By V. Ramirez. North Carolina Agricultural and Technical State University. 2019.
Patients with advanced liver disease buy generic forzest 20mg on-line, including cirrhosis discount 20mg forzest, have a high prevalence of protein- calorie malnutrition which adversely affects the underlying liver disease and results in poor clinical outcome generic forzest 20mg overnight delivery. Restricting protein intake in patients with portosystemic encephalopathy has not been shown to be beneficial in several randomized trials and is therefore not generally recommended buy forzest 20mg visa. Vegetable protein may be less ammoniagenic that meat, postulated to be due to a number of factors. Factors cited include a vegetarian diet increased dietary fiber in the vegetarian diet leading to increased elimination of nitrogen in the gut and increased levels of plasma arginine and citrulline leading to increased ammonia removal via the Krebs-Henseleit cycle. If confirmatory tests are not available and if there are strong clinical grounds for suspecting a deficiency state, appropriate replacement therapy should be initiated. Table 7 lists a number of hereditary liver diseases for which appropriate therapy includes specific dietary interventions. Diet therapy for hereditary liver diseases Disorder Dietary intervention o Tyrosinemia Low-phenylalanine diet o Hereditary fructose Low-fructose, low-sucrose diet intolerance o Galactosemia Galactose-free diet o Glycogen storage Continuous glucose feeding disease o Cerebrotendinous Deoxycholic acid supplementation First Principles of Gastroenterology and Hepatology A. Introduction The decision to intervene nutritionally is based on a number of disparate factors, including the current nutritional status of the patient (well-nourished versus malnourished), the duration of the time the patient will be expected to be unable to eat, the underlying medical condition and the prognosis for recovery. Once the decision to intervene has been made, the next decision is the method of intervention: oral, enteral or parenteral. It is thus important to detect malnourished patients and improve their nutritional status by providing nutritional support. There are several methods to assess nutritional status; the best method would be the one that predicts clinical outcome. In particular, the best method would predict nutrition-associated complications that increase the risk of morbidity and mortality in the absence of nutritional intervention. However, since it is often difficult to dissect out the effects of malnutrition from the effects of disease, nutritional assessment cannot rely on a single parameter or simple model. Furthermore, disease can affect several parameters used for nutritional assessment independently of nutritional status. Body composition Several methods can be used to measure various body compartments and most are used within a research protocol. The ones most frequently used clinically are based on a two compartment model: body fat and lean body mass (muscle, bones). This method is mostly used in population studies and is less reliable in the individual patient because of inter- and intra-observer variability and the effect of hydration status, age and physical activity. Studies have shown that unintentional weight loss of > 10% is a good predictor of adverse clinical outcome. Normalized for height, the 24-hour creatinine excretion is an index of muscle mass and can be compared to published tables. However, in a hospital environment, this is not used because of frequent underlying renal disease and use of diuretics. Plasma proteins Albumin is one of the most studied proteins and several studies have demonstrated that low serum albumin concentration correlates with an increased incidence of medical complications 1 and mortality. Therefore, hospitalized patients may have lower albumin levels for several reasons: inflammatory disorders First Principles of Gastroenterology and Hepatology A. On the other hand, protein-calorie malnutrition causes a decrease in the rate of albumin synthesis, but a short-term reduction in albumin synthesis will have little impact because of albumins low turnover rate (half-life: 20 days) and large pool size. Even during chronic malnutrition, plasma albumin concentration is often maintained because of compensatory decrease in albumin degradation and transfer of extravascular albumin to the intravascular compartment. Another plasma protein, prealbumin, is more responsive to nutritional changes because its turnover rate is rapid with a half-life of 23 days. However, it is also influenced by underlying diseases such as inflammation, infections, renal and liver failure. Immune competence As measured by delayed cutaneous hypersensitivity is affected by severe malnutrition. However, other diseases and drugs may also influence the measurements making it a poor predictor of malnutrition in sick patients. A prognostic nutritional index depending largely on albumin and transferrin was shown to provide a