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The rate of reabsorption from renal tubules is influenced by factors such as pH and rate of renal tubular urine flow muscle relaxant vs anti-inflammatory purchase colospa 135 mg on line. Passive reabsorption of weak bases and acids is altered by urine pH muscle relaxer zoloft buy colospa 135 mg with amex, which influences the fraction of drug that exists in the ionized form muscle relaxant lorazepam 135mg colospa for sale. This occurs because alkalinization of the urine results in more ionized drug that cannot easily cross renal tubular epithelial cells spasms esophagus problems colospa 135 mg line, resulting in less passive reabsorption. Creatinine clearance can be predicted from age and weight according to the equation of Cockroft nd Gault9: Men: Creatinine Clearance (ml/min) 5 [140 2 age(years)] 3 weight(kgs) 72 3 serum creatinine (mg%) Women: 85% of the aforementioned equation. Equation 2-7 250 Creatinine clearance (mls/min) 200 150 Creatinine 100 50 0 20 30 40 50 Age 60 70 80 90 0. As a result, it is usually the nonionized form of the drug that is pharmacologically active, undergoes reabsorption across renal tubules, is absorbed from the gastrointestinal tract, and is susceptible to hepatic metabolism. Conversely, the ionized fraction is poorly lipid soluble and cannot penetrate lipid cell membranes easily (see Table 2-1). A high degree of ionization thus impairs absorption of drug from the gastrointestinal tract, limits access to drug-metabolizing enzymes in the hepatocytes, and facilitates excretion of unchanged drug, as reabsorption across the renal tubular epithelium is unlikely. Determinants of Degree of Ionization the degree of drug ionization is a function of its dissociation constant (pK) a nd the pH o f the surrounding fluid. When the pK and the pH are identical, 50% of the drug exists in both the ionized and nonionized form. Small changes in pH c an result in large changes in the extent of ionization, especially if the pH and pK values are similar. Acidic Absorption Classically, pharmacokinetics is taught as "absorption, distribution, metabolism, and elimination. Acidic drugs are usually supplied in a basic solution to make them more soluble in water and basic drugs are usually supplied in an acidic solution for the same reason, unless the pH affects drug stability, as is the case for most ester local anesthetics. Ion Trapping Because it is the nonionized drug that equilibrates across lipid membranes, a concentration difference of total drug can develop on two sides of a membrane that separates fluids with different pHs,10 because the ionized concentrations will reflect the local equilibration between ionized and nonionized forms based on the pH. This is an important consideration because one fraction of the drug may be more pharmacologically active than the other fraction. Systemic administration of a weak base, such as an opioid, can result in accumulation of ionized drug (ion trapping) in the acid environment of the stomach. A similar phenomenon occurs in the transfer of basic drugs, such as local anesthetics, across the placenta from mother to fetus because the fetal pH is lower than maternal pH. The lipidsoluble nonionized fraction of local anesthetic crosses the placenta and is converted to the poorly lipid-soluble ionized fraction in the more acidic environment of the fetus. The ionized fraction in the fetus cannot easily cross the placenta to the maternal circulation and thus is effectively trapped in the fetus. At the same time, conversion of the nonionized to ionized fraction maintains a gradient for continued passage of local anesthetic into the fetus. The resulting accumulation of local anesthetic in the fetus is accentuated by the acidosis that accompanies fetal distress. The kidneys are the most important organs for the elimination of unchanged drugs or their metabolites. Water-soluble compounds are excreted more efficiently by the kidneys than are compounds with high lipid solubility. This emphasizes the important role of metabolism in converting lipid-soluble drugs to water-soluble metabolites. Drug elimination by the kidneys is correlated with endogenous creatinine clearance or serum creatinine concentration. The magnitude of change in these indices provides an estimate of the necessary change adjustment in drug dosage. Although age and many diseases are associated with a decrease in creatinine clearance and requirement for decreased dosing, pregnancy is associated with an increase in creatinine clearance and higher dose requirements for some drugs. Local conditions at the site of absorption alter solubility, particularly in the gastrointestinal tract. Blood flow to the site of absorption is also important in the rapidity of absorption. For