Blinding (performance bias and detection Low risk Outcome assessments unblinded but un- bias) likely to inuence outcomes All outcomes - outcome assessors? Incomplete outcome data (attrition bias) Low risk No withdrawals noted in the trial buy zoloft 50mg with amex anxiety coach. Low risk Participants were given paracetamol tablets in addition to study medication or placebo purchase genuine zoloft line male depression symptoms uk. Period: one plaster per day at maximum pain site for four to 12 hours for three weeks Participants One hundred and fty-four participants were randomly allocated to a placebo plaster group (N = 77) and a capsicum plaster group (N = 77) purchase 25 mg zoloft amex definition of depression wikipedia. A total 22 participants were excluded due to premature discontinuation of the treatment (N = 19) failure to meet the inclusion criteria (N = 2) or unauthorized concurrent treatment (N = 1) purchase zoloft 100mg with visa depression treatment. Matched placebo plaster Outcomes Primary outcome measure: Arhus Low Back Rating Scale. Secondary outcome measures: global assessment of efcacy and tolerance by physician and patient Notes Total quality score: 6/12 Adverse events: a total of 24 adverse events were reported (C = 15; P = 9). The C group had ve cases of severe adverse events (inammatory contact eczema, urticaria, minute haemorrhagic spots, and vesiculation or dermatitis) and the P group had two such cases (vesiculation or allergic dermatosis). Blinding (performance bias and detection Low risk Study medication and placebo were identi- bias) cal in appearance. Incomplete outcome data (attrition bias) Low risk Out of 154 participants, 22 were excluded All outcomes - drop-outs? Krivoy 2001 Methods Thirty-ve participants randomized to two groups and a further 16 participants acted as controls. Period: four weeks Participants Fifty-one participants with 19 in the Salix alba group, 16 in a placebo group, and 16 in an acetylsalicylate group. Blinding (performance bias and detection Low risk Participants were blinded from treatment bias) groupallocation,andstudymedicationand All outcomes - patients? Krivoy 2001 (Continued) Blinding (performance bias and detection Low risk Outcome assessors were unblinded. How- bias) ever knowing the outcome of interest, All outcomes - outcome assessors? Low risk The groups were similar in baseline mea- suresexcept gender; there were more female participants in the placebo group (P = 0. Low risk Participantswere disallowed the use of anti- inammatory drugs within the trial pe- riod. Period: seven days Participants One hundred and sixty-one participants were randomly allocated to either group. The trial medications were not available to the providersinthe trial country at the time and all stakeholders assumed both medica- tions held active ingredients Blinding (performance bias and detection Low risk This was a double-blinded trial. While bias) there were reservations with the blinding All outcomes - outcome assessors? Low risk Group comparison was similar with no sig- nicant differences noted between groups at baseline Co-interventions avoided or similar? Low risk Anti-inammatory drugs were disallowed during the trial phase with paracetamol used as an emergency medication Compliance acceptable? Rapid improvement and three appli- cations per day may have inuenced non- compliance. Period: three weeks Participants Sixty-one patients were allocated to acupressure with lavender oil (N = 32) or conven- tional treatment (N = 29). Risk of bias Bias Authors judgement Support for judgement Random sequence generation (selection Low risk Participants were allocated by the research bias) team consulting a random numbers table Allocation concealment (selection bias) High risk Patients and clinicians were aware of group allocation. Blinding (performance bias and detection High risk Intervention treatment and control treat- bias) ment were dissimilar with no blinding All outcomes - patients? Blinding (performance bias and detection High risk Providers were aware and involved in the bias) treatment allocation process All outcomes - providers? Blinding (performance bias and detection Unclear risk Unclear from text bias) All outcomes - outcome assessors? Incomplete outcome data (attrition bias) Low risk Of the 61 original participants, 10 partici- All outcomes - drop-outs? High risk No discussion or controlling for medi- cation or additional treatment modalities noted Compliance acceptable? High risk There was no description of the control group s therapy beyond being a conven- tional therapy Selective Reporting Low risk All pre-specied outcomes were reported. Lee 2012 Conference