quantitative estimate of postoperative complication (Blackburn, 1977). It categorizes the patients as being well nourished (A) or as having moderate or suspected malnutrition (B) or severe malnutrition (C) (Table 10). It is important to recognize the multiple facets of malnutrition to detect the patient at risk of nutrition-related complications. Subjective global assessment combined with selective objective parameters defined above is the best clinical way to detect the patients at risk. The nitrogen is excreted predominantly as urea in the urine, but stool and skin losses account for about 23 g daily. In the steady state, ingestion of more nitrogen will merely result in excretion of more nitrogen in the urine, with the excess protein oxidized in the liver and used as an expensive energy source. In growing children or in malnourished adults, the nutritional goal is a positive nitrogen balance, meaning that body tissue is being formed in excess of what is being broken down (i. It is less clear that patients with conditions associated with protein loss, such as nephrotic syndrome and protein-losing enteropathy, benefit from extra protein intake. If energy requirements are met or exceeded, studies have shown that well-nourished adults can maintain nitrogen balance when given as little as 0. In order to allow for biologic variability, the standard recommendation for protein intake is 0. It is important that the protein supplied be of high quality; it should include all essential amino acids and a balanced mix of nonessential amino acids. Malnourished, septic, injured or burned patients will require more protein, in the order of 1. It is not clear that patients with conditions associated with protein loss, such as protein-losing enteropathy, benefit from extra protein intake. Indeed, patients with nephrotic syndrome may even benefit from protein restriction, though this is not firmly established. The Harris-Benedict equation may be less accurate in malnourished or obese individuals. Malnourished patients exhibit resting energy requirements about 10% to 20% below predicted. The resting energy requirements of obese patients will also be below predicted since adipose tissue is less metabolically active than other tissues. In overweight patients, it has been proposed that an adjusted weight be used in the Harris-Benedict equation based on actual and ideal body weight, using the following formula: Adjusted weight = [(actual body wt - ideal wt) 0. Joer (also called Mifflin) formula may be a better choice for calculating resting energy expenditure in the obese patient. The population of subjects upon which the formula is based needs to be understood. Types of Nutritional Intervention The options for refeeding include oral refeeding, tube feeding and total parenteral nutrition. An assessment by a dietitian regarding current food intake and food preferences is essential. It may well be possible by determining food preferences to provide a well-balanced, nutritionally First Principles of Gastroenterology and Hepatology A. In addition, supplements of high-calorie, high-protein foods such as milkshakes or commercially prepared liquid formula diets may allow for adequate intake. If the patient will not or cannot eat, however, nutritional intervention may be indicated. Examples of patients who will not eat include those with anorexia due to tumor or chemotherapy, and those with anorexia nervosa. Such patients generally have a normal or near-normal nonobstructed bowel, and can be fed enterally. Patients who cannot eat because of severe gastrointestinal illness include those with bowel obstruction or ileus. If nutritional intervention is required in these patients, parenteral (intravenous) nutrition will be necessary. These tubes can be placed through the pylorus to feed into the jejunum with only local anesthetic and mild sedation. Despite convincing evidence of efficacy of post-pyloric placement of tubes in reducing pulmonary aspiration, the tube is usually placed in the jejunum if aspiration is a concern.
Several contractile patterns exist within the circular and longitudinal muscle of the colon buy forzest 20 mg online. Ring contractions are due to circular muscle contraction generic 20mg forzest fast delivery, and these are either tonic or rhythmic discount forzest 20mg with amex. Tonic contractions are sustained over hours buy 20 mg forzest with mastercard, form the haustral markings evident on barium x-rays and play a role in mixing. Regular contractions are nonocclusive, occur over a few seconds, and migrate cephalad (right colon) and caudad (left colon). Intermittent ring contractions occur every few hours, occlude the lumen, and migrate caudad. They result in the mass movement of stool, particularly in the sigmoid colon and rectum. Contractions of the longitudinal muscle produce bulging of the colonic wall between the taeniae coli, but the physiological importance of this action remains poorly understood. The origin of the contractions of the longitudinal