Pancreatitis Health Dictionary

Insulin-dependent and non-insulindependent diabetes have a varied pathological pattern and are caused by the interaction of several genetic and environmental factors.

Insulin-dependent diabetes mellitus (IDDM) (juvenile-onset diabetes, type 1 diabetes) describes subjects with a severe de?ciency or absence of insulin production. Insulin therapy is essential to prevent KETOSIS – a disturbance of the body’s acid/base balance and an accumulation of ketones in the tissues. The onset is most commonly during childhood, but can occur at any age. Symptoms are acute and weight loss is common.

Non-insulin-dependent diabetes mellitus (NIDDM) (maturity-onset diabetes, type 2 diabetes) may be further sub-divided into obese and non-obese groups. This type usually occurs after the age of 40 years with an insidious onset. Subjects are often overweight and weight loss is uncommon. Ketosis rarely develops. Insulin production is reduced but not absent.

A new hormone has been identi?ed linking obesity to type 2 diabetes. Called resistin – because of its resistance to insulin – it was ?rst found in mice but has since been identi?ed in humans. Researchers in the United States believe that the hormone may, in part, explain how obesity predisposes people to diabetes. Their hypothesis is that a protein in the body’s fat cells triggers insulin resistance around the body. Other research suggests that type 2 diabetes may now be occurring in obese children; this could indicate that children should be eating a more-balanced diet and taking more exercise.

Diabetes associated with other conditions (a) Due to pancreatic disease – for example, chronic pancreatitis (see PANCREAS, DISORDERS OF); (b) secondary to drugs – for example, GLUCOCORTICOIDS (see PANCREAS, DISORDERS OF); (c) excess hormone production

– for example, growth hormone (ACROMEGALY); (d) insulin receptor abnormalities; (e) genetic syndromes (see GENETIC DISORDERS).

Gestational diabetes Diabetes occurring in pregnancy and resolving afterwards.

Aetiology Insulin-dependent diabetes occurs as a result of autoimmune destruction of beta cells within the PANCREAS. Genetic in?uences are important and individuals with certain HLA tissue types (HLA DR3 and HLA DR4) are more at risk; however, the risks associated with the HLA genes are small. If one parent has IDDM, the risk of a child developing IDDM by the age of 25 years is 1·5–2·5 per cent, and the risk of a sibling of an IDDM subject developing diabetes is about 3 per cent.

Non-insulin-dependent diabetes has no HLA association, but the genetic in?uences are much stronger. The risks of developing diabetes vary with di?erent races. Obesity, decreased exercise and ageing increase the risks of disease development. The risk of a sibling of a NIDDM subject developing NIDDM up to the age of 80 years is 30–40 per cent.

Diet Many NIDDM diabetics may be treated with diet alone. For those subjects who are overweight, weight loss is important, although often unsuccessful. A diet high in complex carbohydrate, high in ?bre, low in fat and aiming towards ideal body weight is prescribed. Subjects taking insulin need to eat at regular intervals in relation to their insulin regime and missing meals may result in hypoglycaemia, a lowering of the amount of glucose in the blood, which if untreated can be fatal (see below).

Oral hypoglycaemics are used in the treatment of non-insulin-dependent diabetes in addition to diet, when diet alone fails to control blood-sugar levels. (a) SULPHONYLUREAS act mainly by increasing the production of insulin;

(b) BIGUANIDES, of which only metformin is available, may be used alone or in addition to sulphonylureas. Metformin’s main actions are to lower the production of glucose by the liver and improve its uptake in the peripheral tissues.

Complications The risks of complications increase with duration of disease.

Diabetic hypoglycaemia occurs when amounts of glucose in the blood become low. This may occur in subjects taking sulphonylureas or insulin. Symptoms usually develop when the glucose concentration falls below 2·5 mmol/l. They may, however, occur at higher concentrations in subjects with persistent hyperglycaemia – an excess of glucose – and at lower levels in subjects with persistent hypo-glycaemia. Symptoms include confusion, hunger and sweating, with coma developing if blood-sugar concentrations remain low. Re?ned sugar followed by complex carbohydrate will return the glucose concentration to normal. If the subject is unable to swallow, glucagon may be given intramuscularly or glucose intravenously, followed by oral carbohydrate, once the subject is able to swallow.

Although it has been shown that careful control of the patient’s metabolism prevents late complications in the small blood vessels, the risk of hypoglycaemia is increased and patients need to be well motivated to keep to their dietary and treatment regime. This regime is also very expensive. All risk factors for the patient’s cardiovascular system – not simply controlling hyperglycaemia – may need to be reduced if late complications to the cardiovascular system are to be avoided.

Diabetes is one of the world’s most serious health problems. Recent projections suggest that the disorder will affect nearly 240 million individuals worldwide by 2010 – double its prevalence in 1994. The incidence of insulin-dependent diabetes is rising in young children; they will be liable to develop late complications.

