Medications can interfere with folate metabolism, including:
anticonvulsant medications (such as phenytoin, primidone, carbamazepine or valproate)
metformin (sometimes prescribed to control blood sugar in type 2 diabetes)
methotrexate, an anti-cancer drug also used to control inflammation associated with Crohn disease, ulcerative colitis and rheumatoid arthritis.
sulfasalazine (used to control inflammation associated with Crohn disease, ulcerative colitis and rheumatoid arthritis)
triamterene (a diuretic)
birth control pills
- Complication of open abdominal surgery, especially when the bowel is frequently manipulated, with possible disruption of bowel anastomosis, inadvertent enterotomy, or small bowel injury.
- Can occur as early as 8 days from initial laparotomy
- Other causes: cancer, irradiation, IBD
Enterocutaneous fistula: abnormal communication between the small or large bowel and the skin
Subtype enteroatmospheric fistula: abnormal communication between GI tract and the atmosphere, associated with high morbidity and mortality
Complications: sepsis, fluid and electrolyte abnormalities, malnutrition
Conservative treatment and electrolyte repletion, antibiotics (in case of infections), nutritional support, control of fistula drainage (e.g., ostomy pouch), skin protection
Spontaneous closure occurs in roughly 70% of patients
Surgical Treatment : attempted 1–4 months after trial of conservative therapy if no signs of spontaneous closure
Lysis of adhesions
Resection of abnormal or diseased bowel
Reanastamosis of healthy bowel
Umbilical cord prolapse
acute, life-threatening emergency for the fetus, in which a part of the umbilical cord lies between the antecedent part of the fetus (mostly head) and the pelvic wall, causing rupture of membranes
Epidemiology: rare (0.5% births)
Etiology: often seen in presentation anomalies (e.g., breech presentation, transverse fetal position), multiple pregnancy, long umbilical cord, or abnormal fetal movement (polyhydramnios, premature birth)
Clinical features: -
- an abrupt change from a previously normal CTG to one with fetal bradycardia or recurrent,
- severe decelerations,
- occuring after the rupture of membranes
Diagnostics: vaginal palpation → thick, pulsating cord is palpable
Treatment: Trendelenburg position; fetus is pushed back into the uterus; immediate tocolysis using β2-mimetics (e.g., fenoterol) → emergency cesarean section
Common pathogens attributed to food poisoning include Norovirus, Salmonella, Clostridium perfringens, Campylobacter jejuni, Staphylococcus aureus, and Escherichia coli.
Incubation periods depend on the cause, and range from a few hours to days. The clinical presentation associated with food poisoning varies, but typical symptoms include diarrhea, nausea, vomiting, and abdominal cramping.
Staphylococcal food poisoning
Pathogen: Staphylococcus aureus
Some strains produce heat-stable enterotoxins that cause staphylococcal food poisoning.
Transmission: ingestion of preformed toxins in contaminated food
Typically involves a short latency period; resolution of symptoms after 24–48 hours
Bacteria proliferate in inadequately refrigerated food (canned meats, mayonnaise/potato salad, custards).
Incubation period: 1–4 hours
Clinical findings: nausea, vomiting, abdominal discomfort, diarrhea
Bacillus cereus infection
Pathogen: Bacillus cereus, a heat-stable, spore-forming bacterium that produces two different enterotoxins
Transmission: The bacterium grows in heated food that cools down too slowly or is improperly refrigerated. Reheated rice is a common source of infection.
Incubation period and clinical findings
Enterotoxin I (emetic form): 30 min to 6 h after ingestion → nausea and vomiting
Enterotoxin II (diarrheal form): 6–15 h after ingestion → watery diarrhea for 24–48 h
Food poisoning from reheated rice - (B. cereus).
L: Lungs - Atypical pneumonia.
Relatively nonproductive cough
Pleuritic or non pleuritic chest pain
Confluent or patchy infiltrates on x-ray
Random fact: Interstitial infiltrates aren’t seen often like in other atypical pneumonias.
E: Encephalon - Neurologic abnormalities.
Confusion or changes in mental status
G: Gastrointestinal symptoms.
ION: Na ion decreases.
Hyponatremia (serum sodium level of 131 meq/L)
Rheumatic fever occurs after a streptococcal infection (usually caused by Group A Beta-Hemolytic Strep (GABHS)).
It is an inflammatory condition that affects the joints, skin, heart and brain.
