagnosis should be excluded in male patients presenting with hypogammaglobulinaemia, particularly if they develop an EBV-related lymphoma. Hypogammaglobulinaemia associated with thymoma...
Disease, such as inflammatory bowel disease, is present. It is also occasionally necessary in gluten-induced enteropathy and when it is essential to replete body stores rapidly (e.g. where severe iron deficiency anaemia is first diagnosed in late pregnancy), or when oral iron cannot keep pace with continuing haemorrhage (e.g. in patients with hereditary haemorrhagic telangiectasia). Patients with chronic renal failure who are being treated with recombinant erythropoietin are also likely to require parenteral iron therapy. In this situation, the demand for iron by the expanded erythron may outstrip the ability to mobilize iron from stores, leading to a 'functional' iron deficiency. Increased red cell loss at dialysis contributes to iron needs and oral iron therapy is usually inadequate to prevent an impaired response to erythropoietin. The use of ' hypochromic cells' for detection of functional iron deficiency is discussed on p. 36.
Tions that can increase susceptibility to CRC. An increased risk for CRC has been confirmed in patients with inflammatory bowel disease of significant duration (8-10 years). Ulcerative colitis is more strongly associated with cancer than Crohn's disease. The incidence of malignancy seems to augment with the extent of bowel involvement and with the severity and duration of the disease 85, 86 . The risk of carcinoma is increased with the duration of colitis it has been estimated to be more than 30 in the third decade of the disease 87 . Other clinical risk factors are a history of pelvic irradiation and non-cancer surgery. Pelvic radiotherapy, which involves mostly women treated for gynaecological neoplasms, can be relevant to the risk of rectal cancer 88 . Some evidence suggests that patients who have undergone cholecystectomy 89 and ureterosigmoidostomy 90 may have an increased chance of CRC too. A history of breast, endometrial or ovarian carcinoma 91 and no or low parity have been...
Although inflammatory bowel disease is a contraindication to those men undergoing EBRT for prostate cancer, owing to the significant rate of GI toxicity, bowel disease has not been shown to influence the toxicity of PB. Wallner etal.14 reported on six patients with inflammatory bowel disease undergoing PB and did not find an increased incidence of GI toxicity.
Prophylactic antimicrobial agents for travelers' diarrhea are generally not recommended for the healthy traveler exceptions include those who cannot afford to be ill during travel and those with a bad 'track record' for travelers' diarrhea. Many travelers, often older persons, are at increased risk of acquiring travelers' diarrhea due to reduced gastric acidity from achlorhydria, gastrec-tomy, or H2 blockers. Others are at increased risk of developing disseminated infection from travelers' diarrhea, such as individuals with congenital and acquired immunodeficiency states. Both of these groups should be advised to take a daily dose of a fluoroquinolone. In addition, this approach should be considered for persons who have underlying illnesses that may flare or lead to severe consequences in the face of dehydration, such as inflammatory bowel disease, chronic renal failure, known cardiac ischemia or failure, and poorly controlled diabetes. Chemoprophylaxis should begin 1 day before...
Sulphasalazine (salicylazosulphapyridine) was one of the earliest prodrugs used in the treatment of inflammatory bowel disease. It contains 5-aminosalicyclic acid (mesalazine) linked covalently to sulphapyridine. 5-aminosalicyclic acid (5-ASA) is not effective orally because it is poorly absorbed, and is inactivated before reaching the lower intestine therefore prior to its administration as a prodrug, its was only effective when given as a suppository or a rectal suspension enema. The prodrug sulphasalazine is similarly poorly absorbed after oral administration, but it is reduced to its active components by bacterial azoreductase in the colon. Additional prodrugs which rely on bacterial activation have also been introduced, including olsalazine (sodium azodisalicylate, a dimer of 5-aminosalicylate linked by an azo bond), ipsalazine (5-ASA p-aminohippurate) and balsalazine (5-ASA 4-amino benzoylglycine) (Figure 7.9).
Several commonly held indications and contraindications for RRP, XRT and brachytherapy are listed in Table 24.5. While precise data regarding each of these issues are lacking, most practitioners abide by these indications when offering treatment options for prostate cancer. Relative indications and contraindications are denoted, for which the data or commonly held opinions are not concrete. Thus, some urologists would not feel comfortable offering RRP to anyone refusing a potential blood transfusion, on the grounds that operative blood loss may potentially be high, which would place the patient at risk. Additionally, the age of the patient is used commonly as a deciding factor between treatment modalities, but these 'loose' age ranges may change as medical care improves with improved life expectancies in the future. Specific patient comorbidities are listed as well, including inflammatory bowel disease as a contraindication for radiotherapy, owing to concerns...
The rationale for performing preoperative colonoscopy is to diagnose and to treat neoplastic lesions. If a cancer were diagnosed, curative resection, if possible, would be required prior to consideration of performing transplantation. Conversely, metastatic cancer is a contraindication to liver transplantation. Neither the underlying cause of the liver disease nor the Child-Pugh-Turcotte score apparently impacts the likelihood of finding a colon lesion. Thus, screening is carried out as it would be done in the general population, and patients older than 50 years should undergo screening examination of the colon. Preoperative colonoscopy should be performed in patients with primary sclerosing cholangitis and associated inflammatory bowel disease because of the increased risk of colonic dyspla-sia and cancer.
Hartmann's procedure was described in 1923 as a technique for the treatment of rectal cancer. It is now frequently performed when primary bowel reanastomosis is deemed unsafe, as in obstructing or perforated diverticular disease, some cases of colon cancer, inflammatory bowel disease, and colorectal trauma. In this procedure, the diseased sigmoid is resected, an end colostomy is created, and the rectal stump is closed off (Fig. 6.14). The Hartmann pouch is a blind segment, which is generally reattached to the proximal colon at a later date, usually within 3 to 6 months after the initial surgery. In some cases, reanastomosis is never performed for example, it may be thought to be unsafe because of high surgical risk due to poor medical condition,
The rate of genito-urinary dysfunction in males after anterior resection for cancer is 0-49 25 this is an acceptable rate in the presence of a certain cancer but for a prophylactic surgery it should be carefully evaluated. The rate of impotence after rectal excision for inflammatory bowel disease is lower than after excision for rectal cancer ranging from 0-25 25-30 . The incidence of sexual dysfunction increases with age and when a mesorectal plane is preferred to close rectal plane of dissection 25 .
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