Although there are complications associated with diabetes, many subjects live normal lives and survive to an old age. People with diabetes or their relatives can obtain advice from Diabetes UK (www.diabetes.org.uk).

Increased risks are present of (a) heart disease, (b) peripheral vascular disease, and (c) cerebrovascular disease.

Diabetic eye disease (a) retinopathy, (b) cataract. Regular examination of the fundus enables any abnormalities developing to be detected and treatment given when appropriate to preserve eyesight.

Nephropathy Subjects with diabetes may develop kidney damage which can result in renal failure.

Neuropathy (a) Symmetrical sensory polyneuropathy; damage to the sensory nerves that commonly presents with tingling, numbness of pain in the feet or hands. (b) Asymmetrical motor diabetic neuropathy, presenting as progressive weakness and wasting of the proximal muscles of legs. (c) Mononeuropathy; individual motor or sensory nerves may be affected. (d) Autonomic neuropathy, which affects the autonomic nervous system, has many presentations including IMPOTENCE, diarrhoea or constipation and postural HYPOTENSION.

Skin lesions There are several skin disorders associated with diabetes, including: (a) necrobiosis lipoidica diabeticorum, characterised by one or more yellow atrophic lesions on the legs;

(b) ulcers, which most commonly occur on the feet due to peripheral vascular disease, neuropathy and infection. Foot care is very important.

Diabetic ketoacidosis occurs when there is insu?cient insulin present to prevent KETONE production. This may occur before the diagnosis of IDDM or when insu?cient insulin is being given. The presence of large amounts of ketones in the urine indicates excess ketone production and treatment should be sought immediately. Coma and death may result if the condition is left untreated.

Symptoms Thirst, POLYURIA, GLYCOSURIA, weight loss despite eating, and recurrent infections (e.g. BALANITIS and infections of the VULVA) are the main symptoms.

However, subjects with non-insulindependent diabetes may have the disease for several years without symptoms, and diagnosis is often made incidentally or when presenting with a complication of the disease.

Treatment of diabetes aims to prevent symptoms, restore carbohydrate metabolism to as near normal as possible, and to minimise complications. Concentration of glucose, fructosamine and glycated haemoglobin in the blood are used to give an indication of blood-glucose control.

Insulin-dependent diabetes requires insulin for treatment. Non-insulin-dependent diabetes may be treated with diet, oral HYPOGLYCAEMIC AGENTS or insulin.

Insulin All insulin is injected – mainly by syringe but sometimes by insulin pump – because it is inactivated by gastrointestinal enzymes. There are three main types of insulin preparation: (a) short action (approximately six hours), with rapid onset; (b) intermediate action (approximately 12 hours); (c) long action, with slow onset and lasting for up to 36 hours. Human, porcine and bovine preparations are available. Much of the insulin now used is prepared by genetic engineering techniques from micro-organisms. There are many regimens of insulin treatment involving di?erent combinations of insulin; regimens vary depending on the requirements of the patients, most of whom administer the insulin themselves. Carbohydrate intake, energy expenditure and the presence of infection are important determinants of insulin requirements on a day-to-day basis.

A new treatment for diabetes, pioneered in Canada and entering its preliminary clinical trials in the UK, is the transplantation of islet cells of Langerhans from a healthy person into a patient with the disorder. If the transplantation is successful, the transplanted cells start producing insulin, thus reducing or eliminating the requirement for regular insulin injections. If successful the trials would be a signi?cant advance in the treatment of diabetes.

Scientists in Israel have developed a drug, Dia Pep 277, which stops the body’s immune system from destroying pancratic ? cells as happens in insulin-dependent diabetes. The drug, given by injection, o?ers the possibility of preventing type 1 diabetes in healthy people at genetic risk of developing the disorder, and of checking its progression in affected individuals whose ? cells are already perishing. Trials of the drug are in progress.... diabetes mellitus

Treatment There is evidence that therapy which lowers the lipid concentration reduces the progression of premature atheroma, particularly in those who suffer from the familial disorder. Treatment should include appropriate diets, usually food that is low in cholesterol and saturated fats. There are a number of drugs available for lowering the lipid content of the plasma, but these should be reserved for patients in whom severe hyperlipidaemia is inadequately controlled by weight reduction. Anion-exchange resins – clo?brate, beza?brate and gem?brozil, for example – and statins such as atorvastatin and simvastatin, as well as nicotinic acid, all lower plasma cholesterol and plasma triglyceride concentration through their e?ect on reducing the hepatic production of lipoproteins. Cholestyramine and colestipol, both of which are anion-exchange resins, bind bile salts in the gut and so decrease the absorption of the cholesterol that these bile salts contain – hence lowering plasma cholesterol concentrations. Probucol lowers plasma cholesterol concentrations by increasing the metabolism of low-density lipoproteins.