abstract only, unknown participants type, unknown if a herbal medicine Liu 2013 Abstract or full text not available. Pabst 2013 Mixed low back and upper back pain with no subgroup analyses Pach 2011 Herbal medicine given by injection Reme 2011 Not a herbal medicine. Previous search strategies August 2013 Embase The animal study lter was updated from 2010 1. January 2011 Medline Back terms and herbal medicine terms were updated from 2009 1. Unclear reected the fact that there was insufcient information to determine whether this criterion was fullled or not. There is a high risk of bias if participants or investigators enrolling participants could possibly foresee assignments and thus introduce selection bias, such as allocation based on: using an open random allocation schedule (e. Blinding of participants Performance bias due to knowledge of the allocated interventions by participants during the study There is a low risk of performance bias if blinding of participants was ensured and it was unlikely that the blinding could have been broken; or if there was no blinding or incomplete blinding, but the review authors judge that the outcome is not likely to be inuenced by lack of blinding. Blinding of personnel or care providers (performance bias) Performance bias due to knowledge of the allocated interventions by personnel or care providers during the study There is a low risk of performance bias if blinding of personnel was ensured and it was unlikely that the blinding could have been broken; or if there was no blinding or incomplete blinding, but the review authors judge that the outcome is not likely to be inuenced by lack of blinding. Blinding of outcome assessors (detection bias) Detection bias due to knowledge of the allocated interventions by outcome assessors There is low risk of detection bias if the blinding of the outcome assessment was ensured and it was unlikely that the blinding could have been broken; or if there was no blinding or incomplete blinding, but the review authors judge that the outcome is not likely to be inuenced by lack of blinding, or: for patient-reported outcomes in which the patient was the outcome assessor (e. The percentage of withdrawals and drop-outs should not exceed 20% for short-term follow-up and 30% for long-term follow-up and should not lead to substantial bias (these percentages are commonly used but arbitrary, not supported by literature) (van Tulder 2003). Selective reporting (reporting bias) Reporting bias due to selective outcome reporting There is low risk of reporting bias if the study protocol is available and all of the study s pre-specied (primary and secondary) outcomes that are of interest in the review have been reported in the pre-specied way, or if the study protocol is not available but it is clear that the published reports include all expected outcomes, including those that were pre-specied (convincing text of this nature may be uncommon). There is a high risk of reporting bias if not all of the study s pre-specied primary outcomes have been reported; one or more primary outcomes is reported using measurements, analysis methods or subsets of the data (e. Group similarity at baseline (selection bias) Bias due to dissimilarity at baseline for the most important prognostic indicators. Co-interventions (performance bias) Bias because co-interventions were different across groups There is low risk of bias if there were no co-interventions or they were similar between the index and control groups (van Tulder 2003). Antibiotics are one class of antimicrobials, a larger group which also includes anti-viral, anti-fungal, and anti-parasitic drugs. The first antibiotic was discovered by Alexander Fleming in 1928 in a significant breakthrough for medical science. Antibiotics are among the most frequently prescribed medications in modern medicine. Side effects of antibiotics Antibiotics can literally save lives and are effective in treating illnesses caused by bacterial infections. Many of these side effects are not dangerous, although they can make life miserable while the drug is being taken. Allergic reactions cause swelling of the face, itching and a skin rash and, in severe cases, breathing difficulties. The type of antibiotics you take depends on the type of infection you have and what kind of antibiotics are known to be effective. The main classes of antibiotics: Aminoglycosides Cephalosporins Fluoroquinolones Macrolides Penicillins Tetracyclines Macrolides There are a couple of new relatives of erythromycin (azithromycin and clarithromycin) that work the same way, but kill more bugs and have slightly fewer side effects. Macrolide antibiotics are