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Hepatitis

Hepatitis is an inflammation of the liver, most commonly caused by a viral infection. There are five main hepatitis viruses, referred to as types A, B, C, D and E. These five types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread. In particular, types B and C lead to chronic disease in hundreds of millions of people and, together, are the most common cause of liver cirrhosis and cancer.

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Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis B, C and D usually occur as a result of parenteral contact with infected body fluids. Common modes of transmission for these viruses include receipt of contaminated blood or blood products, invasive medical procedures using contaminated equipment and for hepatitis B transmission from mother to baby at birth, from family member to child, and also by sexual contact.

Acute infection may occur with limited or no symptoms, or may include symptoms such as jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.

Cirrhosis

Cirrhosis is a complication of many liver diseases that is characterized by abnormal structure and function of the liver. The diseases that lead to cirrhosis do so because they injure and kill liver cells, and the inflammation and repair that is associated with the dying liver cells causes scar tissue to form. The liver cells that do not die multiply in an attempt to replace the cells that have died. This results in clusters of newly-formed liver cells (regenerative nodules) within the scar tissue. There are many causes of cirrhosis; they include chemicals (such as alcohol, fat, and certain medications), viruses, toxic metals (such as iron and copper that accumulate in the liver as a result of genetic diseases), and autoimmune liver disease in which the body's immune system attacks the liver.

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Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules (lumps that occur as a result of a process in which damaged tissue is regenerated), leading to loss of liver function. Cirrhosis is most commonly caused by alcoholism, hepatitis B and C, and fatty liver disease, but has many other possible causes. Some cases are idiopathic (i.e., of unknown cause). Ascites (fluid retention in the abdominal cavity) is the most common complication of cirrhosis, and is associated with a poor quality of life, increased risk of infection, and a poor long-term outcome. Other potentially life-threatening complications are hepatic encephalopathy (confusion and coma) and bleeding from esophageal varices. Cirrhosis is generally irreversible, and treatment usually focuses on preventing progression and complications. In advanced stages of cirrhosis the only option is a liver transplant.

Symptoms of Cirrhosis of the Liver

Individuals with cirrhosis may have few or no symptoms and signs of liver disease. Some of the symptoms may be nonspecific, that is, they don't suggest that the liver is their cause. Some of the more common symptoms and signs of cirrhosis include

  • Yellowing of the skin (jaundice) due to the accumulation of bilirubin in the blood
  • Fatigue
  • Weakness
  • Loss of appetite
  • Itching
  • Easy bruising from decreased production of blood clotting factors by the diseased liver
  • Individuals with cirrhosis also develop symptoms and signs from the complications of cirrhosis

Acid Peptic Disease

Acid peptic disorders include a number of conditions whose pathophysiology is believed to be the result of damage from acid and pepsin activity in the gastric secretions. We will focus on gastroesophageal reflux disease (GERD) and peptic ulcer disease, the two most common and well-defined disease states.

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Gastroesophageal reflux disease

GERD is defined as chronic symptoms of heartburn, acid regurgitation, or both, or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus.1 Reflux esophagitis occurs in a subgroup of GERD patients with histopathologically demonstrated characteristic changes in the esophageal mucosa. Nonerosive reflux disease, also known as endoscopy-negative reflux disease, occurs in patients who have typical GERD symptoms caused by intraesophageal acid but who do not have visible mucosal injury at endoscopy.

Functional heartburn is defined as episodic retrosternal burning without evidence of increased esophageal acid exposure or other structural esophageal abnormalities.

Peptic ulcer disease

Peptic ulcers (gastric and duodenal) are defects in the GI mucosa, the lining of the Gastrointestinal tract that extend through the muscularis mucosa.

Pathophysiology

Peptic ulcer disease is the end result of an imbalance between aggressive and defensive factors in the gastroduodenal mucosa. H. pylori infection, NSAIDs, and acid secretory abnormalities are the major factors that disrupt this equilibrium. Although acid peptic injury is necessary for ulcers to form, acid secretion is normal in almost all patients with gastric ulcers and increased in only one third of patients with duodenal ulcers. A defect in bicarbonate production and, in turn, acid neutralization in the duodenal bulb is also seen in patients with duodenal ulcer disease.

This abnormality resolves with eradication of H. pylori infection when it is present. However, a small percentage of ulcers is not related to H. pylori infection or NSAID use. These are classified as idiopathic and may be related to defective mucosal defense mechanisms, tobacco use, genetics, rapid gastric emptying, or psychological stress.

Gastrointestinal bleeding

Gastrointestinal bleeding or gastrointestinal hemorrhage describes every form of hemorrhage (loss of blood) in the gastrointestinal tract, from the pharynx to the rectum. It has diverse causes, and a medical history, as well as physical examination, generally distinguishes between the main forms. The degree of bleeding can range from nearly undetectable to acute, massive, life-threatening bleeding.

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Signs and symptoms

Gastrointestinal bleeding can range from microscopic bleeding, where the amount of blood is such that it can only be detected by laboratory testing, to massive bleeding where bright red blood is passed and hypovolemia and shock may develop. Blood that is digested may appear black rather than red, resulting in "coffee ground" vomit or stool.

Differential diagnosis

Gastrointestinal bleeding can be roughly divided into two clinical syndromes: upper gastrointestinal bleeding and lower gastrointestinal bleeding.Types of causes include: infections, cancers, vascular disorders, adverse effects of medications, and blood clotting disorders.