example, increased blood flow evoked by rubbing or applying heat at the subcutaneous or intramuscular injection site enhances systemic absorption, whereas decreased blood fl w due to vasoconstriction impedes drug absorption. Finally, the area of the absorbing surface available for drug absorption is an important determinant of drug entry into the circulation. Oral Administration Oral administration of a drug is often the most convenient and economic route of administration. Disadvantages of the oral route include (a) e mesis caused by irritation of the gastrointestinal mucosa by the drug, (b) d estruction of the drug by digestive enzymes or acidic gastric fluid, and (c) irregularities in absorption in the presence of food or other drugs. Furthermore, drugs may be metabolized by enzymes or bacteria in the gastrointestinal tract before systemic absorption can occur. With oral administration, the onset of drug effect is largely determined by the rate and extent of absorption from the gastrointestinal tract. The principal site of drug absorption after oral administration is the small intestine due to the large surface area of this portion of the gastrointestinal tract. Changes in the pH of gastrointestinal fluid that favor the presence of a drug in its nonionized (lipidsoluble) fraction thus favor systemic absorption.
Other newer agents spasms compilation colospa 135mg for sale, such as cetuximab (monoclonal antibody to epidermal growth factor receptor) have been shown to be ineffective in tumours with Kras or Braf mutations spasms or twitches purchase colospa 135mg with amex. Hence kidney spasms causes generic 135mg colospa, Kras/Braf mutation analysis is required to identify patients with tumours that might respond to cetuximab therapy spasms in 8 month old discount colospa 135mg with visa. Other agents such as temozolomide, alone or in combination with other agents, are also used in relapsed disease. Preoperative adjuvant radiotherapy reduces local recurrence rates, but not overall survival. Postoperative intensive follow-up is associated with a 9% survival improvement by identifying those with surgically salvageable relapse. Pre-operative radiotherapy and curative surgery for the management of localised rectal carcinoma. Either a 5-day short-course regimen of 45 Gy daily or a long-course regimen of 52 Gy given weekly over 3 months is administered. The former is reserved for patients with operable but tethered tumours or very low or anterior tumours, or if extrarectal spread is evident. Postoperative radiotherapy results in poor bowel function and may damage the small intestine, and hence the importance of preoperative staging to guide administration of radiotherapy before surgery whenever possible. Trials of radiotherapy alone for rectal cancer, without resection, have yet to establish the place of this approach. Palliative therapy In addition to resection with curative intent, surgery can provide valuable palliation for patients with local disease relapse, hepatic or other distant metastases. This is achieved through improving symptoms or by averting distressing features of advanced local disease. In some instances, diversion of the faecal stream through a defunctioning colostomy or ileostomy may be all that is feasible. Hence, the vast majority of patients undergo surgical resection, whether curative or palliative. In a small number of cases with poor functional status and/or extensive metastatic load and in whom surgical resection is relatively contraindicated, combined radiological and colonoscopic placement of an intraluminal expanding stent will palliate an obstructing colonic cancer. Radiotherapy has an important role in palliation of locally advanced irresectable rectal cancer and can control pain, mucus discharge, disordered bowel habit, bleeding and faecal incontinence. It also has a value in palliation of rectal cancer recurrence and in alleviating bone pain from metastases. It may rarely be used to palliate locally invasive colonic cancer invading the abdominal wall, but this approach is restricted because the fields are difficult to define and damage to adjacent bowel is likely. Palliative chemotherapy is used extensively to treat symptoms of disseminated disease, and to control disease progression and extend survival. The marked improvement in survival from colorectal cancer is due to a combination of earlier diagnosis across all stages, improved perioperative anaesthetic and surgical management, and improved adjuvant therapies, especially chemotherapy. However, overall prognosis is even better for patients who have no evidence of metastases on preoperative staging tests and who have undergone a resection with curative intent. This underscores the importance of preoperative staging when performing radical