used to treat respiratory tract infections, genital, gastrointestinal tract, soft tissue infections caused by susceptible strains of specific bacteria. Macrolides bind with ribosomes from susceptible bacteria to prevent protein production. This action is mainly bacteriostatic, but can also be bactericidal in high concentrations. Macrolides cause very little allergy problems compared to the penicillins and cephalosporins, the biggest concern with these medicines is that they can irritate the stomach. The most commonly-prescribed macrolides: erythromycin clarithromycin azithromycin roxithromycin Aminoglycosides Aminoglycoside antibiotics are used to treat infections caused by gram-negative bacteria. Aminoglycosides may be used along with penicillins or cephalosporins to give a two-pronged attack on the bacteria. When injected, their side effects include possible damage to the ears and to the kidneys. This can be minimized by checking the amount of the drug in the blood and adjusting the dose so that there is enough drug to kill bacteria but not too much of it. The most commonly-prescribed aminoglycosides: amikacin gentamicin kanamycin neomycin streptomycin tobramycin Cephalosporins Cephalosporins are grouped into "generations" by their antimicrobial properties. Cephalosporins are categorized chronically, and are therefore divided into first, second, and third generations. Currently, three generations of cephalosporins are recognized and a fourth has been proposed. Each newer generation of cephalosporins has greater gram negative antimicrobial properties than the preceding generation. The later-generation cephalosporins have greater effect against resistant bacteria. Cephalosporins have a bacteriocidal effect by inhibiting the synthesis of the bacteria cell wall. The most commonly-prescribed cephalosporins: First generation o cephazolin o cefadroxil o cephalexin o cephradine Second generation o cefaclor o cefuroxime o cefprozil o loracarbef Third generation o cefotaxime o cefixime o cefpodoxime o ceftazidime o cefdinir Fourth generation o cefepime o cefpirome Fluoroquinolones Fluoroquinolones are known as broad-spectrum antibiotics, meaning they are effective against many bacteria. Common side effects of fluoroquinolones include mainly the digestive system: mild stomach pain or upset, nausea, vomiting, and diarrhea. The most commonly-prescribed fluoroquinolones: ciprofloxacin gatifloxacin gemifloxacin levofloxacin moxifloxacin norfloxacin ofloxacin trovafloxacin Penicillins Penicillin was the first antibiotic discovered by Alexander Fleming in 1929. Penicillins are sometimes combined with other ingredients called beta-lactamase inhibitors, which protect the penicillin from bacterial enzymes that may destroy it before it can do its work. People who have been allergic to cephalosporins are likely to be allergic to penicillins.

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In females order zoloft 50 mg depression after test cycle, vaginitis is another syndrome Urge incontinence: unlike stress incontinence order generic zoloft canada depression and definition, be- which commonly overlaps purchase zoloft without a prescription anxiety service dog. Surgery (clam cystoplasty to increase the size of the blad- Age der using bowel) is rarely successful 50mg zoloft free shipping depression loneliness. In patients with cognitive awareness of bladder Sex lling and the ability to independently toilet, bladder F > M training is used to learn methods of deliberately sup- pressing the urge to pass urine. In patients without cognitive awareness or lack of motivation to remain Aetiology dry, scheduled or prompted voiding reduces the num- Most frequently due to bacteria, in particular E. These and Histoplasma capsulatum), parasites (the protozoan tend to cause a dry mouth and may cause constipa- Trichomonas vaginalis and the uke Schistosoma haema- tion and/or urinary retention. Pathophysiology Combined stress and urge incontinence may be treated r Bacterialvirulencefactors:Criticaltothepathogenesis with behavioural therapy with or without medical ther- of bacteria is adherence to the uroepithelium as infec- apy. Surgicaltreatmentappearstobelesseffectivethanin tions ascend from the urethral orice to the bladder pure stress incontinence. A culture is regarded as Urine itself is inhibitory to the growth of normal uri- 5 positive if >10 of a single organism per mL. Further investigations are required in children Clinical features (see page 268), males and females with recurrent infect- Acute cystitis typically presents with dysuria (a burning ions. Macroscopic haematuria is not uncommon, although this should Management