muscle is not completely understood, but it depends upon the slow wave frequency of smooth muscle. Action potentials occur on the peaks of these membrane oscillations and hence they control the frequency of contractions. The nature of the contractile patterns within the colon depends upon the fed state. This is best exemplified during eating when the gastrocolic reflex is activated. Food in the duodenum, particularly fatty foods, evokes reflex intermittment rhythmic contractions within the colon, and corresponding mass movement of stool. This action, which is mediated by neural and humoral mechanisms, accounts for the observation by many individuals that eating stimulates the urge to defecate. These bacteria digest a number of undigested food products normally found in the effluent delivered to the colon, such as the complex sugars contained in dietary fiber. They are passively and actively transported into the colonocytes where they become an First Principles of Gastroenterology and Hepatology A. Examination of this area devoid of luminal content typically reveals signs of inflammation, termed diversion colitis. Fermentation of sugars by colonic bacteria is also an important source of colonic gases such as hydrogen, methane and carbon dioxide. These gases, particularly methane, largely account for the tendency of some stools to float in the toilet. Nitrogen gas, which diffuses into the colon from the plasma, is the predominant gas. However, the ingestion of large quantities of undigested complex sugars such as found in beans of the maldigestion of simple sugars such as lactose can result in large increases in production of colonic gas. View of the normal submucosal vessels visible through the healthy transparent mucosa overlying the vessels. Normal ileocecal valve seen in the bottom left of the image, looking down at the cecal pole. When bile salts or long-chain fatty acids are malabsorbed in sufficient quantities, their digestion by colonic bacteria generates potent secretagogues. Shaffer 318 Bile salt malabsorption typically occurs following resection of less than 100cm of the terminal ileum, usually for management of Crohn disease. When the resection involves segments greater than 100 cm of ileum, the liver cannot sufficiently increase the synthesis of bile acids from cholesterol. A deficiency of bile acids enters the duodenum and if the concentration of bile acids is below the critical micellar concentration, bile salf micelles do not form, lipids are malabsorbed, and fatty" Diarrhea (known as steatorrhea) develops. The mechanisms by which multiple metabolites of bile salts and hydroxylated metabolites of long-chain fatty acids act as secretagogues provide an example of how multiple regulatory systems can interact to control colonic function. These mechanisms include disruption of mucosal permeability, stimulation of chloride and water secretion by activating enteric secretomotor neurons, enhancement of the paracrine actions of prostaglandins by increasing production, and direct effects on the enterocyte that increase intracelluar calcium. Non-pathogenic bacteria also signal to mucosal cells and can evoke cytokine signaling from colonocytes to effector cells (e. Some species of bacteria stimulate pro-inflammatory responses whereas others are anti-inflammatory. These signaling pathways are enhanced when the tight junctions between epithelial cells are altered. This increased leakiness or permeability of the colon allows bacteria greater access to the epithelium and immune cells in the lamina propria. This bacterial-epithelial signaling underlies the rationale for the use of probiotics where healthy or anti-inflammatory bacteria are ingested (e. Rowe A variety of modalities can be used to image the colon, depending on the persons clinical presentation. Traditionally, patients presenting acutely with abdominal pain would have conventional radiographs (views of the abdomen) before any further cross sectional imaging was performed. Conventional Radiography/Plain Films Conventional radiography, or the abdominal series, includes a supine, erect or decubitus view and an image that includes the lung bases. This allows evaluation of the intestinal gas pattern and the presence of free air. A single supine view of the abdomen or flat plate is used to evaluate for the presence of excessive amounts of stool. While a radiograph can be useful in the evaluation of the potential presence and level of obstruction, adynamic ileus, or pneumatosis intestinalis. Barium Imaging Imaging of the colon has been traditionally achieved by performing a barium th enema. A bowel preparation will include a low residue diet for 1-2 days prior to the examination and a cathartic preparation. A tube is placed in the rectum and the colon is distended with a large volume of low density barium. Multiple spot images are obtained of the various colonic segments to visualize the entire colon free from th overlapping loops. Later in the 20 century, the double contrast barium enema