surgery. Only a minority of patients with unresectable liver or lung metastases will survive to 5 years and most die within 2 years. Operative mortality is low ($3%) for elective resections but is 18% in patients requiring emergency surgery for complications such as obstruction and perforation, emphasising the importance of early detection and timely surgery. Patients with isolated hepatic metastases may be candidates for hepatic resection with a view to cure (see Chapter 14), and there is significant evidence for long-term survival benefit in selected patients. Staging systems provide useful prognosis to guide therapy and inform patients of expected outcome. Other malignant tumours of the large intestine Squamous cancer of the large bowel these poor-prognosis tumours are not metastatic anal carcinomas, but arise in the caecum and proximal colon from an area of squamous metaplasia in long-standing ulcerative colitis. Carcinoid tumour of the large bowel Large bowel carcinoid tumours are very rare, but benign lesions may be found incidentally during rectal examination as solitary, spherical, hard, sessile, yellowish submucosal nodules. Malignant carcinoid tumours of the colon are highly malignant and may give rise to the carcinoid syndrome if liver metastases are present (60% present with metastases at diagnosis). Secondary involvement of the large bowel in generalised nodal disease is more common. Primary lymphomas are treated by resection, followed by chemotherapy and radiotherapy. Secondary malignant lymphoma and malignant lymphomatous polyposis are treated by systemic chemotherapy and targeted radiotherapy. Gastrointestinal stromal tumours (including leiomyosarcoma) these tumours are rare in the large bowel and were discussed earlier with respect to the small bowel. They arise from the muscle of the bowel wall, most usually the rectum, and are usually diagnosed by digital examination or by sigmoidoscopy. There is a spectrum from benign to malignant and the tumours are often impossible to distinguish clinically; resection is therefore advisable.
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Despite being continuous muscle relaxant benzodiazepine discount colospa 135 mg with amex, the pain may wax and wane in intensity over several hours spasms in hand colospa 135 mg, and vomiting and retching are common muscle relaxant m 58 59 buy discount colospa 135mg on line. Resolution occurs when the stone falls back into the gallbladder lumen or passes onwards into the common bile duct kidney spasms no pain discount 135 mg colospa overnight delivery. In some patients, the obstruction does not resolve and the patient develops acute cholecystitis. Chronic cholecystitis Repeated bouts of transient gallbladder obstruction (biliary colic) or acute cholecystitis culminate in fibrosis, contraction of the gallbladder and chronic inflammatory change with marked thickening of the wall. Chronic inflammatory change may be present in the absence of gallstones, as is the case in the gallbladders of typhoid carriers. The incidence of carcinoma of the gallbladder is increased in patients with longstanding gallstones. Acute cholecystitis Fistulation When large gallstones are present for a long time they can erode by the effect of pressure through the wall of the gallbladder into surrounding structures. Those eroding into the duodenum can pass into the small bowel, resulting in mechanical small bowel obstruction known as gallstone ileus. It usually begins with an attack of biliary colic, although its onset may be more gradual. There is severe right hypochondrial pain radiating to the right subscapular region, and occasionally to the right shoulder, together with tachycardia, pyrexia, nausea, vomiting and leucocytosis. The pain in acute cholecystitis is usually constant and continues for 24 hours or more, differentiating this from biliary colic where pain is short-lasting. Abdominal tenderness and rigidity may be generalised but are most marked over the gallbladder. In the remainder, tenderness may spread and pyrexia and tachycardia Choledocholithiasis When gallstones (usually small) enter the common bile duct via the cystic duct, they may pass spontaneously or give rise to obstructive jaundice, cholangitis or acute pancreatitis. Gallstone pancreatitis most commonly occurs when a small stone becomes temporarily arrested at the ampulla of Vater. The development of a tender mass, associated with rigors and marked pyrexia, signals empyema formation. The gallbladder may become gangrenous and perforate, giving rise to biliary peritonitis. Usually, this is associated with stones in the common bile duct, but compression of the bile ducts due to surrounding inflammation may be responsible. Acute cholecystitis must be differentiated from perforated peptic