prompt further investigation for any other underlying Empirical antibiotic therapy is used in symptomatic pa- disease such as urinary stones or a bladder malignancy. Both Intravenous antibiotics should be used in those who are pyelonephritis and prostatitis may be due to ascending systemically unwell or those who are vomiting. Quinolones such present nonspecically with fever, falls, vomiting, or as ciprooxacin are useful as resistant E. Macroscopy r Intravenoustherapyisoftenwithacephalosporinwith The urine is cloudy due to the pyuria (pus cells) and or without gentamicin. Over time, recurrences can cause chronic sistance, and some centres advise a cycling regime, e. If there is any evidence of obstruction this requires rapid drainage Aetiology (see page 256). Management Mild cases may respond to oral antibiotics as for urinary Pathophysiology tract infection, but many require intravenous therapy Predisposing factors to ascending infection include suchasgentamicinandciprooxacin. Antibiotics should be tailored to the sensitivity stasis due to obstruction, dilatation or neurological and specicity, and continued for 10 14 days (longer causes and reux. Clinical features Fever >38C, rigors, loin pain and tenderness with or withoutlowerurinarytractsymptoms. Denition An abscess that forms in the kidney, or in the perinephric Macroscopy/microscopy fat,astheresultofascendinginfectionorhaematogenous The kidneys appear hyperaemic, and tiny yellow-white spread. These have become less common, due to more spherical abscesses may be seen in the cortex. Aetiology Complications r As with other urinary tract infections, the most common Gram negative septicaemia causing shock is uncom- organisms are E. Necrotic renal papillae due to inammatory thrombosis of the vasa recta, can be Pathophysiology shed, causing obstruction and acute renal failure. Commonly the infection ascends via the lower urinary r Recurrent infections cause renal scarring and im- tract to cause pyelonephritis. U&Es and creatinine (assess hy- kidney into the perinephric fat, or by direct haematoge- dration and renal function). It In reux nephropathy, the papillae are damaged, and the may not be possible to differentiate it from a renal calyces become dilated and clubbed. However, hypertension Antibiotic choice is as for pyelonephritis, until culture may lead to damage to the single functioning kidney. In large abscesses (>3 cm) medi- cal therapy alone is often insufcient, and percutaneous drainage or even partial or total nephrectomy may be Clinical features required. The term should largely be replaced by reux nephropathy, the Macroscopy most common form. The kidneys are smaller than normal, with an irregular, blunted, distorted pelvicalyceal system and areas of scar- Incidence/prevalence ring 1 2 cm in size. Accountsforabout15%ofcasesofend-stagerenalfailure and is an important cause of hypertension in later life. Microscopy Aetiology Areas of interstitial brosis with chronic inammatory The development of chronic pyelonephritis requires cell inltration. The tubules are atrophic or dilated and there to be infections in a kidney with an underlying the glomeruli show periglomerular brosis. Intravenous pyelogram and renal ultra- and japonicum can cause proteinuria and nephrotic syn- sound may also identify damaged kidneys (but are less drome by immune complex deposition and may cause sensitive) and dilated ureters. Management Managment Patients with chronic renal failure require appropriate Praziquantel is the treatment of choice. Acute epididymo-orchitis Previously severe reux was treated with surgical re- Denition implantation of the ureters, this has now been shown to Acute primary infection of the epididymis and the testis. Denition Sex Schistosomiasis is the disease caused by the parasitic Male ukes, schistosomes. Clinical features Pathophysiology Patients present with a greatly enlarged and very tender The eggs of S. Microscopy Sex Thereisextensiveinltrationoftheseminiferoustubules M > F (4:1) and interstitium with neutrophils, initial oedema is con- siderable and there is often patchy haemorrhage. Aetiology Risk factors include: dehydration, urinary tract infec- Complications tions, disorders of calcium handling (hypercalcaemia, Infertility is an important complication. Pathophysiology Stone formation usually occurs because compounds of Management low solubility are present in the urine in high concentra- Treatment is with antibiotics, bed rest and scrotal sup- tions. In young adults, erythromycin (to cover Chlamy- such as magnesium, citrate and organic inhibitors such dia)isprobably best, whereas in older individuals or as glycoseaminoglycans and