By Z. Anog. New England College of Optometry.

Colonoscopy is preferred over barium enema in the initial workup of suspected diverticular disease because of its superior sensitivity and specificity buy epivir-hbv 150 mg amex symptoms quivering lips. However order epivir-hbv 100 mg on-line hair treatment, colonoscopy is less rewarding and more danger- ous in the evaluation of acute complications of perforated diverticular disease. Fiber is the mainstay of the medical management of uncomplicated diverticulosis or mild diverticulitis. A high-fiber diet is believed to reduce intracolonic pressures, presumably eliminating the “cause” of diverticular disease. Complications of colonic diverticula that may require surgical con- sultation or intervention are hemorrhage and the complications of perforation of a diverticulum, which include chronic left lower quad- rant pain, phlegm, abscess, peritonitis, fistula, and stricture. The source of the bleeding is generally right sided, even though the diverticula predominantly are present on the left. The majority of patients (70–82%) stop bleeding; up to one third continue to bleed and require intervention. Once resuscitation is under way, attention is directed toward local- ization of the source. If the nasogastric tube and proctosigmoidoscopic evaluation suggest a distal source, a nuclear medicine test is the pre- ferred first step. Angiographic localization is attempted in those with a positive nuclear medicine scan. In most cases, the perforation is microscopic, causing localized inflam- mation in the colonic wall or paracolic tissues. In more severe cases, an abscess may form or the diverticulum freely may rupture into the peri- toneal cavity, causing generalized peritonitis. The average age at pre- sentation is the early 60s; more than 90% of cases occur after 50 years of age. Patients with acute diverticulitis typically present with the gradual onset of left lower quadrant pain and low-grade fever. On physical examination, tenderness to pal- pation usually is present in the left lower quadrant or suprapubic region. Rectal examination may reveal a boggy mass anteriorly if a pelvic abscess is present. Unlike diverticulosis, acute diverticulitis usually is not associated with hemorrhage, but 30% to 40% of cases have guaiac-positive stool. Plain-film abdominal series including an upright chest x-ray should be obtained to rule out free intraperitoneal air or lower lobe pneumo- nia. These studies may be normal or may demonstrate a distal large- bowel obstruction, localized ileus, or extracolonic air. Note the “streaking” of the fat characteristic of inflammation and the thickening of the sigmoid colon bowel wall. Ideal patients for outpatient management are those who are able to tolerate a diet, have no systemic symptoms or peritoneal signs, and are reliable. Immunocompromise, steroid therapy, and advanced age are contraindications to outpatient therapy (see Algo- rithm 25. Purulent or fecal peritonitis may develop secondary to rupture of a contained abscess or free perforation of a diverticulum. Aggressive intravenous resuscitation, antibiotics, and surgery are required for patients who present in this fashion. They are explored urgently, and a resection with descending colostomy and oversewing of the rectal stump is performed in all but the sickest patients. Fistulas develop in only 2% of patients with diverticulitis, but fistula is the indication for surgery in 20% of those undergoing surgery for diverticulitis and its associated complications (Fig. The bladder is affected most commonly, with nearly two thirds of all patients in one series having colovesical fistulas. Such patients may present with pneu- maturia, fecaluria, abdominal pain, urinary symptoms (frequency, urgency, dysuria), hematuria, and fever and chills. Colovaginal fistu- las, the next most common diverticular fistula, present with vaginal discharge, air, or stool per vagina. The indications for surgery for diverticulitis are recurrent attacks, a severe attack, age less than 50 years, immunocompromised pa- tients, or a severe complication of perforation such as significant 25.