ulcer, high retrocaecal appendicitis, acute pancreatitis, myocardial infarction and basal pneumonia. Acute cholecystitis can develop in the absence of gallstones (acalculous cholecystitis), although this is rare. Chronic cholecystitis Chronic cholecystitis is the most common cause of symptomatic gallbladder disease. The patient gives a history of recurrent flatulence, fatty food intolerance and right upper quadrant pain. The pain is worse after meals and is often associated with a feeling of distension and heartburn. The differential diagnosis includes duodenal ulcer, hiatus hernia, myocardial ischaemia, chronic pancreatitis and gastrointestinal neoplasia. Symptoms for mucocoele are the same as those for chronic cholecystitis but a nontender piriform swelling may be palpable in the right hypochondrium. Management of acute cholecystitis Patients with acute cholecystitis are admitted to hospital to be monitored; analgesics, intravenous fluid and a broad-spectrum antibiotic such as a cephalosporin are prescribed. The duration of the illness and hospitalisation is reduced, and further attacks of acute cholecystitis during the waiting period for elective surgery are averted. In hospitals serving populations with a high burden of disease, dedicated processes, access to appropriate investigations and facilities alongside experienced surgical staff are key requirements for successfully managing these patients via an acute pathway. There is little muscle in the wall of the bile duct, and pain is not a symptom unless the stone impedes flow through the sphincter of Oddi. Impaction of a stone at the sphincter obstructs the flow of bile, producing jaundice, pale stools and dark urine. Obstruction commonly persists for several days but may clear spontaneously, as a result either of passage of the stone or of its disimpaction. In longstanding obstruction the bile ducts become markedly dilated and the diameter of the common bile duct may exceed its upper limit of 7 mm. Long-standing intermittent biliary obstruction may lead to secondary biliary cirrhosis. Obstructive jaundice due to stones in the common bile duct has to be distinguished from other causes of obstructive jaundice, notably malignant obstruction and cholestatic jaundice. Acute viral or alcoholic hepatitis may occasionally be confused with obstructive jaundice. Acute pancreatitis may be associated with a stone in the common bile duct (Chapter 15). Simply stated, if the gallbladder is palpable in the presence of jaundice, the jaundice is unlikely to be due to stone and one should think of a malignant cause of the lower extrahepatic biliary tree. However, exceptions to the law are due to double impaction of the cystic duct and the common bile duct due to stone, pancreatic duct calculi, and worm-induced obstruction (ascaris or clonorchis). Distended gallbladders are not always easy to feel but can be detected readily by ultrasound. If the patient is unfit for surgery, has a delayed presentation or disease severity suggests surrounding inflammation, this will make identification of the relevant anatomical structures difficult. Ultrasound-guided percutaneous drainage of the gallbladder may be performed as an interim measure.
The fibrinous exudate effectively glues the omentum to the inflamed viscus muscle relaxant oral generic colospa 135 mg online, walling it off and preventing further spread of the inflammatory process muscle relaxant carisoprodol discount 135mg colospa with amex. In addition muscle relaxant cz 10 purchase 135 mg colospa fast delivery, the exudate inhibits intestinal peristalsis spasms everywhere purchase colospa amex, resulting in a paralytic ileus, which limits the spread of the inflammation and infection. As a result of the ileus, fluid accumulates within the lumen of the intestine and, along with the formation of intraperitoneal transudate and exudate, this leads to a decrease in the intravascular volume, producing the clinical features of hypovolaemia. Infarction An infarct is an area of ischaemic necrosis caused either by an occlusion of the arterial supply or the venous drainage in a particular tissue, or by a generalised hypoperfusion in the context of shock (Table 12. An inflammatory response begins to develop along the margins of an infarct within a few hours, stimulated by the presence of the necrotic tissue. The consequences of decreased perfusion of a tissue depend on several factors: the availability of an alternative vascular supply, the rate of development of the hypoperfusion, the vulnerability of the tissue to hypoxia, and the blood oxygen content. In the context of acute abdominal pain, intestinal infarction is the most common cause. Other organs that may infarct include the ovaries, kidneys, testes, liver, spleen and pancreas. Clinical features In