The statins (atorvastatin, cerivastatin, ?uvastatin, pravastatin and simvastatin) inhibit an enzyme involved in synthesising cholesterol, especially in the liver. They are more e?ective than anion-exchange resins in lowering LDL (low-density lipoprotein) cholesterol – a form of low-density cholesterol carried in the bloodstream, high levels of which are believed to be the main cause of atheroma. Statins are, however, less e?ective than the clo?brate group in reducing triglycerides and raising HDL (highdensity lipoprotein) cholesterol (high-density cholesterol).... hyperlipidaemia

Pancreatectomy may be performed to treat pancreatitis or localized cancer of the pancreas (see pancreas, cancer of).

Rarely, it is performed to treat insulinomas.

Pancreatectomy may lead to diabetes mellitus and malabsorption.... pancreatectomy

Common symptoms are diarrhoea and weight loss; and in severe cases, there may also be malnutrition (see nutritional disorders), vitamin deficiency, mineral deficiency, or anaemia. Diagnosis may be made by tests on faeces, blood tests, barium X-ray examination and jejunal biopsy. In most cases, dietary modifications or supplements are successful in treating the disorder. In severe cases, intravenous infusion of nutrients is needed (see feeding, artificial).... malabsorption

Alcohol depresses the central nervous system and disturbs both mental and physical functioning. Even small doses of alcohol will slow a person’s re?exes and concentration; potentially dangerous effects when, for example, driving or operating machinery. Drunkenness causes slurred speech, muddled thinking, amnesia (memory loss), drowsiness, erectile IMPOTENCE, poor coordination and dulled reactions – thereby making driving or operating machinery especially dangerous. Disinhibition may lead to extreme euphoria, irritability, misery or aggression, depending on the underlying mood at the start of drinking. Severe intoxication may lead to COMA and respiratory failure.

Persistent alcohol misuse leads to physical, mental, social and occupational problems, as well as to a risk of DEPENDENCE (see also ALCOHOL DEPENDENCE). Misuse may follow several patterns: regular but controlled heavy intake, ‘binge’ drinking, and dependence (alcoholism). The ?rst pattern usually leads to mainly physical problems such as gastritis, peptic ulcer, liver disease, heart disease and impotence. The second is most common among young men and usually leads to mainly social and occupational problems – getting into ?ghts, jeopardising personal relationships, overspending on alcohol at weekends, and missing days o? work because of hangovers. The third pattern – alcohol dependence – is the most serious, and can severely disrupt health and social stability.

Many researchers consider alcohol dependence to be an illness that runs in families, with a genetic component which is probably passed on as a vulnerable personality. But it is hard to disentangle genetic, environmental and social factors in such families. In the UK there are estimated to be around a million people suffering from alcohol dependence and a similar number who have di?culty controlling their consumption (together about 1:30 of the population).

Alcohol causes tolerance and both physical and psychological dependence (see DEPENDENCE for de?nitions). Dependent drinkers classically drink early in the morning to relieve overnight withdrawal symptoms. These symptoms include anxiety, restlessness, nausea and vomiting, and tremor. Sudden withdrawal from regular heavy drinking can lead to life-threatening delirium tremens (DTs), with severe tremor, hallucinations (often visual – seeing spiders and monsters, rather than the pink elephants of romantic myth), and CONVULSIONS. This must be treated urgently with sedative drugs, preferably by intravenous drip. Similar symptoms, plus severe INCOORDINATION and double-vision, can occur in WERNICKE’S ENCEPHALOPATHY, a serious neurological condition due to lack of the B vitamin thiamine (whose absorption from the stomach is markedly reduced by alcohol). If not treated urgently with injections of thiamine and other vitamins, this can lead to an irreversible form of brain damage called Korsako?’s psychosis, with severe amnesia. Finally, prolonged alcohol misuse can cause a form of dementia.

In addition to these severe neurological disorders, the wide range of life-threatening problems caused by heavy drinking includes HEPATITIS, liver CIRRHOSIS, pancreatitis (see PANCREAS, DISEASES OF), gastrointestinal haemorrhage, suicide and FETAL ALCOHOL SYNDROME; pregnant women should not drink alcohol as this syndrome may occur with more than a glass of wine or half-pint of beer a day. The social effects of alcohol misuse – such as marital breakdown, family violence and severe debt – can be equally devastating.

Treatment of alcohol-related problems is only moderately successful. First, many of the physical problems are treated in the short term by doctors who fail to spot, or never ask about, heavy drinking. Second, attempts at treating alcohol dependence by detoxi?cation or ‘drying out’ (substituting a tranquillising drug for alcohol and withdrawing it gradually over about a week) are not always followed-up by adequate support at home, so that drinking starts again. Home support by community alcohol teams comprising doctors, nurses, social workers and, when appropriate, probation o?cers is a recent development that may have better results. Many drinkers ?nd the voluntary organisation Alcoholics Anonymous (AA) and its related groups for relatives (Al-Anon) and teenagers (Alateen) helpful because total abstinence from alcohol is encouraged by intensive psychological and social support from fellow ex-drinkers.