Neoplastic cells from the bladder are not found they should be referred to a pathologist for in urinary sediment cytological examination generic epivir-hbv 100 mg online treatment 30th october. Which of the following statements regarding cells Answers to Questions 7–11 found in urinary sediment is true? Transitional cells are considered a an eccentric round nucleus normal component of the sediment unless present C purchase 100 mg epivir-hbv overnight delivery denivit intensive treatment. Clumps of bacteria are frequently mistaken for significant when seen conclusively in the sediment. Conclusive Body fluids/Apply knowledge of fundamental biological identification requires staining. Trichomonas vaginalis characteristics/Urine sediment/2 displays an indistinct nucleus and two pairs of 8. Renal tubular epithelial cells are shed into the when passing through the glomerulus, often urine in largest numbers in which condition? Oval fat bodies are often seen in: approximately 150 × 60 μm and are nonoperculated. B Oval fat bodies are degenerated renal tubular epithelia that have reabsorbed cholesterol from the Body fluids/Correlate clinical and laboratory data/ filtrate. Although they can occur in any inflammatory Urine sediment/2 disease of the tubules, they are commonly seen in the nephrotic syndrome, which is characterized by marked proteinuria and hyperlipidemia. All of the following statements regarding urinary Answers to Questions 12–17 casts are true except: A. C Proteinuria accompanies cylindruria because protein jogging or exercise is the principle component of casts. An occasional granular cast may be seen in a exercise, hyaline casts may be present in the normal sediment sediment in significant numbers but will disappear C. Hyaline casts will dissolve readily in alkaline urine solute concentration, slow movement of filtrate, and Body fluids/Apply knowledge to recognize sources of reduced filtrate formation. The appearance of a error/Urine casts/2 cast is dependent upon the location and time spent in the tubule, as well as the chemical and cellular 13. Reduced filtrate formation cells, immunoglobulins, light chains, cellular proteins, D. C Pseudocasts are formed by amorphous urates that characteristics/Urine casts/2 may deposit in uniform cylindrical shapes as the 14. Granular casts may form by Body fluids/Apply knowledge of fundamental biological degeneration of cellular casts, but some show no characteristics/Urine casts/1 evidence of cellular origin. Hyaline casts may also be increased in Body fluids/Apply knowledge to identify sources of patients taking certain drugs such as diuretics. Broad error/Urine casts/2 casts form in dilated or distal tubules and indicate 16. Which of the following statements regarding severe tubular obstruction seen in chronic renal failure. Fine granular casts are more significant than tubules and signal end-stage renal failure. Cylindroids coarse granular casts are casts with tails and have no special clinical B. Broad casts are associated with severe renal hematuria from ruptured vessels, but not casts. Body fluids/Apply knowledge of fundamental biological Sediment in chronic glomerulonephritis is variable, characteristics/Urine casts/2 but usually exhibits moderate to severe intermittent hematuria. Lower urinary tract obstruction Body fluids/Correlate clinical and laboratory data/ Urine sediment/2 346 Chapter 6 | Urinalysis and Body Fluids 18. Both waxy and broad casts Body fluids/Apply knowledge of fundamental biological form in chronic renal failure when there is severe characteristics/Urine casts/2 stasis, and they are associated with a poor prognosis. Small yellow-brown granular crystals at an are normal with the exception of a positive blood acid pH may be uric acid, bilirubin, or hemosiderin. Prussian blue stain hemosiderin include transfusion reaction, hemolytic Body fluids/Select course of action/Urine sediment/3 anemia, and pernicious anemia. C Epithelial casts are rarely seen but indicate a disease following is considered an abnormal finding? Acidify a 12-mL aliquot with three drops of glacial acetic acid and heat to 56°C for 5 minutes before centrifuging D. How can hexagonal uric acid crystals be Answers to Questions 23–28 distinguished from cystine crystals?

Reiter’s cells trusted 100mg epivir-hbv medicine 79, macrophages with ingested globular inclusions purchase 150mg epivir-hbv amex anima sound medicine, are seen in Reiter’s syndrome and other inflammatory diseases. Calcium pyrophosphate or apatite crystal-induced arthritis, uric acid and sodium urate C. B Calcium pyrophosphate crystals occur as needles or characteristics/Synovial fluid/1 small rhombic plates and can be confused with uric acid. A synovial fluid sample is examined using a differentiates uric acid and pseudogout crystals. Crystals are seen that are yellow when the the slow vibrating light, the crystals appear yellow. Calcium is perpendicular to the slow vibrating light, the pyrophosphate gives the reverse effect. Cholesterol level is often more than 40 mg/dL below the serum level and about 25–40 mg/dL lower in inflammatory Body fluids/Apply principles of special procedures/ arthritis, which includes gout. Osteoarthritis and Synovial fluid/2 hemorrhagic arthritis are not usually associated with 37. Normally, IgG in synovial fluid is Body fluids/Correlate clinical and laboratory data/ about 10% of the serum IgG level. Which of the following organisms accounts for Answers to Questions 39–40 the majority of septic arthritis cases in young and middle-age adults? Which of the following statements about Answers to Questions 1–3 amniotic fluid bilirubin measured by scanning spectrophotometry is true? Baseline correction is not required if a scanning from 350 to 600 nm, then drawing a baseline using spectrophotometer is used the points at 365 nm and 550 nm. Chloroform extraction is necessary only when absorbance (ΔA) of hemoglobin at 410 nm and meconium is present bilirubin at 450 nm are determined by subtracting the D. In normal amniotic fluid, bilirubin increases absorbance of the baseline from the respective peaks. Rh antibody titer of the mother with increasing gestational age because fetal urine B. Lecithin/sphingomyelin (L/S) ratio contributes more to amniotic fluid volume as the C. B Respiratory distress syndrome develops when processes/L/S ratio/2 surfactants are insufficient to prevent collapse of the infant’s alveoli during expiration. Tests measuring pulmonary phospholipid surfactants are the most specific and sensitive indicators of respiratory distress syndrome. Most of the surfactants in the amniotic fluid are present in the form of lamellar bodies. These can be counted using an electronic cell counter at the settings for enumerating platelets. Which of the following statements regarding Answers to Questions 4–6 the L/S ratio is true? Sphingomyelin levels increase during the third constant throughout gestation and serves as an trimester, causing the L/S ratio to fall slightly internal reference. Meconium contains less lecithin during the last 2 weeks of gestation than amniotic fluid and will usually decrease the D. Which of the following conditions is most likely its presence indicates fetal lung maturity. Centrifugation at 1,000 × g for 10 minutes 3:1 more closely correlates with fetal lung maturity D. Centrifuge speed is below expected levels should be the minimum required to spin down cells C. Samples that cannot levels than expected for the time of gestation be measured immediately should be refrigerated D. Samples are stable for up to 3 days at 2 days following delivery, stillbirth, or abortion 2°C–8°C and for months when frozen at –20°C or lower. Meconium and blood may also introduce Body fluids/Correlate clinical and laboratory data/ errors when measuring the L/S ratio. Blood has Chorionic gonadotropin/2 an L/S ratio of approximately 2:1 and will falsely raise the L/S ratio when fetal lungs are immature and depress the L/S ratio when fetal lungs are mature.

