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Clostridium perfringens 8-16hours +++ Clostridia grow in Stools can be tested Abrupt onset of profuse diarrhea, abdominal rewarmed meatand for enterotoxin or cramps, nausea; vomiting occasionally. Stool and airway, ventilation, and intravenous poly mented fish, foods held food can be valent antitoxin (see text). C difficile Usually occurs after +++ ++ Associated with antimicro Stool tested for toxin. Abrupt onset ofdiarrhea thatmay be 7-10days of bial drugs; clindamycin bloody; fever. Enterohemorrhagic 1-8 days + +++ Undercooked beef, Shiga-toxin-producing Usually abrupt onset of diarrhea, often Escherichia coli, especially hamburger; E coli can be cui bloody; abdominal pain. In adults, it is including Shiga-toxin unpasteurized milkand tured on special usually self-limited to 5-10 days. I cholerae 24-72 hours + +++ Contaminated water, fish, Stool culture on Abrupt onset of liquid diarrhea in endemic m shellfish, street vendor 1" special medium. V Campylobacterjejuni 2-5 days +++ + Raw or undercooked Stool culture on Fever, diarrhea that can be bloody, cramps. Abrupt onset of diarrhea, ofen with blood : : cases) contaminated with and pus in stools, cramps, tenesmus, and s human feces. Gradual or abrupt onset of diarrhea and : m ized milk, cheese, juices, low-grade fever. No antimicrobials unless : raw fruits and high risk(see text) or systemic dissemina) " vegetables. Yersinia enterocolitica 24-48 hours + + Undercooked pork, Stool culture on Severe abdominal pain (appendicitis-like contaminated water, special medium. Noroviruses and other 12-48 hours ++ +++ + Shellfish and fecally Clinical diagnosis with Nausea, vomiting (more common in chil caliciviruses contaminated foods negative stool cui dren), diarrhea (more common in adults), touched by infected tures. Less than 3 weeks following exposure may documented and erythromycin is the drug of choice) cou? suggest dengue, leptospirosis, and yellow fever; pled with the fact that most infectious diarrhea is self? more than 3 weeks suggest typhoid fever, malaria, limited, routine use of antibiotics for all patients with and tuberculosis. Antibiotics should be con? sidered in patients with evidence of invasive disease (white cells in stool, dysentery), with symptoms 3-4 days. General Considerations or more in duration, with multiple stools (eight to ten or more per day), and in those with impaired immune the differential diagnosis offever inthe returning traveler responses. The evaluation is best done by identify? without dysentery (bloody stools), and they should be used ing whether a particular syndrome is present, then refining in low doses because of the risk of producing toxic mega? the differential diagnosis based on an exposure history. Postinfectious irritable bowel syndrome can follow the travel history should include directed questions infection and is approached in a similar fashion as in non? regarding geography (rural versus urban, specifc country infectious irritable bowel syndrome.
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The early postprandial phase results from the rapid emptying of the stomach including larger than normal food particles, with the osmotic shift of fluid into the duodenal lumen plus the distention of the human releasing gastrointestinal and pancreatic hormones. These hormones cause the gastrointestinal and vascular symptoms of the early dumping syndrome. The rapid and early absorption of nutrients causes prompt secretion of insulin, and the late dumping syndrome characterized by reactive hypoglycaemia (Tack et al. A modified oral glucose tolerance test may be used to establish the reactive hypoglycaemia. The dumping syndrome does not always respond to dietary maneuvers, and pectin or guar gum may be needed to slow gastric emptying, a carbose to slow starch digestion and reduce pos-prandial reactive hypoglycaemia, or in extreme cases somatostatin injections may be given to slow gastric emptying and to slow sugar absorption. There are numerous centrally acting drugs used for the treatment First Principles of Gastroenterology and Hepatology A. Some persons with severe, intractable gastroparesis, such as may occur with severe type I diabetes, may improve with near-total gastrectomy and Roux-en-Y anastomosis. Slowed gastric emptying and delayed small intestinal transit occur in persons with cirrhosis. If intractable symptoms persist, acupuncture (P6 point) or gastric electrical stimulation may be of limited benefit. Unfortunately, nausea and vomiting is common during pregnancy, particularily during the first trimester. Curiosly, vitamin b6 (thiamine), soda crackers, and ginger are often helpful (Table 4). Non-pharmaceutical options (Dietary and lifestyle modifications) for the treatment of nausea and vomiting during pregnancy o Avoidance of precipitating factors o Frequent, small meals high in carbohydrate and low in fat o Vitamin B6 (thiamine) o Ginger o Stimulation of P6 acupuncture point o Treat dehydration, electrolyte disturbances o Correct malnutrition o Soda crackers (unproven benefit) Avoid offending foods/beverages Modified from: Keller J, et al. Nature Clinical Practice Gastroenterology & Hepatology 2006; 3(5): page 258; and printed with permission: Keller J, et