Pletal

By L. Knut. Illinois Wesleyan University.

Hypoxic ischaemic brain injury Denition Incidence Theglobalbraindamageresultingfromafailureoftissue Accounts for 15% of strokes cheap 50 mg pletal overnight delivery. Aetiology Age Generalised failure of blood ow or oxygenation may Occurs most commonly in the elderly discount pletal 100mg. Aetiology/pathophysiology r Prolonged uncontrolled hypertension is the most Pathophysiology commoncause. Pseudoaneurysmsformonneperfo- The generalised loss of perfusion results in diffuse death rating arteries, these have a tendency to rupture lead- of neurones. Within the range of 80 170 mmHg r Arteriovenous malformations may haemorrhage es- systolic pressure the cerebral blood ow is independent pecially in younger patients. Bloodaccumulatesoverdaysorweeks coma are more common in intracerebral haemorrhage. Theremaybefur- ther accumulation of uid due to the osmotic pressure Macroscopy of the degenerating blood, or further acute bleeds. If the patient survives the haematoma is removed Clinical features by phagocytosis, and replaced by gliosis. Classically the patient has a brief loss of consciousness Management at the time of injury, then a lucid interval followed r Resuscitate as necessary with management of the air- by development of headache, progressive hemipare- way, breathing and circulation. Headache, drowsiness, and confusion in cerebellar bleeds which may cause obstructive hy- (dementia if chronic) are common. Anyrisk factors present, particularly hypertension, should be managed to help prevent recurrence. Subarachnoid haemorrhage Aetiology Denition Tearingofbloodvesselswhichmaybetraumaticorspon- Spontaneous intracranial arterial bleeds into the sub- taneous. Risk Incidence factors include a tendency to fall and clotting abnormal- 15 per 100,000 per year. Saccular or berry aneurysms arise due to defects in the 2 Oral nimodipine (a calcium-channel blocker) has internal elastic lamina of arteries and occur in 2% of the been shown to reduce mortality. Severe hypertension may junctionsofarteriesonthecircleofWillisorwithitsadja- needtobecontrolledbuthypotensionmustbeavoided cent branches. Common sites include the anterior com- to prevent further loss of perfusion pressure, so pa- municating artery, the posterior communicating artery tients are kept well hydrated with intravenous saline. Most are idiopathic, but 3 In suitable patients surgical or radiological interven- theyareassociatedwithdiseasessuchasarteritis,coarcta- tion for aneurysms takes place a few days later in a tionoftheaorta,Marfan ssyndromeandadultpolycystic neurosurgical centre: kidney disease. Neurolog- ical signs, papilloedema and retinal haemorrhages may Prognosis be present. Without Alayer of blood is present over the brain in the subara- interventiontheriskofrebleedingis30%inthefollowing chnoid space and in the cerebrospinal uid. Complications Intracranial venous thrombosis The blood acts as an irritant, causing vascular spasm leading to further ischaemia, infarction and cerebral Denition oedema. Pathophysiology r Cortical vein thrombosis results in a stroke and The organisms may spread directly from the nasophar- seizures. This condition arises from raisedintracranialpressure,cranialnervepalsiesorother mastoiditis and is now rare. Neisseria meningitidis may cause meningitis, sep- loedema, focal signs, confusion and epilepsy. Patients are examined for a petechial rash which sug- Bacterial meningitis gests N. Complications Aetiology Neurological and cerebrovascular complications in- The likely organism changes with age. In adults, the clude intracranial venous thrombosis, cerebral oedema most common are Neisseria meningitidis, Streptococcus and hydrocephalus. Less common intravascular coagulation occur in 8 10% of patients organisms include gram-negative bacilli (particularly as with meningococcal meningitis. There may be r Nasopharyngeal clearance may be recommended for oedema, focal infarction and congested vessels in the the patient and household kissing contacts, e. Cephalosporins provide good clearance of nasal carriage in the patient, but penicillins do not. Poor givenstill demonstrates the causative organism in many prognostic markers include hypotension, confusion and cases. Abroad-spectrum antibiotic such as a cephalosporin at high doses is initially recommended due to the increasing emergence of penicillin-resistant strepto- Viral meningitis cocci. Once cultures and sensitivities are available, the course and choice of agent can be determined Denition (ceftriaxone/cefotaxime for Haemophilus inuenzae Acute viral infection of the meninges is the most com- andStreptococcuspneumoniae,penicillinforN. Aetiology Pathophysiology Mayarise as a complication of miliary tuberculosis or In viralmeningitis there is a predominantly lymphoid in primary or post primary infections.