technique was developed. It involves the introduction of a small volume of high density barium through a small rectal tube, followed by insufflation of a large volume of room air, allowing good colonic distention and mucosal coating of the barium. Some institutions routinely use pharmacologic agents such as glucagons, or the anticholinergic buscopan, to induce colonic hypotonia. However, a technically adequate study First Principles of Gastroenterology and Hepatology A. The goal of the double contrast barium enema is to evaluate each portion of the colon in air contrast and with the barium pool. A series of spot images during fluoroscopic evaluation and subsequent standard series of abdominal radiographs performed by the technologist comprise a complete examination. A single contrast enema may be adequate for the detection of larger colonic lesions, obstructing lesions, as well as the depiction of diverticular disease. A double contrast study is preferred for the assessment of mucosal abnormalities as well as the detection of small polypoid lesions. In particular, the findings of inflammatory bowel disease involving the colon are well depicted on a double contrast study. Single contrast study demonstrating a large cecal mass which proved to be an adenocarcinoma. Double contrast barium enema showing multiple diverticula as well as a subcentimeter polyp (white arrow) which proved to be a tubular adenoma. In an urgent or emergent setting, the oral bowel preparation may be shortened or eliminated, positive contrast may be administered via the rectum. Unless there is a contraindication, intravenous contrast is recommended to evaluate the solid abdominal viscera, as well as to enhance the visualization of blood vessels and the bowel wall. Shaffer 322 demonstrates diffuse concentric wall thickening of the splenic flexure in a patient with ischemic colitis. Shows markedly irregular bowel wall thickening identified by the black arrows involving the cecum, ileocecal valve, as well as the terminal ileum, in keeping with a primary adenocarcinoma. The development of new technologies has highlighted the limitations of barium studies. While a barium study can evaluate the mucosa, it is unable to evaluate the lumen, bowel wall, and the extracolonic structures.
The authors note that some randomisation information was inadequate and bias from unblinded assessors cannot be ruled out purchase forzest 20mg on-line. There is insufficient evidence to make a recommendation about specific diets for improving glycaemic control discount forzest 20 mg free shipping. There is no evidence on patient satisfaction buy forzest 20mg on-line, quality of life or hospital admission rates with reference to particular diets buy forzest 20mg online. Insufficient evidence exists to make a comparison of hyper and hypoglycaemia rates between different diets. High dropout rates and poor compliance with carbohydrate- and energy-restricted diets demonstrated in trial settings would suggest that such diets are not widely applicable or acceptable to patients. In patients who adhere to a low carbohydrate diet a reduction in insulin and/or oral hypoglycaemic agent dose is likely to be necessary. B People with type 2 diabetes can be given dietary choices for achieving weight loss that may also improve glycaemic control. Options include simple caloric restriction, reducing fat intake, consumption of carbohydrates with low rather than high glycaemic index, and restricting the total amount of dietary carbohydrate (a minimum of 50 g per day appears safe for up to six months). Supplementation with 500 mg tocopherol (vitamin E) per day for six weeks in patients with well + 122 1 controlled type 2 diabetes caused increased heart rate and blood pressure. B Vitamin E supplementation 500 mg per day is not recommended in people with type 2 diabetes. Studies either show a beneficial effect or no effect, but there is no evidence of a harmful effect. One large trial from Finland demonstrated a short term reduction in the development of type 2 1+ diabetes in high risk subjects (overweight and impaired glucose tolerance) by encouraging lifestyle change, including diet and exercise advice. However, it is not always possible to identify if the benefit is wholly attributable to the intervention, or dependent on how or where the care is delivered. Intensive therapy or contact in patients with diabetes shows clinically beneficial effects on weight and glycaemic control during the period of intervention. Pre-packaged meal programmes show significant clinical benefit in terms of weight, blood pressure, glycaemic control and lipids during the study period but are impractical outside the trial setting. For women 4 consuming more than 24 g/day average alcohol increases their risk of developing liver disease and breast cancer. B People with diabetes can take alcohol in moderation as part of a healthy lifestyle but should aim to keep within the target consumption recommended for people without diabetes. Both acute