general, the patient will complain of severe abdominal pain and the onset will depend on the nature of the underlying process. Embolisation will result in sudden onset of pain, whereas the onset in thrombosis is likely to be more gradual. It may be caused by the presence of a lesion within the lumen of the viscus, an abnormality in its wall, or a lesion outside the viscus causing extrinsic compression. The smooth muscle in the wall of the obstructed viscus will contract in an effort to overcome the impedance. If the obstruction is not overcome, there will be an increase in intraluminal pressure and proximal dilatation. The end result depends on the anatomical location of the obstruction, whether it is partial or complete, and whether the blood supply to the organ is compromised. An obstructed inguinal hernia, on the other hand, will not only produce proximal dilatation of the intestine (usually associated with vomiting) but may also result in ischaemia of the bowel wall, leading to infarction and perforation. Perforation Spontaneous perforation of an intraabdominal viscus may be the result of a range of pathological processes. Weakening of the wall of the viscus, which might be associated with a locally advanced malignancy of the bowel, as well as degeneration, inflammation, infection or ischaemia, will all predispose to perforation. An increase in the intraluminal pressure of a viscus, such as occurs in a closed-loop obstruction. Perforation can also be iatrogenic, and may occur during the insertion of a Verres needle at laparoscopy, because of a careless cut or suture placement during surgery, and during the course of an endoscopic procedure. The resultant clinical picture depends on the nature of the perforated viscus and the relative sterility and toxicity of the material within the abdominal cavity, in addition to the speed with which the perforation is surrounded and sealed (if at all) by the adjacent structures and omentum. The inevitable peritoneal contamination will lead to either localised or generalised peritonitis, and the associated symptoms and signs, as already discussed. Clinical assessment the ability to make an accurate assessment by taking a good history and performing an appropriate examination is a vital skill in the management of the patient with acute abdominal pain. Although an exact diagnosis is often impossible to make after a detailed history and initial assessment, and often relies on further investigations, it is the formulation of an appropriate, safe and effective management plan that is the most important issue. Right hypochondrium Epigastrium Left hypochondrium History the main presenting complaint of patients with an acute abdomen is pain. However, the importance of a full history is very important and is essential in all patients. In order to describe the site of pain, the abdomen is traditionally divided into either quarters or nine regions (Figs 12. Right Left iliac Hypogastrium iliac or fossa fossa suprapubic region Nature of pain As discussed above, inflammation produces a constant pain made worse by local or general disturbance, and pain which is made worse by movement or coughing suggests inflammation of the parietal peritoneum. In this situation, the patient will often be seen to lie very still to avoid exacerbating the pain. The pain itself is severe and may be helped by moving around or drawing the knees up towards the chest. Underlying inflammation must be suspected when a colicky pain does not disappear between spasms, or becomes continuous. In the case of intestinal obstruction, this might mean strangulation, for which urgent surgery is required. For example, pain from a duodenal ulcer may radiate through to the back, indicating that inflammation has occurred through the wall of the duodenum to involve structures of the posterior abdominal wall, such as the pancreas and retroperitoneum. Ureteric pain radiates to the tip of the penis in men and to the area around the urethra in women. Typically, pain from a perforation is sudden and that from inflammation is gradual. Patients with the former can usually remember exactly what they were doing at the time of onset, whereas in the latter localisation in time is more difficult. Furthermore, it is often useful to ask the patient to rate pain severity using a score on a numerical or pictorial scale (visual analogue scale). Examination During the course of taking a history it is possible to form a general impression of the state of the patient. The unwell patient with acute abdominal pain may look pale and sweaty, lie flat on the bed, be cerebrally obtunded, and be unable to move without Perforation experiencing pain. Others, however, may look surprisingly well, have a good colour, sit up in bed, talk normally and be able to move freely.