nephrocalcin. Stones commonly contain calcium oxalate (80%) but Urinary stones about half of these also contain hydroxyapatite. Incidence/prevalence The pain is characteristically in sharp, intense waves over Affects about 10% of the population at some time in abackground pain, occurring in the loin, radiating to their lives. Stones within calyces on passing urine, inability to pass urine or the sensation cannot be broken up this way. Subsequent management If the stone obstructs a single functioning kidney, To reduce the risk of recurrence, all patients should be postrenal acute renal failure results. Calcium oxalate stones may also be given to increase urine levels of citrate lookspiky,calciumphosphatestonesareoftensmooth which inhibits calcium stone formation. This should be avoided if there is carbonate to alkalinise the urine, or d-penicillamine. Strain all urine to try Despite preventative strategies recurrence rates are as to catch the stone so that it can be analysed. Some recom- Aurinary stone which lls the calyces and pelvis of a mend anti-spasmodic drugs. Ensure adequate uid in- kidney, these are usually associated with infection and take. Aetiology/pathophysiology Surgical techniques are needed if the stone does not Stag horn calculi are struvite stones (i. It may be necessary to relieve obstruction urgently, vite and calcium carbonate-apatite). Obstruction can be teus or Klebsiella causes increased amounts of ammonia, relieved by retrograde stent insertion (usually requires due to the presence of urease (which breaks down urea general anaesthetic), or percutaneous nephrostomy in- into ammonia and carbon dioxide). Characteristically the patient presents with an acutely tender swollen testis of sudden onset, there may be a Clinical features history of minor trauma or recent vigorous exercise. Later,pain,haema- Nausea and vomiting are common associated symp- turia and impaired renal function. There may be history of previous self-resolving episodes of pain, particularly at night in young boys Investigations (can be associated with nocturnal sexual arousal that As for urinary stones. If <10% renal function the kid- veals a red hemiscrotum, with an asymmetrically high, ney should be removed. If there is >25% function in a swollen testis (pulled up by the shortened, twisted sper- younger patient many would probably try to preserve matic cord). The cremasteric response is absent in tor- sion (stroking or pinching the inside of the thigh should Management cause the ipsilateral testis to rise), but this response is not Open surgery, or very slow gradual breaking up of reliable below the age of 30 months or over 12 years. Nephrectomy is advised for a can be difcult to distinguish particularly as the testis symptomatic stag horn calculus in a poorly functioning can also swell in this condition. Complications If surgery is delayed beyond 12 18 hours the blood sup- Disorders of the male genital ply is compromised and infarction occurs requiring sur- system gical orchidectomy. Investigations Torsion of the testis Diagnosis is clinical and surgery should not be delayed. Age Most occur in young children and peri-pubertally, less Management common over 25 years. The scrotum is explored, the twist is reversed and if the testis is viable both testes are xed in position as the Sex condition is a bilateral defect. Aetiology Torsion occurs if the testis is insufciently xed by its Hydrocele lower pole to the tunica vaginalis by the gubernaculum testis, so allowing it to twist. Pathophysiology Twisting of the testis on the spermatic cord leads to ve- Incidence/prevalence nous/haemorrhagic infarction. Aetiology Most hydroceles are idiopathic but may occur secondary Incidence/prevalence to trauma, infection or neoplasm. Pathophysiology Fluid accumulates between the two layers (parietal and Aetiology/pathophysiology visceral) of the tunica vaginalis.

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F > M (2:1) Pathophysiology Geography Several different patterns of disease may result from gall- More common in developed world order zoloft 100mg online anxiety young adults. Aetiology Gallstones may be cholesterol stones (more common in the developed world) best order for zoloft anxiety yoga, pigment stones (more common Clinical features in the Far East) or mixed stones discount zoloft 100mg on line depression test by goldberg. Normally bile salts and r Impaction of a gallstone in the outlet of the gallblad- lecithin keep the cholesterol soluble cheap zoloft 100 mg visa mood disorder with depression, forming micelles. Onset is often after a versely, sudden weight reduction and cholesterol- meal or in the evening, the