al. Gastric Neuromuscular o Tachygastria o Decreased fundic accommodation o Increased fundic accommodation o Antral hypomotility o Pylorospasm o Antroduodenal dyscoordination First Principles of Gastroenterology and Hepatology A. The volume of the meal alters the rate of gastric emptying in proportion to the volume of the meal. Hypergastrinemia From our appreciation of the numerous ways in which acid secretion may be turned on or off, it is straight-forward to work out the causes of hypergastrinemia, and those mechanisms of hypergastrinemia which would be associated with increased gastric acid secretion, and might lead to severe peptic ulcer disease (Table 8 and 9) Table 8. Causes of hypergastrinemia With acid hypersecretion With variable acid secretion With acid hyposecretion Gastrinoma Hyperthyroidism Atrophic gastritis Isolated retained gastric antrum Chronic renal failure Pernicious anemia Antral G-cell hyperplasia Pheochromocytoma Gastric cancer Massive small bowel resection Postvagotomy and pyloroplasty Pyloric outlet obstruction Hyperparathyroidism First Principles of Gastroenterology and Hepatology A. There are many possible explanations for an elevated serum gastrin concentration (Table 9). It is one of the most common complaints bringing patients to consult their family physician. These patients may also complain of nausea, fullness, early satiety, bloating, or regurgitation. Dyspepsia is a symptom or symptoms, and when the person presents, their symptom is not diagnosed, so this is called uninvestigated dyspepsia.
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Patients will give a his? tory of a transient lump in the breast or cyclic breast pain. Because a mass due to fibrocystic condition is dif? increases during premenstrual phase of cycle. Excisional biopsy is rarely necessary but should be done for lesions with atypia or where imag? ing and biopsy results are discordant. General Considerations conservative, since the primary objective is to exclude Fibrocystic condition is the most frequent lesion of the cancer. It is common in women 30-50 years of age but rare in postmenopausal women who are not taking hor? monal replacement. There may be an increased risk in women who drink Pain, fluctuation in size, and multiplicity oflesions are the alcohol, especially women between 18 and 22 years of age. If a dominant mass is present, the include cysts (gross and microscopic), papillomatosis, diagnosis of cancer should be assumed until disproven by adenosis, fibrosis, and ductal epithelial hyperplasia. Mammography may behelpful, but the breast tissue Although fibrocystic condition has generally been consid? in these young women is usually too radiodense to permit ered to increase the risk of subsequent breast cancer, only a worthwhile study. Sonography is useful in differentiating the variants with a component of epithelial proliferation a cystic mass from a solid mass, especially in women with (especially with atypia), papillomatosis, or increased breast dense breasts. Final diagnosis, however, depends on analy? density on mammogram represent true risk factors. If no fluid is obtained by this common benign neoplasm occurs most frequently in aspiration, if fuid is bloody, if a mass persists after aspira? young women, usually within 20 years after puberty. It is tion, or if at any time during follow-up a persistent or somewhat more frequent and tends to occur at an earlier recurrent mass is noted, biopsy should be performed. Multiple tumors are found in 10-15% Breast pain associated with generalized fibrocystic of patients. Fibroade? this treatment suppresses pituitary gonadotropins, but noma does not normally occur after menopause but may androgenic effects (acne, edema, hirsutism) usually make occasionally develop after administration of hormones. No treatment is usually necessary ifthe diagnosis can Similarly, tamoxifen reduces some symptoms of fibrocys? be made by core needle biopsy Excision with pathologic tic condition, but because ofits side effects, it is not useful examination of the specimen is performed if the diagnosis for young women unless it is given to reduce the risk of is uncertain or the lesion grows signifcantly. Postmenopausal women receiving hormone or freezing of the fbroadenoma, appears to be a safe pro? replacement therapy may stop or change doses of hor? cedure if the lesion is a biopsy-proven fibroadenoma prior mones to reduce pain. Cryoablation is not appropriate for all fibroad? form of gamolenic acid, has been shown to decrease pain enomas because some are too large to freeze or the diagno? in 44-58% of users. Studies have also cryoablation of a histologically proven fibroadenoma demonstrated a low-fat diet or decreasing dietary fat exceptthat some patients mayfeel reliefthat a mass is gone. It roidal anti-infammatory drugs or anti-hormonal drugs is usually not possible to distinguish a large fbroadenoma such as tamoxifen are rarely of value. Presumed fibroadenomas larger than 3-4 em should be Some studies suggest that eliminating caffeine from the excised to rule out phyllodes tumors. It may reach a large size studies and report relief of symptoms after giving up coffee, and, if inadequately excised, will recur locally.
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