Useful contacts are: Alcoholics Anonymous; Al-Anon Family Groups UK and Eire (including Alateen); Alcohol Concern; Alcohol Focus Scotland; and Alcohol and Substance Misuse.

1 standard drink =1 unit

=••• pint of beer

=1 measure of spirits

=1 glass of sherry or vermouth

=1 glass of wine

Limits within which alcohol is believed not to cause long-term health risks:... alcohol

K

Diagram of glomerulus (Malpighian corpuscle).

Fortunately the body has two kidneys and, as most people can survive on one, there is a good ‘functional reserve’ of kidney tissue.

Symptoms Many patients with kidney disorders do not have any symptoms, even when the condition is quite advanced. However,

others experience loin pain associated with obstruction (renal colic) or due to infection; fevers; swelling (oedema), usually of the legs but occasionally including the face and arms; blood in the urine (haematuria); and excess quantities of urine (polyuria), including at night (nocturia), due to failure of normal mechanisms in the kidney for concentrating urine. Patients with chronic renal failure often have very di?use symptoms including nausea and vomiting, tiredness due to ANAEMIA, shortness of breath, skin irritation, pins and needles (paraesthesia) due to damage of the peripheral nerves (peripheral neuropathy), and eventually (rarely seen nowadays) clouding of consciousness and death.

Signs of kidney disease include loin tenderness, enlarged kidneys, signs of ?uid retention, high blood pressure and, in patients with end-stage renal failure, pallor, pigmentation and a variety of neurological signs including absent re?exes, reduced sensation, and a coarse ?apping tremor (asterixis) due to severe disturbance of the body’s normal metabolism.

Renal failure Serious kidney disease may lead to impairment or failure of the kidney’s ability to ?lter waste products from the blood and excrete them in the urine – a process that controls the body’s water and salt balance and helps to maintain a stable blood pressure. Failure of this process causes URAEMIA – an increase in urea and other metabolic waste products – as well as other metabolic upsets in the blood and tissues, all of which produce varying symptoms. Failure can be sudden or develop more slowly (chronic). In the former, function usually returns to normal once the underlying cause has been treated. Chronic failure, however, usually irreparably reduces or stops normal function.

Acute failure commonly results from physiological shock following a bad injury or major illness. Serious bleeding or burns can reduce blood volume and pressure to the point where blood-supply to the kidney is greatly reduced. Acute myocardial infarction (see HEART, DISEASES OF) or pancreatitis (see PANCREAS, DISORDERS OF) may produce a similar result. A mismatched blood transfusion can produce acute failure. Obstruction to the urine-?ow by a stone (calculus) in the urinary tract, a bladder tumour or an enlarged prostate can also cause acute renal failure, as can glomerulonephritis (see below) and the haemolytic-uraemia syndrome.

HYPERTENSION, DIABETES MELLITUS, polycystic kidney disease (see below) or AMYLOIDOSIS are among conditions that cause chronic renal failure. Others include stone, tumour, prostatic enlargement and overuse of analgesic drugs. Chronic failure may eventually lead to end-stage renal failure, a life-threatening situation that will need DIALYSIS or a renal transplant (see TRANSPLANTATION).

Familial renal disorders include autosomal dominant inherited polycystic kidney disease and sex-linked familial nephropathy. Polycystic kidney disease is an important cause of renal failure in the UK. Patients, usually aged 30–50, present with HAEMATURIA, loin or abdominal discomfort or, rarely, urinary-tract infection, hypertension and enlarged kidneys. Diagnosis is based on ultrasound examination of the abdomen. Complications include renal failure, hepatic cysts and, rarely, SUBARACHNOID HAEMORRHAGE. No speci?c treatment is available. Familial nephropathy occurs more often in boys than in girls and commonly presents as Alport’s syndrome (familial nephritis with nerve DEAFNESS) with PROTEINURIA, haematuria, progressing to renal failure and deafness. The cause of the disease lies in an absence of a speci?c ANTIGEN in a part of the glomerulus. The treatment is conservative, with most patients eventually requiring dialysis or transplantation.

Acute glomerulonephritis is an immune-complex disorder due to entrapment within glomerular capillaries of ANTIGEN (usually derived from B haemolytic streptococci – see STREPTOCOCCUS) antibody complexes initiating an acute in?ammatory response (see IMMUNITY). The disease affects children and young adults, and classically presents with a sore throat followed two weeks later by a fall in urine output (oliguria), haematuria, hypertension and mildly abnormal renal function. The disease is self-limiting with 90 per cent of patients spontaneously recovering. Treatment consists of control of blood pressure, reduced ?uid and salt intake, and occasional DIURETICS and ANTIBIOTICS.