Upper gastrointestinal

Upper gastrointestinal bleeding is characterized by hematemesis (vomiting up blood) and melena (tarry stool containing altered blood). About half of cases are due to peptic ulcer disease. Esophagitis and erosive disease is the next most common causes.In those with liver cirrhosis 50-60% of bleeding is due to esophageal varices.Approximately half of those with peptic ulcers have an H. pylori infection.Other causes include: gastric or duodenal ulcers, Mallory-Weiss tears, cancer, and angiodysplasia.

A number of medications are found to cause upper GI bleeds.Lower gastrointestinal bleeding Lower gastrointestinal bleeding is typically from the colon, rectum or anus.Causes include: hemorrhoids, cancer, angiodysplasia, colitis, and aortoenteric fistula.It may be indicated by red blood per rectum, especially in the absence of hematemesis. Isolated melena may originate from anywhere between the stomach and the proximal colon.

Morbid Obesity and Treatment Options

Obesity is a condition in which one has too much body fat (adipose tissue). Obesity is determined by calculating the Body Mass Index (BMI), which measures weight for height and is stated in numbers.

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1. Health Hazards of Morbid Obesity

Severe obesity damages the body by its mechanical, metabolic and physiological adverse effects on normal body functioning. These "co-morbidities" affect nearly every organ in the body in some way, and produce serious secondary illnesses, which may also be life threatening. The cumulative effect of these co-morbidities can interfere with a normal and productive life and can shorten life as well. The risk of developing these medical problems is proportional to the degree of obesity.

  • People who are obese do not live for as long as those who are not obese and the earlier a person become obese; the more years of life are lost.
  • Heart Disease- Severely obese persons are approximately 6 times as likely to develop heart disease as those who are of normal weight. Heart disease is the leading cause of death today and obese persons tend to develop it earlier in life.
  • High Blood Pressure- Hypertension is much more common in obese persons and leads to development of heart disease, and damage to the blood vessels throughout the body, causing susceptibility to strokes, kidney damage, and hardening of the arteries.
  • Diabetes Mellitus- Overweight persons are 40 times as likely to develop Type 2, Adult-onset diabetes. Once diabetes occurs, it becomes even harder to lose weight, because of hormone changes which causes higher fat accumulation in the body.
  • Sleep Apnea Syndrome- Sleep apnea – the stoppage of breathing during sleep – is commonly caused in the obese, by compression of the neck, closing the air passage to the lungs.
  • Respiratory Insufficiency
  • Heartburn - Reflux Disease and Reflux Nocturnal Aspiration
  • Asthma and Bronchitis
  • Gallbladder Disease - Gallbladder disease occurs more frequently in the obese, in part due to repeated efforts at dieting, which predispose one to this problem.
  • Stress Urinary Incontinence
  • Degenerative Disease of Lumbo-Sacral Spine (Backbone)
  • Degenerative Arthritis of weight bearing joints like knee and hip
  • Venous Stasis Disease in the lower extremities
  • Emotional/Psychological Illness- Extremely overweight persons face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, and remarks from strangers. They often experience discrimination at work. Stereotypes of obese people – such as that they are lazy – may result in lower self esteem and poor body image.
  • Social Effects- Severely obese persons suffer inability to qualify for many types of employment and there tends to be a higher rate of unemployment among them. There is a general societal belief that obesity is a consequence of a lack of self-discipline, or moral weakness.

2. Surgical options for treating Morbid Obesity

The morbidly obese have to seriously consider surgery for reducing weight to avoid its ill effects. Surgery for Morbid Obesity is for the following situations

  • The person's BMI is over 40, or is 35 or higher and a serious medical problem (hypertension, diabetes, heart disease, joint problems, reflux) that is made worse by obesity is present.
  • If it has not been possible to reduce or maintain weight under a medically supervised program.
  • If the person has been obese for at least 5 years

3. Surgical Treatment options available are

Laproscopic Adjustable Gastric Banding

  • An Inflatable Gastric Band is used, thus creating an Hourglass structure to the Stomach.
  • This procedure may lead to about 39% of the excess weight being reduced within 18 months after the surgery.
  • This procedure needs a high level of compliance from patient regards lifestyle and diet post surgery.
  • There is always a risk of the Band eroding into the stomach, slipping out of place, and can also produce vomiting, development of GERD or sometimes the device can also fail to function.

Laproscopic Sleeve Gastrectomy

  • Laparoscopic Sleeve Gastrectomy is safer than other procedures.
  • In this procedure, 80% of the stomach is stapled and removed which induces weight loss by restriction in food intake and early satiety, due to loss of hunger producing hormones.
  • Digestion and absorption is normal.
  • By eating less the body draws the required energy from its own fat stores and thus you lose weight.

The R OUX-EN-Y Gastric Bypass

  • In this procedure, a small, 15 to 20 cc, pouch is created at the top of the stomach.
  • The small bowel is divided. The bilio-pancreatic limb is reattached to the small bowel and the other end is connected to the pouch, creating the Roux limb.
  • The small pouch releases food slowly, causing a sensation of fullness with very little food intake.
  • The bilio-pancreatic limb preserves the action of the digestive tract.

Bilio Pancreatic Diversion with Duodenal Switch

  • In this procedure, greater weight loss can happen with less dietary compliance from the patient.
  • There may be an increased risk of malnutrition and vitamin deficiency and intermittent diarrhea can also occur.
  • Constant follow-up is needed for this procedure in order to monitor for complications.

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