Clinical features r Asmallbowelcontrastfollowthroughmayrevealdeep The clinical picture is dependent on the area affected cheap pletal 100mg fast delivery. Stric- Colonic disease presents with passage of blood and mu- tures are also demonstrated order 100mg pletal overnight delivery. Abdominal pain is vari- lar endoscopy can be used to visualise the small able from chronic to acute, and may occur in any part bowel. It may mimic other pathologies such r Other investigations include a white cell scan to iden- as intestinal obstruction or acute appendicitis. The next step is often antibiotics in ileitis or colitis (usually ciprooxacin and metronidazole) these may work by reducing inammation due to Aetiology infection, or transmigration of bacteria through the Associated with constipation and straining to pass stool gut wall. Suggested that low bre Western diet teroids which may be given as enemas in colonic dis- accounts for increased incidence. Steroids are withdrawn following induction of remission, but relapse may Pathophysiology occur. These drain to the portal system and contain no mercaptopurine may be used to allow the reduction valves. Azathioprine requires careful monitoring as it may cause bone marrow sup- lapsing through the anus. The anal sphincter contracts around r Elemental and polymeric diets may be used, particu- aprolapsed haemorrhoid causing venous congestion larly in children. Surgical: 80 90% of patients will require some form of surgical intervention during their lifetime. Surgery may Clinical features berequiredforcomplicationsorifthereisfailureofmed- Patients normally present with rectal bleeding which is ical treatment and severe symptoms. Severe volves resection of affected bowel; however, poor wound bleeding may cause blood in the toilet. Prolapse may be healing may lead to stulas, so surgery is avoided if pos- noted and cause a mucus discharge. Prognosis Investigations The condition runs a course of relapses and remis- Proctoscopy visualises the piles, prolapse is demon- sions. Mortality is twice that of the gen- in cases of rectal bleeding to exclude other pathology eral population, operative mortality of 5%. The risk of and a barium enema or colonoscopy may be indicated malignancy is 2 3% (slightly higher than the general depending on the index of suspicion of inammatory population). Weakness in the surrounding muscula- Small asymptomatic piles are managed conservatively, ture may cause irregular bowel motions, faecal incon- a high-bre diet may reduce constipation. The prolapse may only be demon- piles can be treated by sclerosing injection into the pedi- strated on straining. More severe haemorrhoids may be treated by follow- ing: Management r Ligation: The pile is pulled down through a procto- r Children are often managed conservatively, it is rare scope and a rubber band is applied to the pedicle. Con- pile is treated at a time with intervals of 3 weeks be- stipation should be avoided by dietary intervention. Post-operative pain is common especially on defeca- r Complete prolapse requires a pelvic repair procedure tion. Complications include haemorrhage and rarely including mobilisation of the rectum, xation to the anal stenosis, abscesses, ssures or stulas. Patients often report the onset of symp- toms when passing hard, constipated stool. Aetiology 2 Secondary ssure-in-ano are seen in inammatory Partial prolapse is more likely when there is a shallow bowel disease when they are often multiple and may sacral curve such that the rectum is directly above the occur anywhere around the anal circumference. Complete prolapse results from poor pelvic oor muscle tone, which may follow gynaecological surgery. Pathophysiology 10% of children with cystic brosis present with rectal Fissures are longitudinal tears, which develop into canoe prolapse. Swelling and inammation at the anal verge Pathophysiology may form a sentinel pile (haemorrhoid). Initially prolapse only occurs on defecation with sponta- neous return; however, with time the prolapse becomes Clinical features more permanent. Thesentinelpilemaybevis- Clinical features ible on examination, rectal examination is very painful There is often discomfort on passing stool possibly with and often impossible. Examination under anaesthesia bleeding and mucus due to inammation of the pro- (proctoscopy/sigmoidoscopy) allows diagnosis. Patients often present with an abscess, the incision of which completes the stula. Patients with a completed Management stula present with a discharging sinus that causes lo- Primaryanalssuresmayhealspontaneously.