pain is variable in inten- reducing diets may precipitate gallstones by mo- sity over several hours. Inammation is initially caused by concentrated multiple, small and irregular in shape. Patients develop acute onset of severe griping Complications pain in the right upper quadrant radiating to the right Amucocele occurs when long-standing obstruction oc- subscapularregionandoccasionallytotherightshoul- curs without infection, the bile is resorbed and instead der. Associated features include fever, tachycardia, the epithelium secretes clear mucus. Onexam- tis may lead to empyema (pus-lled gallbladder), per- ination there is abdominal tenderness and guarding in foration with abscess formation and biliary peritonitis the right upper quadrant, which may become gener- (chemical and bacterial). Murphy s sign is usu- Investigations ally present (inspiration during right hypochondrial r Full blood count (and investigation for haemolytic palpation causes pain and arrest of inspiration as the anaemia in pigment gallstones). Liver function tests, inamed gallbladder moves downwards and impinges blood cultures, inammatory markers and amylase on the ngers). Management r Patients with asymptomatic gallstones are usually Macroscopy managed conservatively. It may be performed as an Surgical resection is often not feasible due to local spread emergency (severe or complicated acute cholangi- and metastases. Sometimes aggressive segmental resec- tis), early elective (during initial admission for acute tion of the liver and regional lymph nodes is carried out. In acute cholecystitis 90% of patients settle with conser- vative management within 4 5 days. Ascending cholan- Carcinoma of the bile ducts gitishasamortalityofupto20%inseverecasesrequiring emergency decompression. Carcinoma of the gallbladder is rare, but almost always associated with gallstones. The tumour can arise anywhere in the biliary sys- Aetiology/pathophysiology tem and may be multifocal. It causes obstruction and Unknown, but associated with gallstones and chronic hence dilatation of the proximal ducts. Histologically 90% of tumours are adeno- carcinomas and 10% are squamous carcinomas. Clinical features The usual presentation is progressive obstructive jaun- Clinical features dice. Other symptoms include vague epigastric or right Patients may have a history of gallstone disease. A mass is often palpable in the right upper empyema presenting with biliary colic and a non-tender quadrant. Direct invasion of local structures, especially the liver, is almost invari- Macroscopy/microscopy ableatpresentation. Spreadviathelymphaticsandblood The carcinoma commonly appears as a sclerotic stricture occurs early. The islets of Langerhans are islands of endocrine cells scattered throughout the pancreas. They are clustered Investigations around a capillary network into which they secrete their r Ultrasound may show dilated intrahepatic ducts and hormones. Management Acute pancreatitis Curative treatment is only attempted if the tumour is localised and the patient is t for radical resection. Denition r Carcinoma of the common bile duct is treated by the Acute inammation of the pancreas with variable in- Whipple s operation (see page 221). Incidence The remaining biliary tree is anastomosed to a Roux Almost 5 25 per 100,000 per year and rising. Palliative treatments include insertion of a stent or anas- Age tomosis of a Roux loop of jejunum to a biliary duct in More common >40 years. The prognosis is better for patients with carcinoma of Aetiology the common bile duct who are suitable for a Whipple s Biliary tract disease (80%), especially cholelithiasis, gall- operation. Alcoholism is the second most common cause (20% in the United Disorders of the pancreas Kingdom). Causes are as follows: r Obstruction: Gallstones, biliary sludge, carcinoma of the pancreas. Introduction to the pancreas r Drugs/toxins: Alcohol, azathioprine, steroids, diuret- The pancreas has two important functions: the produc- ics. Translocation of gut pancreatitis bacteria can result in local infection and septicaemia. Within 48 hours of admission Shock may result from the release of bradykinin and Age >55 years prostaglandins, or secondary to sepsis. Haemorrhage may cause Grey Turner s sign, which is bruising around the left loin and/or Cullen s sign, bruising around the umbilicus. The pancreas appears oedematous with grey-white Other investigations are required to assess the sever- necrotic patches. Bacterial infection leads to inamma- ity and to monitor for complications: full blood count, tion and pus formation. Healing results in brosis with clotting screen, urea and electrolytes, liver