The offending allergens are identified by allergy This treatment involves repeated injections of high- sensitivity tests buy 100mg epivir-hbv with mastercard medications and mothers milk 2014. The ini- are made on the patient’s back and a liquid suspen- tial concentration of the solution is too weak to sion of the allergen is introduced into the scratch 150mg epivir-hbv medicine zithromax. Additional exposure to higher If antibodies to the allergen are present in the concentrations promotes tolerance of the allergen. The degree Autoimmunity is the failure of the body to distin- of deficiency varies from mild to severe. Women are carriers of the trait but generally attacks the antigens found on its own cells to such do not have symptoms of the disease. Types of Mild symptoms include nosebleeds, easy bruis- autoimmune disorders range from those that affect ing, and bleeding from the gums. Severe symp- only a single organ to those that affect many toms produce areas of blood seepage (hematomas) organs and tissues (multisystemic). If blood enters joints Myasthenia gravis is an autoimmune disorder (hemarthrosis), it is associated with pain and, that affects the neuromuscular junction. Uncontrolled the limbs and eyes and those affecting speech and bleeding in the body may lead to shock and death. Treatment consists of attempting to reach a bal- ance between suppressing the immune response to Infectious Mononucleosis avoid tissue damage, while still maintaining the immune mechanism sufficiently to protect against Infectious mononucleosis is one of the acute disease. Most autoimmune diseases have periods of infections caused by the Epstein-Barr virus flare-up (exacerbations) and latency (remissions). It is usually found in young adults and Autoimmune diseases are usually chronic, requiring tends to appear in early spring and fall. Saliva lifelong care and monitoring, even when the person and respiratory secretions have been implicated may look or feel well. Currently, few autoimmune as significant infectious agents, hence the name diseases can be cured; however, with treatment, “kissing disease. Other signs and symptoms include gum infec- Edema tion (gingivitis), headache, tiredness, loss of appetite (anorexia), and general malaise. In most Edema is an abnormal accumulation of fluids in cases, the disease resolves spontaneously and the intercellular spaces of the body. In some cases, however, of edema is a decrease in the blood protein level the liver and spleen enlarge (hepatomegaly/ (hypoproteinemia), especially albumin, which splenomegaly). Less common clinical findings controls the amount of plasma leaving the vascular include hemolytic anemia with jaundice and channels. Recovery usually ensures a lymph drainage, high sodium intake, increased lasting immunity. Edema limited to a specific area (localized) Oncology may be relieved by elevation of that body part and application of cold packs. Systemic edema may be Oncological disorders associated with the blood, treated with medications that promote urination lymph, and immune systems include leukemia, (diuretics). Closely associated with edema is a condition called ascites, in which fluid collects within the Leukemia peritoneal or pleural cavity. The chief causes of Leukemia is an oncological disorder of the blood- ascites are interference in venous return in cardiac forming organs, characterized by an overgrowth disease, obstruction of lymphatic flow, distur- (proliferation) of blood cells. The disease is generally categorized by the type of Hemophilia leukocyte population affected: granulocytic (myel- ogenous) or lymphocytic. Hemophilia is a hereditary disorder in which the The various types of leukemia may be further blood-clotting mechanism is impaired. In the acute form, two main types of hemophilia: hemophilia A, the cells are highly embryonic (blastic) with few Pathology 245 mature forms, resulting in severe anemia, infec- become excessively large, they may press on the tions, and bleeding disorders. This form of trachea, causing difficulty in breathing (dyspnea), leukemia is life threatening. Although there is a or on the esophagus, causing difficulty in swallow- proliferation of blastic cells in chronic forms of ing (dysphagia). Newer meth- Although the causes of leukemia are unknown, ods of treatment include bone marrow transplants.