Chronic glomerulonephritis is also due to immunological renal problems and is also classi?ed by taking a renal biopsy. It may be subdivided into various histological varieties as determined by renal biospy. Proteinuria of various degrees is present in all these conditions but the clinical presentations vary, as do their treatments. Some resolve spontaneously; others are treated with steroids or even the cytotoxic drug CYCLOPHOSPHAMIDE or the immunosuppressant cyclosporin. Prognoses are generally satisfactory but some patients may require renal dialysis or kidney transplantation – an operation with a good success rate.

Hydronephrosis A chronic disease in which the kidney becomes greatly distended with ?uid. It is caused by obstruction to the ?ow of urine at the pelvi-ureteric junction (see KIDNEYS – Structure). If the ureter is obstructed, the ureter proximal to the obstruction will dilate and pressure will be transmitted back to the kidney to cause hydronephrosis. Obstruction may occur at the bladder neck or in the urethra itself. Enlargement of the prostate is a common cause of bladder-neck obstruction; this would give rise to hypertrophy of the bladder muscle and both dilatation of the ureter and hydronephrosis. If the obstruction is not relieved, progressive destruction of renal tissue will occur. As a result of the stagnation of the urine, infection is probable and CYSTITIS and PYELONEPHRITIS may occur.

Impaired blood supply may be the outcome of diabetes mellitus and physiological shock, which lowers the blood pressure, also affecting the blood supply. The result can be acute tubular necrosis. POLYARTERITIS NODOSA and SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) may damage the large blood vessels in the kidney. Treatment is of the underlying condition.

Infection of the kidney is called pyelonephritis, a key predisposing factor being obstruction of urine ?ow through the urinary tract. This causes stagnation and provides a fertile ground for bacterial growth. Acute pyelonephritis is more common in women, especially during pregnancy when bladder infection (CYSTITIS) spreads up the ureters to the kidney. Symptoms are fever, malaise and backache. Antibiotics and high ?uid intake are the most e?ective treatment. Chronic pyelonephritis may start in childhood as a result of congenital deformities that permit urine to ?ow up from the bladder to the kidney (re?ux). Persistent re?ux leads to recurrent infections causing permanent damage to the kidney. Specialist investigations are usually required as possible complications include hypertension and kidney failure.

Tumours of the kidney are fortunately rare. Non-malignant ones commonly do not cause symptoms, and even malignant tumours (renal cell carcinoma) may be asymptomatic for many years. As soon as symptoms appear – haematuria, back pain, nausea, malaise, sometimes secondary growths in the lungs, bones or liver, and weight loss – urgent treatment including surgery, radiotherapy and chemotherapy is necessary. This cancer occurs mostly in adults over 40 and has a hereditary element. The prognosis is not good unless diagnosed early. In young children a rare cancer called nephroblastoma (Wilm’s tumour) can occur; treatment is with surgery, radiotherapy and chemotherapy. It may grow to a substantial size before being diagnosed.

Cystinuria is an inherited metabolic defect in the renal tubular reabsorption of cystine, ornithine, lysine and arginine. Cystine precipitates in an alkaline urine to form cystine stones. Triple phosphate stones are associated with infection and may develop into a very large branching calculi (staghorn calculi). Stones present as renal or ureteric pain, or as an infection. Treatment has undergone considerable change with the introduction of MINIMALLY INVASIVE SURGERY (MIS) and the destruction of stone by sound waves (LITHOTRIPSY).... kidneys, diseases of

The purpose of enteral feeding is to give a liquid, low-residue food through a naso-gastric feeding tube. It has the advantage over parenteral nutrition that the septic complications of insertion of CATHETERS into veins are avoided. Enteral feeding may either take the form of intermittent feeding through a large-bore naso-gastric tube, or of continuous gravity-feeding through a ?ne-bore tube.

A number of proprietary enteral foods are available. Some contain whole protein as the nitrogen source; others – and these are called elemental diets – contain free amino acids. DIARRHOEA is the most common problem with enteral feeding and it tends to occur when enteral feeding is introduced too rapidly or with too strong a preparation.... enteral feeding

Severe hypothermia is sometimes complicated by gastric erosions and haemorrhage, as well as pancreatitis (see PANCREAS, DISORDERS OF). Infants and the elderly are less e?cient at regulating temperature and conserving heat than other age groups, and are therefore more at risk from accidental hypothermia during cold weather if their accommodation is not warm enough. Approximately half a million elderly people are at risk in Britain each winter from hypothermia. The other major cause of accidental hypothermia is near-drowning in icy water. Deliberate hypothermia is sometimes used to reduce metabolic rate so that prolonged periods of cardiac arrest may occur without tissue HYPOXIA developing. This technique is used for some cardiac and neurosurgical operations and is produced by immersion of the anaesthetised patient in iced water or by cooling an extracorporeal circulation.