function tests, calcication. Complications In the most severe cases there is systemic organ failure: Management r Cardiovascularsystem:Shock(hypotension,tachycar- The early management depends on the severity of the dia, arrhythmias). Patients require careful uid balance zymes walled off by compressed tissue), pancreatic using central venous pressure monitoring and uri- abscesses (which may contain gas indicating infection nary catheterisation to allow accurate urine output withgas-formingbacteria)andduodenalobstruction. Prophylactic Investigations broad-spectrumantibioticsaregiventoreducetherisk When supportive clinical features are present the diag- of infective complications. Ascites and persistent obstructive jaundice with conservative management require laparoscopic may occur. Prognosis Investigations Pancreatitis is a serious condition: overall mortality is Serum amylase uctuates, but may be moderately raised 10%. Endoscopic retrograde cholangiopancreatography mayshowscarringoftheductalsystemandevenstonesin the pancreatic duct. Magnetic resonance cholangiopan- Chronic pancreatitis creatography is increasingly being used. Denition Chronic pancreatitis is an inammatory condition that Management results in irreversible morphological change and impair- Precipitating factors especially alcohol need to be re- ment of exocrine and endocrine function. Adequate analgesia is required, thoracoscopic splanchnicectomymayberequiredinrefractorypainnot Age associated with main pancreatic duct dilatation. Surgical M > F techniques include sphincteromy or sphincteroplasty, partial pancreatectomy or opening the pancreatic duct Aetiology/pathophysiology along its length and anastomosing it with the duodenum Two patterns of chronic pancreatitis are seen, a chronic or jejunum. Total pancreatectomy can be carried out, relapsing course with recurring acute pancreatitis and with replacement oral pancreatic enzymes and insulin. Risk factors includealcoholabuse,hereditarypancreatitis,ductalob- Tumours of the pancreas struction (e. Hy- percalcaemia, hyperlipidaemia and congenital pancre- Denition atic malformations are recognised associations. Clinical features Incidence Patients may present with an acute episode of pancre- 10 per 100,000 per annum and rising. Late com- plications include impaired glucose tolerance, diabetes Age mellitus and malabsorption (steatorrhoea) associated Mainly >60 years. Aetiology There appears to be some familial clustering and hence Investigations it is suggested that genetic susceptibility may play an There are no useful tumour markers or pancreatic func- important role. Specic inherited risks include famil- tion tests for diagnosis, which must be histological. Mosttumoursdevelop intheheadofthepancreasandthesetendtopresentearly ducts and may also be used for intervention. Clinical features Pancreatic cancer is associated with several clinical syn- Management dromes: Surgical resection offers the only chance of cure, but only r One third of patients present with painless obstructive about 10 15% of patients are suitable for radical surgery jaundice, i. Chronic epigastric pain radiating to the back similar to chronic pancre- denectomy with block resection of the head of pan- atitis develops in most patients at some stage. There is signicant orrhoea is common and failure to absorb the fat- perioperative morbidity and mortality. Stents of the bile duct and/or duodenum tend to become blocked and Macroscopy/microscopy have to be replaced. Most tumours are moderately differentiated The prognosis is extremely poor with an overall 5-year adenocarcinoma with a prominent brous stroma. Radiolabelled octreotide (a somato- statin analogue) can be used for localisation of the primary tumour and detection of any metastases. Insulinoma: Ausually benign islet-cell tumour that may r Several options are available for the treatment of occur in the pancreas or at ectopic sites causing the metastatic neuroendocrine tumors including oc- hypersecretion of insulin. There may be gradual in- treotide, interferon,chemotherapy and hepatic tellectual and motor impairment with insidious per- artery embolisation. Severe attacks of hypoglycaemia can Glucagonoma: This is a very rare tumour of the islet cells produce sweating, palpitations, tremulousness and a of the pancreas which is often asymptomatic. Patients maypresentwithnecrolyticmigratoryerythema,painful may present with a hypoglycaemic coma. Treatment is by resection where possible, or sys- centrations of insulin may be helpful, endoscopic ul- temic treatment as for insulinoma. Symptoms r Associated symptoms include nausea, vomiting, frank haematuria (blood in the urine).