alcohol consumption and acute hypoglycaemia adversely affect cognitive function and their effects 3 are additive. The checklist was designed by members of the guideline development group based on their experience and their understanding of the evidence base. Healthcare professionals should: explain the health risks associated with smoking and encourage patients to quit. People with diabetes should: speak to their family members about their diabetes to encourage diabetes awareness to help prevent development of type 2 diabetes in their first degree relatives by lifestyle modification. Furthermore, researchers use different terms to describe the foci of their studies yet measure the same outcome. These different ways of describing diabetes outcomes are included in the literature. Similarly, researchers use a wide variety of psychological terms to describe human behaviour and the nature of psychological interventions even when detailing broadly the same things. For example, some investigators of children with type 1 diabetes who are finding life and control difficult report childhood behavioural problems, some detail parenting problems, and others highlight family dysfunction. These descriptions commonly reflect the theoretical position of researchers rather than substantial differences in reported behaviour. Research on the efficacy of psychological interventions in diabetes is in its infancy. Most outcomes have been reported over relatively short periods considering diabetes is a lifelong condition and conclusions about using these interventions on ethnic minorities may be problematic because of their lack of representation in the research. In most intervention studies reviewed, patients are recruited into trials from diabetes clinics, are not newly diagnosed and do not have significant comorbid medical problems. Some trials recruit only patients with poorly controlled diabetes,154,155 whereas others have wider inclusion criteria. Whether the burden of managing diabetes causes psychological and social problems or vice versa, however, is unclear. The following factors are associated with poorer control in children and young people with type 1 diabetes:157 aspects of family functioning including conflict; lack of cohesiveness and lack of openness 4 depression anxiety maternal distress eating disorders behavioural problems. The following factors are associated with poorer control in adults with type 1 diabetes:158 clinical depression and subclinical levels of mood disruption 4 anxiety eating disorders. There are some screening tools which have been validated and are widely used with the general population and with those who have medical conditions. The performance of some self report screening tools has been assessed in people with type 1 and type 2 diabetes. It is worth noting that some symptoms of diabetes overlap with symptoms of common psychological problems. On one hand this can make identification of psychological problems more difficult than is usually the case, and on the other hand this can lead to false positives when using screening tools designed for use with the general population. In the absence of this evidence there are screening tools which have been validated and are widely used with the general population and with those who have medical conditions. It should be noted that this effect size is smaller than is represented in the general literature on treatments for distress, however most patients in the studies included in the systematic review were not distressed at baseline. A further systematic review of family interventions (including educational and psychological 1++ components) on children and adolescents reported a slightly larger improvement in HbA1c (0. That is, studies did not target people with diabetes who were experiencing clinical levels of psychological problems and therefore significant reductions in this area were unlikely. However it is difficult to synthesise the evidence as behavioural outcomes are often not clearly defined or comparable across studies. As well as inevitably limiting guidance in this area, the lack of empirical evidence also means that it is unclear whether or not people with diabetes need to receive treatments that are dissimilar to those received by people without diabetes. No evidence was identified on how to treat emotional and behavioural problems in children and young people with diabetes. However, cognitive behavioural therapy may be less effective in patients with complications. Healthcare professionals should: on those occasions where significant psychosocial problems are identified, explain the link between these and poorer diabetes control. They should advise patients where best to obtain further help, and facilitate this if appropriate. People with diabetes (or parents/guardians) should: try to speak to their general practitioner or diabetes team if they feel they (or their children) have significant psychosocial issues such as those detailed in this section. The remainder of the