Treatment of hypothermia is by warming the patient and treating any complications that arise. Passive warming is usual, with conservation of the patient’s own body heat with insulating blankets. If the core temperature is below 28 °C, then active rewarming should be instituted by means of warm peritoneal, gastric or bladder lavage or using an extracorporeal circulation. Care must be taken in moving hypothermic patients, as a sudden rush of cold peripheral blood to the heart can precipitate ventricular ?brillation. Prevention of hypothermia in the elderly is important. Special attention must be paid to diet, heating the home and adequate clothing in several layers to limit heat loss.... hypothermia

METABOLIC DISORDERS such as URAEMIA and pancreatitis (see PANCREAS, DISORDERS OF)

Bowel infarction

Drug ingestion

Massive blood transfusion, transfusion reaction (see TRANSFUSION OF BLOOD), CARDIOPULMONARY BYPASS, disseminated intravascular coagulation

Treatment The principles of management are supportive, with treatment of the underlying condition if that is possible. Oxygenation is improved by increasing the concentration of oxygen breathed in by the patient, usually with mechanical ventilation of the lungs, often using continuous positive airways pressure (CPAP). Attempts are made to reduce the formation of pulmonary oedema by careful management of how much ?uid is given to the patient (?uid balance). Infection is treated if it arises, as are the possible complications of prolonged ventilation with low lung compliance (e.g. PNEUMOTHORAX). There is some evidence that giving surfactant through a nebuliser or aerosol may help to improve lung e?ectiveness and reduce oedema. Some experimental evidence supports the use of free-radical scavengers and ANTIOXIDANTS, but these are not commonly used. Other techniques include the inhalation of NITRIC OXIDE (NO) to moderate vascular tone, and prone positioning to improve breathing. In severe cases, extracorporeal gas exchange has been advocated as a supportive measure until the lungs have healed enough for adequate gas exchange. (See also RESPIRATORY DISTRESS SYNDROME; HYALINE MEMBRANE DISEASE; SARS.)... indirect insult

Pancreatic cancer The incidence of pancreatic cancer is rising: around 7,000 cases are now diagnosed annually in the UK, accounting for 1–2 per cent of all malignancies. There is an established association with heavy cigarette-smoking, and the cancer is twice as common in patients with diabetes mellitus as compared with the general population. Cancer of the pancreas is hard to diagnose; by the time symptoms occur the tumour may be di?cult to treat surgically – with PALLIATIVE bypass surgery the only procedure.

Chronic pancreatitis may be painless; it leads to pancreatic failure causing MALABSORPTION SYNDROME and diabetes mellitus, and the pancreas becomes calci?ed with shadowing on X-RAYS. The malabsorption is treated by a low-fat diet with pancreatic enzyme supplements; the diabetes with insulin; and pain is treated appropriately. Surgery may be required.

Acute pancreatitis An uncommon disease of the pancreas which may start gradually or suddenly, usually accompanied by severe abdominal pain which often radiates through to the back. Biliary tract disease and alcohol account for 80 per cent of patients admitted with acute pancreatitis, while other causes include drugs (see AZATHIOPRINE and DIURETICS) and infections such as MUMPS. Patients are acutely ill with TACHYCARDIA, fever and low blood pressure; many go into SHOCK. The condition may be mistaken for a perforated PEPTIC ULCER, except that in acute pancreatitis the blood concentration of AMYLASE is raised. The main complication is the formation of a PSEUDOCYST. Treatment includes intravenous feeding, ANTICHOLINERGIC drugs and ANALGESICS. Regular measurements of blood GLUCOSE, CALCIUM, amylase and blood gases are required. Abdominal ULTRASOUND may identify gall-stones (see under GALL-BLADDER, DISEASES OF). If the patient deteriorates, he or she should be admitted for intensive care as haemorrhagic pancreatic necrosis may be developing. LAPAROTOMY and DEBRIDEMENT may be called for. Mortality is 5–10%.... pancreas, disorders of

The preferred route for the infusion of hyperosmolar solutions is via a central venous catheter (see CATHETERS). If parenteral nutrition is required for more than two weeks, it is advisable to use a long-term type of catheter such as the Broviac, Hickman or extra-corporeal type, which is made of silastic material and is inserted via a long subcutaneous tunnel; this not only helps to ?x the catheter but also minimises the risk of ascending infection.

Dextrose is considered the best source of carbohydrate and may be used as a 20 per cent or 50 per cent solution. AMINO ACIDS should be in the laevo form and should contain the correct proportion of essential (indispensable) and non-essential amino acids. Preparations are available with or without electrolytes and with or without fat emulsions.

