e-book Gastrointestinal Bleeding: A Practical Approach to Diagnosis and Management

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If anemia is detected, it is reasonable to look for nonhematologic causes such as gastrointestinal bleeding, a cardiac cause, or a nutritional deficiency. Anemia has a variety of possible hematologic causes, as shown in a study in the United States.

Eosinophilia: a pragmatic approach to diagnosis and treatment

In cases of isolated thrombocytopenia or combined bicytopenia eg, anemia and thrombocytopenia , abdominal ultrasonography should be done to evaluate for splenomegaly. Blood tests to evaluate for immune-mediated cytopenias, including idiopathic thrombocytopenic purpura and hemolytic anemia, include the direct and indirect Coombs antiglobulin tests, the lactate dehydrogenase level, the reticulocyte count, and the haptoglobin level.

Other immune-mediated causes of cytopenia include connective tissue disorders and vasculitides, and an antinuclear antibody titer and rheumatoid factor level can also be considered. If all these tests are negative, the next step is referral to a hematologist-oncologist for further workup, which may include a review of the peripheral blood smear; bone marrow aspiration and biopsy for evaluation of iron stores and bone marrow cellularity; and specialized tests such as assessment of antiplatelet antibodies, protein electrophoresis, or fluorescence in situ hybridization to evaluate for specific clonal disorders.

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Each has its prognostic and therapeutic implications. The purpose of classification systems for any medical condition is to uniformly evaluate and group patients with a disease subtype to compare patient populations similarly throughout the world, to predict prognosis, and to dictate therapeutic directions. Before you perform an examination, obtain relevant information from the referring clinician.

Don't let the clinician simply 'order' a sonogram or CT, but discuss the patient's age and posture, laboratory results and the number one clinical diagnosis and differential diagnosis. Based on that information and your own degree of confidence with the modalities decide for yourself whether to perform sonography or CT.

Sonography has the advantage of close patient contact, enabling assesment of the spot of maximum tenderness and the severity of illness without ionizing radiation. In general the diagnostic accuracy of CT is higher than sonography. In patients with inconclusive US-results, CT can serve as an adjunct to sonography, and vice versa.

We advocate the following two-step radiological approach of an acute abdomen. Confirm or exclude the most common disease 2. Screen for general signs of pathology You have to be familiar with all the diagnoses listed in Table 1 to be able to recognize them. The clinical presentation of patients with an acute abdomen is often nonspecific. Both surgical and nonsurgical diseases may present with a similar clinical history and symptoms.

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Laboratory findings leucocyte count, erythrocyte sedimentation rate, CRP are equally nonconclusive. Findings may be normal in patients who need emergency surgery such as appendicitis and may be abnormal in patients without a surgical disease like salpingitis. A plain abdominal film has a limited value in the evaluation of abdominal pain. A normal film does not exclude an ileus or other pathology and may falsely reassure the clinician.

An ileus may not be appreciated on a plain abdominal film if bowel loops are filled with fluid only without intraluminal air figure. Alternatively if a plain abdominal film does indicate an ileus than sonography or CT are usually needed to identify its cause. Thus, a plain abdominal film is seldomly useful, with the exception of detection of kidney stones or a pneumoperitoneum. For all other indications use sonography or CT. Many disorders may cause an acute abdomen, but fortunately only a few of these are common and clinically important.

Focus on confirming or excluding these frequent disorders:. Pain in the RLQ, regardless of any other symptom or laboratory results, should be considered to be appendicitis until proven otherwise. If you are unable to find the appendix you cannot rule out the diagnosis of appendicitis unless a good alternative diagnosis is found.


If you do not find the appendix and there is no altermative diagnosis call the results of the examination indeterminate. Do not call it:' no appendicitis'. Normal Appendix. Your first task is to identify the appendix. At sonography and CT the appendix is seen as a blind-ending nonperistaltic tubular structure arising from the base of the cecum. Do not mistake a small bowel loop for the appendix.