section includes updated material which is relevant to the management of children, adolescents and adults with type 1 diabetes. In 2009 the Scottish Diabetes Survey indicated there were 27,363 patients with type 1 diabetes in Scotland. Non-type 1 diabetes is being recognised with increasing frequency, particularly emerging molecular forms of diabetes, diabetes secondary to pancreatic disease and a rise in type 2 diabetes and other insulin-resistance syndromes in the young. While there are known antibody markers of prediction in high risk subjects, there is no evidence for effective methods of prevention of type 1 diabetes. The evidence on the role of the intensification of therapy in the attempt to achieve as rapid as possible normoglycaemia is inconsistent. In particular, there is no evidence of a sustained effect of any specific insulin therapy on glycaemic control during the first few months after diagnosis. Therefore, no recommendation can be given for the most appropriate insulin therapy at diagnosis. Thus, there is no agreed single target for 1+ glycaemic control in these patients. The guideline development group concluded that identifying a single target for all people with type 1 diabetes was not appropriate, but that patients should discuss this with their healthcare professionals, in the knowledge that the overall aim is to achieve the lowest HbA1c as possible, which does not interfere with the patients quality of life. B Intensive insulin therapy should be delivered as part of a comprehensive support package.
Additionofadailysteroidtabletinlowestdose performed by pricking standard allergens into the providing adequate control forzest 20 mg; maintain high dose skin can help the patient recognise and avoid envi- inhaled steroid forzest 20mg low price; consider other treatments to min- ronmental precipitants buy cheap forzest 20mg on-line. Bronchial reactivity may be imise use of oral steroids generic forzest 20mg overnight delivery; refer for specialist care. Management of chronic asthma Acute severe asthma The patient should be asked about precipitating fac- Acute severe asthma is a life-threatening condition. It Sedation may depress respiration further and is is this lack of recognition of severity plus inadequate contraindicated. The term status asthmaticus is sometimes used taline) plus ipratropium by oxygen-driven nebuliser to describe severe asthma attacks that have not re- or intravenous infusion if inhaled therapy cannot be sponded to conventional therapy. Continue oral prednisolone 4050 mg daily for at least ve Clinical days or until recovery. Clinical presentation Inabilitytospeakordifculty inmaintainingspeechis one criterion of severity. Hypoxaemia is usually then Respiratory failure can be dened as a reduction in present. Much more commonly, both arterial gas hypotension signify a very severe attack and vigorous levels are abnormal. Investigation Acute Arterial blood gases provide the most useful guide to the severity of the attack and to the success of treat-. It should apnoea, drug overdosage, stroke) also be performed if there is a failure to respond to. Thesepatientsareparticularlylikelytodevelop patients in whom the diagnosis is suspected. Oxygen is given continuously until the acute situation (including infection and heart failure) has recovered. For chronic respira- tory failure controlled oxygen can be given continu- Acute on chronic respiratory ously at homewithimprovement in symptomsand an increase in life expectancy (Trials Box 11. Clinical presentation Indications for respiratory support and mechanical ventilation. Haemophilus inuen- zae, Legionella species, Chlamydia psittaci and Staph- ylococcus aureus account for most of the remainder. Thisrare condition occursfollowingexposure to aller- gens such as certain foods, e. Clinical features Investigations range from mild with ushing of the face, pruritus Investigationsareperformedtoestablishthediagnosis andblotchywheals,toseverewithasthma,respiratory and assess severity. Blood count white cell count>15109/l suggests challenge is given if there is hypotension. Hydrocor- bacterial infection; white cell count>20109/l or tisone takes several hours to act. Haemoglobin rst injection of adrenaline (epinephrine)) in a dose of 200mg slowly intravenously or intramuscularly, for haemolysis. Gram staining and culture of sputum but cough is should be identied and avoided. Most patients will unproductive in one-third of patients, and negative wish to carry self-adminstration preassembled pens results are common, particularly if antibiotics have containing adrenaline (epinephrine) for intramuscu- been given. Pleural uid, if present, should be aspirated for by C1 esterase deciency (autosomal dominant). It responds to danazol prophylaxis Management and fresh frozen plasma (or if available plasma de- rived C1 inhibitor) to correct the deciency during. In uncomplicated pneu- Pneumonia monia,treatmentisusuallystartedwithoralamoxicillin or a macrolide (erythromycin or clarithromycin). In