The main hazards of intravenous feeding are blood-borne infections made possible by continued direct access to the circulation, and biochemical abnormalities related to the composition of the solutions infused. The continuous use of hypertonic solutions of glucose can cause HYPERGLYCAEMIA and glycosuria and the resultant POLYURIA may lead to dehydration. Treatment with INSULIN is needed when hyper-osmolality occurs, and in addition the water and sodium de?cits will require to be corrected.... parenteral nutrition

Most attacks of hiccups last only a few minutes, and are not medically significant.

Rarely, they may be due to a condition, such as pneumonia or pancreatitis, that causes irritation of the diaphragm or phrenic nerves.

Chlorpromazine, haloperidol, or diazepam may be prescribed for frequent, prolonged attacks.... hiccup

Ultrasound is replacing ISOTOPE scanning in many situations, and also RADIOGRAPHY. Ultrasound of the liver can separate medical from surgical JAUNDICE in approximately 97 per cent of patients; it is very accurate in detecting and de?ning cystic lesions of the liver, but is less accurate with solid lesions – and yet will detect 85 per cent of secondary deposits (this is less than COMPUTED TOMOGRAPHY [CT] scanning). It is very accurate in detecting gall-stones (see GALL-BLADDER, DISEASES OF) and more accurate than the oral cholecystogram. It is useful as a screening test for pancreatic disease and can di?erentiate carcinoma of the pancreas from chronic pancreatitis with 85 per cent accuracy.

Ultrasound is the ?rst investigation indicated in patients presenting with renal failure, as it can quickly determine the size and shape of the kidney and whether there is any obstruction to the URETER. It is very sensitive to the presence of dilatation of the renal tract and will detect space-occupying lesions, di?erentiating cysts and tumours. It can detect also obstruction of the ureter due to renal stones by showing dilatations of the collecting system and the presence of the calculus. Adrenal (see ADRENAL GLANDS) tumours can be demonstrated by ultrasound, although it is less accurate than CT scanning.

The procedure is now the ?rst test for suspected aortic ANEURYSM and it can also show the presence of clot and delineate the true and false lumen. It is good at demonstrating subphrenic and subhepatic abscesses (see ABSCESS) and will show most intra-abdominal abscesses; CT scanning is however better for the retroperitoneal region. It has a major application in thyroid nodules as it can di?erentiate cystic from solid lesions and show the multiple lesions characteristic of the nodular GOITRE (see also THYROID GLAND, DISEASES OF). It cannot differentiate between a follicular adenoma and a carcinoma, as both these tumours are solid; nor can it demonstrate normal parathyroid glands. However, it can identify adenomas provided that they are more than 6 mm in diameter. Finally, ultrasound can di?erentiate masses in the SCROTUM into testicular and appendicular, and it can demonstrate impalpable testicular tumours. This is important as 15 per cent of testicular tumours metastasise whilst they are still impalpable.

Ultrasonic waves are one of the constituents in the shock treatment of certain types of gallstones and CALCULI in the urinary tract (see LITHOTRIPSY). They are also being used in the treatment of MENIÈRE’S DISEASE and of bruises and strains. In this ?eld of physiotherapy, ultrasonic therapy is proving of particular value in the treatment of acute injuries of soft tissue. If in such cases it is used immediately after the injury, or as soon as possible thereafter, prompt recovery is facilitated. For this reason it is being widely used in the treatment of sports injuries (see also SPORTS MEDICINE). The sound waves stimulate the healing process in damaged tissue.

Doppler ultrasound is a technique which shows the presence of vascular disease in the carotid and peripheral vessels, as it can detect the reduced blood ?ow through narrowed vessels.

Ultrasound in obstetrics Ultrasound has particular applications in obstetrics. A fetus can be seen with ultrasound from the seventh week of pregnancy, and the fetal heart can be demonstrated at this stage. Multiple pregnancy can also be diagnosed at this time by the demonstration of more than one gestation sac containing a viable fetus. A routine obstetric scan is usually performed between the 16th and 18th week of pregnancy when the fetus is easily demonstrated and most photogenic. The fetus can be measured to assess the gestational age, and the anatomy can also be checked. Intra-uterine growth retardation is much more reliably diagnosed by ultrasound than by clinical assessment. The site of the placenta can also be recorded and multiple pregnancies will be diagnosed at this stage. Fetal movements and even the heartbeat can be seen. A second scan is often done between the 32nd and 34th weeks to assess the position, size and growth rate of the baby. The resolution of equipment now available enables pre-natal diagnosis of a wide range of structural abnormalities to be diagnosed. SPINA BIFIDA, HYDROCEPHALUS and ANENCEPHALY are probably the most important, but other anomalies such as multicystic kidney, achondroplasia and certain congenital cardiac anomalies can also be identi?ed. Fetal gender can be determined from 20 weeks of gestation. Ultrasound is also useful as guidance for AMNIOCENTESIS.