Major criteria are referred to as Jones criteria
J – Joint involvement which is usually migratory and inflammatory joint involvement that starts in the lower joints and ascends to upper joints
O – (“O” Looks like heart shape) – indicating that patients can develop myocarditis or inflammation of the heart
N – Nodules that are subcutaneous
E – Erythema marginatum which is a rash of ring-like lesions that can start in the trunk or arms. When joined with other rings, it can create a snake-like appearance
S – Sydenham chorea is a late feature which is characterized by jerky, uncontrollable, and purposeless movements resembling twitches
Minor criteria include
C – CRP Increased
A – Arthralgia
F – Fever
E – Elevated ESR
P – Prolonged PR Interval
A – Anamesis
L – Leukocytosis
Diagnosis of rheumatic fever is made after a strep infection (indicated by either throat cultures growing GABHS OR elevated anti-streptolysin O titers in the blood) and:
Two major criteria OR
One major criterion and two minor criteria
- any cause of acute pericarditis may result in chronic pericarditis
- dyspnea, fatigue, palpitations
- abdominal pain
- general examination - mimics CHF (especially right-sided HF)
• ascites, hepatosplenomegaly, edema
- pulses: increased JVP, Kussmaul's sign (paradoxical increased in JVP with inspiration),
- Friedrich's sign (prominent “y” descent > “x” descent)
- pressures: BP normal to decreased, +/– pulsus paradoxus
- precordial examination: +/– pericardial knock (early diastolic sound)
- 12 lead ECG: low voltage, flat T wave, +/– AF
- chest x-ray: pericardial calcification, effusions
- CT or MRI: pericardial thickening
- cardiac catheterization: equalization of RV and LV diastolic pressures, RVEDP > 1/3 of RV systolic pressure
- medical: diuretics, salt restriction
- surgical: pericardiectomy
TYPES OF TRACHEOSTOMY TUBE
Metallic Tracheostomy Tube
Nonmetallic Tracheostomy Tube
Cuffed Tracheostomy Tubes
Uncuffed Tracheostomy Tubes
Nonmetallic Tracheostomy Tube - Cuffed tubes are used in situation where positive pressure ventilation is required, or when the airway is at risk from aspiration. (In unconscious patient or when patient is on respiration).
Metallic Tracheostomy Tube -Metallic tubes are formed from the alloy of silver, copper and phosphorus .
Purines synthesis and metabolism
Purines are biologically synthesized as nucleotides and in particular as ribotides, i.e. bases attached to ribose 5-phosphate. Both adenine and guanine are derived from the nucleotide inosine monophosphate (IMP), which is the first compound in the pathway to have a completely formed purine ring system
The major site of purine synthesis is in the liver. Synthesis of the purine nucleotides begins with PRPP and leads to the first fully formed nucleotide, inosine 5'-monophosphate (IMP). This pathway is diagrammed below. The purine base without the attached ribose moiety is hypoxanthine.
Biosynthesis of purine and pyrimidine nucleotides requires carbon dioxide and the amide nitrogen of glutamine. Both use an amino acid nucleus – glycine in purine biosynthesis and aspartate in pyrimidine biosynthesis. Both use PRPP as the source of ribose 1-phosphate.
The end product of purine catabolism in man is uric acid.
Biosynthesis Of Pyrimidine Nucleotides
CO2 reacts with N of glutamine to form carbamoyl phosphate, which fuses with aspartate to form carbamoyl aspartate.
Carbamoyl aspartate on ring closure forms the first pyrimidine ring named OROTATE.
Orotate combines with PRPP to form OMP which is the first pyrimidine nucleotide.
OMP forms UMP which can be converted to CMP or dTMP
Management of H. Pylori Infection
- Gram – rod
- Causes erosion of protective epithelial cells -> gastritis or peptic ulcer
H2 antagonist or PPI + Abx
- Metronidazole or amoxicillin/clarithromycin
- PPI + 2 or 3 antimicrobials is standard
- Ex: Ranitidine + Peptobismol + Clarithromycin + Amoxicillin 7-14 days
-Add bismuth if resistant H. pylori
- Ex: PPI + BMT (Bismuth + Metronidazole + tetracycline) 7days
Treatment for ZE Syndrome
- Gastrinoma of the duodenum or pancreas
-Elevated gastrin levels- Peptic/gastric ulcers
High dose PPI until resorting to surgery or chemotherapy for tumor removal