Community-acquired pneumonia affects approxi- severe pneumonia intravenous therapy is given, often mately 510/1000 adults per year. One in 1000 re- usingacombinationofamacrolide(erythromycin)and quires hospitalisation, and mortality in these patients a second- or third-generation cephalosporin (cefurox- is around 10%. The choice of antibiotics should takeaccountoflocalguidelines,whichwilltakeaccount Clinical presentation of other factors, including the incidence of Clostridium difcile enteritis. The likely causa- Pneumococcal pneumonia is the most common bacte- tive agent cannot be predicted from clinical ndings. Hepatitis, encephalitis, renal failure and hae- and those with pre-existing lung disease. Treatment is with tetracycline or presents acutely with fever, pleuritic pain and rust- erythromycin. It causes both lobar and broncho- Viral pneumonia in children is commonly due to pneumonia. A polysaccharide pneu- is a respiratory virus which produces syncytium for- mococcal vaccine is available for those at high risk. Infection may be shouldbegivenatleast2weeksbeforesplenectomyand indistinguishable from acute bacterial bronchitis or before chemotherapy. It may complicate Acute viral pneumonia in adults is less common inuenzal pneumonia, and this makes it relatively butoccursduringepidemicsofinuenza. It also occurs ache and myalgia are followed after a few days by dry in patients with underlying disease, which prevents a cough and chest pain. The viruses sequent bronchiectasis are relatively common ofmeasles,chickenpoxandherpeszostermaydirectly complications. The diagnosis is conrmed by a rise in Legionnaires disease was rst described in a group specic antibody titre. The caus- Aspiration pneumonia comes in two main varie- ative Gram-negative bacillus ourishes in the cooling ties, differentiated from each other by the type of uid waters of air conditioners and may colonise hot-water aspirated and the circumstances in which it occurs. It begins as an inuenza-like Aspiration of gastric contents may produce a severe illness with fever, malaise and myalgia, and proceeds chemical pneumonitis with considerable pulmonary with cough (little sputum), dyspnoea and sometimes oedema and bronchospasm (Mendelson syndrome). The acute respiratory distress and shock can be very Diarrhoeaandvomitingarecommonandrenalfailure rapidlyfatalandverydifculttotreat. Examination shows consolidation that in states of reduced consciousness such as general usually affects both lung bases. X-ray changes may anaesthesia, drunks and when gastric lavage (for drug persist for more than 2 months after the acute illness. Erythromycin or ciprooxacin are the antibiotics of Aspiration of bacteria from the oropharynx may choice, but the mortality remains high. The bacteria,apartfrom Bacteroides, are near- moniae or psittacosis) should be suspected in all ly all penicillin-sensitive and amoxicillin (or ampicil- patients who develop pneumonia that does not re- lin) with metronidazole are the antibiotics of choice spond to standard antibiotics. The clinical picture resembles bacterial of the cardia, and in patients with diverticula or pha- pneumonia, although cough and sputum are absent ryngeal pouch. Recurrent bacterial pneumonia in the absence of Respiratory symptoms and signs and X-ray chronic bronchitis arouses suspicion of: changes (patchy consolidation with small effusions). It is transmitted in the excrement of infected Respiratory disease 117 Opportunistic infection of the lungs occurs in patients. Twice- sputum is foul and purulent and there is a high dailyposturaldrainagewillhelpemptydilatedairways polymorph cell count. Antibiotics, as for chronic bronchitis, are Investigation given for acute infections and exacerbations. Treat- Sputum is sent for Gram stain and culture, and blood ment is unnecessary in the absence of symptoms. Chest X-ray shows round lesions which Surgery is rarely indicated unless there is uncon- usually have a uid level, and serial X-rays monitor trolled bleeding because the disease is seldom limited progress. Patients with severe copytoexcludeobstructionandtoobtainabiopsyand disease may develop respiratory failure. Treatment Pneumothorax Antibiotic therapy is given according to sensitivities Aetiology and continued until healing is complete. In resistant cases, repeat- Spontaneous pneumothorax ed aspiration, antibiotic instillation and even surgical This is the most common type and usually occurs in excision may be required. Dyspnoea rapidly increases in tension Bronchiectasis pneumothorax and the patient becomes cyanosed. The classical signs are diminished movement on the Bronchiectasis means dilatation of the airways. It only affected side with deviation of the trachea to the other becomes of clinical signicance when infection and/ side. There is hyperresonance to percussion and re- or haemoptysis occurs within these dilatated airways. Pneumothoraces are best diagnosed by seeing a lung edge on X-ray; it is Aetiology clearest on an expiratory lm (Fig.