Secondly determine if the appendix is normal or inflamed. The outer-to-outer diameter of the appendix is the most important imaging criterium. Although an overlap of appendiceal diameters in normal and inflamed appendices can incidentally be found, a threshold value of mm is generally used. A normal appendix has a maximum diameter of 6 mm, is surrounded by homogeneous non-inflamed fat, is compressible and often contains intraluminal gas. Inflamed Appendix An inflamed appendix has a diameter larger than 6 mm, and is usually surrounded by inflamed fat. The presence of a fecolith or hypervascularity on power Doppler strongly supports inflammation.

CT depicts an inflamed appendix as a fluid-filled blind-ending tubular structure surrounded by fat-stranding.

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In the case on the left a hyper-attenuating wall is seen on the enhanced CT. In patients who lack intra-abdominal fat the use of iv. If the pain is located in the LLQ your main concern is sigmoid diverticulitis. In diverticulitis sonography and CT show diverticulosis with segmental colonic wall thickening and inflammatory changes in the fat surrounding a diverticulum. Complications of diverticulitis such as abscess formation or perforation, can best be excluded with CT. An important pitfall is colon cancer, which may present with similar imaging features, especially when the colon cancer is surrounded by fat stranding due to invasive groth, desmoplastic reaction or inflammation.

Frequently it is not possible to reliably distinguish diverticulitis from colon cancer and therefore we routinely include colon cancer in the differential diagnosis of sigmoid diverticulitis.

Acute Gastrointestinal Bleeding causes,features,diagnosis and treatment

Cholecystitis occurs when a calculus obstructs the cystic duct. The trapped bile causes inflammation of the gallbladder wall. As gallstones are often occult on CT, sonography is the preferred imaging method for the evaluation of cholecystitis, also allowing assesment of the compressiblity of the gallbladder. The diagnosis of a hydropic galbladder is solely made on the non-compressability of the galbladder.

Do not rely on measurements. Some galbladders happen to be small and others are large. The imaging appearance of cholecystis consists of an enlarged hydropic meaning non-compressible gallbladder with a thickened wall in the region of maximum tenderness the so-called ' Murphy sign '.

The inflamed gallbladder usually contains stones or sludge, whereas the obstructing calculus itself may or may not be identified because it is located deep within the galbladder neck or cystic duct. The gallbladder may be surrounded by inflamed fat, but on sonography this frequently is not seen, while CT sometimes does show fat-stranding. Potential pitfalls are pancreatitis, hepatitis or right-sided heart failure, which all may lead to thickening of the gallbladder wall without cholecystitis.

Therefore be certain that hydropic obstruction of the gallbladder is present before assigning the diagnosis of cholecystitis. Its most common cause is gastric pathology in which radiological imaging plays a minor role. After excluding these frequent disorders, search for signs of any other pathology, by systematically screening the whole abdomen. Look for inflamed fat, bowel wall thickening, ileus, ascites and free air. Inflamed fat is shown as fat-stranding at CT. Inflamed fat usefully points out where and what the problem is.

As a rule, the organ or structure in the centre or nearest to the inflamed fat is the cause of the inflammation. Spara som favorit.

Regulation of eosinophilia

Skickas inom vardagar. Laddas ned direkt. Skickas inom vardagar specialorder. Gastrointestinal bleeding is an age-old problem. The original description of g- trointestinalbleedingmayhavebeenfromGalenandhisworkconnectingdyspepsia andmelanoticstool. Thechangesinourmanagementofgastrointestinalbleeding overthecenturieshavebeendrivenbynaturalalterationsinthespectrumofdiseases, expanding our understanding of these diseases and the never ending advances in technologyandpharmacologythathaveoccurredrelativetoGIdiseases.

Review article: the management of lower gastrointestinal bleeding

Academic interestingastrointestinalbleedingpeakedinthelasthalfofthetwentiethcentury withtheexpandingroleofsurgery,thediscoveryofacid-basedpepticulcerthe- pies,andtheriseof? More recently there has been a decrease incidenceinbleedingdiseasesofthegutandthereforeadecreasinginterestinthe scholarlywritingaboutthesediseases. Therehasnotbeenamajortextbookwritten aboutgutbleedinginover10yearsandthereforetheintentionofthistextbookisto?

CliniciansatDukeUniversitywhohaveacommoninterestinthegastrointes- naltracthavecollaboratedintheconstructionofthistext.