In gynaecology, POLYCYSTIC OVARY SYNDROME can readily be detected as well as FIBROID and ovarian cysts. Ultrasound can monitor follicular growth when patients are being treated with infertility drugs. It is also useful in detecting ECTOPIC PREGNANCY. (See also PREGNANCY AND LABOUR.)... ultrasound

The most common lipid disorders are the hyperlipidaemias, which are characterized by high levels of lipids in the blood and can cause atherosclerosis and pancreatitis.

There are also some very rare lipid disorders due solely to heredity, such as Tay–Sachs disease.... lipid disorders

Symptoms. Weight loss. Pain upper abdomen. Change of bowel habit. Phlebitis. Low blood sugar. Sugar in the urine. Jaundice when head of the pancreas is involved. As little benefit is said to be gained from chemotherapy or radiotherapy, and because a majority of these tumours are unresectable, there would appear to be good grounds for herbal medicine, either as primary or supportive treatment.

Of possible therapeutic value for relief of accompanying gastric and pressure symptoms only: Sarsaparilla, Liquorice, Dandelion, Peppermint, Fennel, German Chamomile.

Tea. Barberry bark. 1 teaspoon to each cup of cold water. Steep overnight. Dose: half-1 cup 3 or more times daily.

Formula. Equal parts: Barberry bark, Dandelion, Galangal. Dose: Powders: 500mg (two 00 capsules or one-third teaspoon). Liquid extracts: 1 teaspoon (5ml). Tinctures: 2 teaspoons. Thrice daily to commence: after fourteen days increase as tolerated.

Primrose oil. High doses GLA believed to improve immune system and prevent weight loss.

Macrobiotic diet. A retired English doctor had cancer of the pancreas, inoperable, the size of a cricket ball, for which conventional treatment could do nothing. Regression being almost impossible, he would die within a few months. In the meantime he was advised to try the Macrobiotic diet comprising wholefoods, compost grown vegetables, vegetable oils and natural drinks such as carrot juice and herbal teas. He and his wife, living in Italy, carefully followed the diet, drank water only from a local spring and ate vegetables organically grown on their own land. The tumour diminished in size and the doctor recovered.

Note: Cessation of cigarette smoking will result in a decreased incidence of the disease in the male adult population. (American Journal of Public Health 1989 79 1016)

A substance found in fish oil has been shown experimentally to prevent cancer of the pancreas. Mackerel, herring and sardines are among fish with the ingredient.

Treatment by oncologist or general practitioner. ... cancer – pancreas

Most common cause is a tumour on one of the glands or swelling of all four. Bone fragility leads to fractures and deformity.

Alternatives. Formula. Equal parts: Gotu Kola, Red Clover, Goat’s Rue, Bladderwrack.

Tea: 1 heaped teaspoon to each cup boiling water; infuse 15 minutes; dose, 1 cup.

Liquid Extracts: one to two 5ml teaspoons in water.

Tinctures: one to three 5ml teaspoons in water.

Powders: 500mg (two 00 capsules or one-third teaspoon). Thrice daily. ... hyperparathyroidism

The mumps virus is spread in airborne droplets. The incubation period is 2–3 weeks; an affected person is infectious for about a week before and up to 2 weeks after symptoms appear.

Infected children often have no symptoms, or they may feel slightly unwell and have some discomfort around the parotid glands. In more serious cases, there is pain around the glands and chewing becomes difficult; one or both glands then become swollen, painful, and tender. A fever and headache may develop. The swelling subsides within a week to 10 days. When only one gland is affected, the second often swells as the first gland’s swelling subsides. Complications of mumps include viral meningitis, pancreatitis, and epididymo-orchitis.

Diagnosis is usually made from the symptoms. There is no specific treatment.... mumps

Vomiting may be due to overindulgence in food or alcohol, is a common side effect of many drugs, and may follow general anaesthesia. Vomiting is also common in gastrointestinal disorders such as peptic ulcer, acute appendicitis, gastroenteritis, and food poisoning. Less commonly, it is due to obstruction (see pyloric stenosis; intussusception) or a tumour of the digestive tract. It may also be due to inflammation (see hepatitis; pancreatitis; cholecystitis).

Other possible causes are pressure on the skull (see encephalitis; hydrocephalus; brain tumour; head injury; migraine), conditions affecting the ear’s balancing mechanism (see Ménière’s disease; labyrinthitis; motion sickness), and hormonal disorders (see Addison’s disease).

Vomiting may be a symptom of ketoacidosis in poorly controlled diabetes mellitus. It may also be a symptom of an emotional problem or be part of the disorders anorexia nervosa or bulimia.

Persistent vomiting requires medical investigation. Treatment depends on the cause. Antiemetics may be given. (See also vomiting blood; vomiting in pregnancy.)... vomiting