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Isopropyl alcohol ingestion is distinguished only once a specific drug level is done by the history or once acidosis has developed in the absence of an elevated anion gap phenergan 25mg without prescription anxiety symptoms jaw pain. Methanol and ethylene glycol will be characterized by an increased serum osmolar gap and metabolic acidosis with an elevated anion gap buy phenergan 25 mg amex anxiety symptoms 6 dpo. Fomepizole (alcohol dehydrogenase inhibitor) is the drug of choice; it inhibits the production of toxic metabolites without leading to intoxication discount phenergan 25 mg fast delivery anxiety knot in stomach. Consider dialysis for those with severe anion gap metabolic acidosis or signs of end-organ damage (coma, seizures, renal failure). In the past, methanol and ethylene glycol intoxication were treated with ethanol infusion (to prevent the production of the toxic metabolites), followed by hemodialysis to remove the substance from the body. A total of 2,500 people come to your emergency department at the same time to be treated for smoke inhalation. Among them is a 68-year-old man with a history of aortic stenosis who had to walk down 90 flights of stairs. Carboxyhemoglobin decreases release of oxygen to tissues and inhibits mitochondria, resulting in tissue hypoxia and anaerobic metabolism (similar to what would occur with anemia). Early neurologic symptoms include headache (most common), nausea, blurry vision, and dizziness, while late symptoms include confusion, seizures, impaired judgment, and syncope. Influenza is the most common misdiagnosis because most people present during wintertime. The first step in treatment is removal from the source of exposure and 100% oxygen administration. In room air, carbon monoxide has a half-life of 4–6 hours, which decreases to 40–80 minutes on 100% oxygen and to 15–30 minutes with hyperbaric oxygen. The most common household acids are various toilet, drain, swimming pool, and metal cleaners. The most common alkali ingestions or exposures are from liquid and crystalline lye, dishwasher detergent, hair relaxer, and oven cleaner. The most common serious injury is from the oral ingestion of liquid drain cleaner. Symptoms from ingestion injury include the following: Oral pain Drooling Odynophagia Abdominal pain Possible esophageal injury with subsequent stricture formation (from either acid or alkali ingestion) Possible gastric perforation In most circumstances, alkali exposures are more serious than acid exposures, since alkaline substances are more destructive to tissues. The history of exposure with subsequent characteristic injury is sufficient to establish the diagnosis. Irrigate ocular exposures with large volumes of saline or water, followed by fluorescein staining to determine if there is significant corneal injury. Do not induce emesis with acid or alkaline ingestion because it can worsen the injury. Do not try to neutralize the acid with a base or a base with an acid because a heat-producing reaction can occur, which would destroy more tissue. In addition to their analgesic and euphoric effects, opiates also cause pupillary constriction, constipation, bradycardia, hypothermia, and hypotension. Since opioids decrease gastric emptying by relaxation of smooth muscle, gastric lavage may be used in cases of overdose with oral agents. Amphetamines work in a similar way but are less likely to produce severe toxicity or death. Severe toxicity from cocaine is far more likely with smoked (“crack”) or injected cocaine rather than snorted (inhaled). Combined alpha/beta agents such as labetalol or alpha-blockers such as phentolamine are useful to control hypertension. Avoid pure beta-blockers because they lead to unopposed alpha stimulatory effects. Cocaine withdrawal can cause depression as a result of the norepinephrine depletion. Very infrequently, they lead to death from respiratory depression; most deaths are associated with ethanol or barbiturate ingestion. Rarely, this may cause hypotension, cardiac dysrhythmias, lactic acidosis, seizures, or coma. As with any overdose, the first step is to stabilize the patient’s airway, breathing, and circulation. Although they may cause delirium and bizarre behavior, the adverse effects are often limited to their anticholinergic effects: flushed skin, dry mouth, dilated pupils, and urinary retention. Clinical Recall A 19-year-old man is brought to the emergency room in an unconscious state after consuming an unknown substance at a party. Lead is ingested from paint, soil, dust, drinking water, and in the past from gasoline. In children, “lead lines” are densities seen at the metaphyseal plate of the long bones, indicating long-term exposure. Although effective, it has a narrow therapeutic window and is associated with toxicity. Acute exposure to lithium can cause leukocytosis, whereas chronic exposure can produce aplastic anemia. Elevated lithium in the blood will confirm toxicity, although levels may not correlate with clinical symptoms. Lithium is readily dialyzed because of water solubility, low volume of distribution, and lack of protein binding. Thus, hemodialysis is indicated for patients who have renal failure (and unable to eliminate lithium) and patients who cannot tolerate hydration (e. Lithium is a monovalent cation that does not bind to charcoal, so activated charcoal has no role. Her husband says she was in so much pain lately that she took half a bottle of extra pills 30 minutes ago. Salicylate intoxication results from the ingestion of a large amount of aspirin and other salicylate-containing medications, resulting in a complex, systemic toxicity. Tinnitus is one of the more specific complaints and is one of the best ways to identify the case, so as to answer the question: “Which of the following is the most likely diagnosis? Salicylates also interfere with Krebs cycle and lead to a metabolic acidosis through the reversion to anaerobic glycolysis as a method of energy production in the body. In other words, salicylates lead to significant lactic acid production with metabolic acidosis and elevated anion gap. However, respiratory alkalosis may be the predominant defect, especially in early stages. If the patient comes within 1 hour post-ingestion, attempt gastric decontamination. The mainstay of therapy, however, is increasing urinary excretion by alkalinizing the urine and administering aggressive fluid resuscitation.

In sophisticated centres careful monitoring is started immediately with measure of central venous pressure generic phenergan 25 mg on-line anxiety symptoms losing weight, pulmonary wedge pressures by Swan-Ganz catheter buy phenergan 25 mg line anxiety ridden, urine output and arterial and venous blood gases generic phenergan 25mg free shipping anxiety 40 year old woman. A patient with ascending cholangitis may respond temporarily to supportive treatment or shock therapy. This improvement is usually short-lived, unless prompt drainage of the biliary tract is performed. The use of specific antibiotics based on appropriate culture and sensitivity test is desirable. Antibiotics must be chosen on the basis of the suspected organisms prior to the sensitivity results. Often a combination of antibiotics may be started in the beginning before getting the sensitivity result. When the report becomes available more specific antibiotic coverage should be instituted if the infection is not under control. Mechanical ventilation alongwith endotracheal intubation is frequently needed in treating patients with late septic shock. Inadequate tissue oxygenation is a consistent feature of shock and attention to all components of the oxygen transport system is essential. Steroids have been used for quite sometime in the treatment of septic shock, though its effectivity is still questioned. The serious question which has been asked that whether administering an agent that impaires the immune response of the body will be beneficial or not. On the other hand favourable responses with improvement in cardiac, pulmonary and renal functions and better survival rates have been reported with this therapy. It has been suggested that steroids protect the body cell and its contents from the effect of endotoxin. Larger doses of steroids are known to exert inotropic effect on the heart and produce mild peripheral vasodilatation. Short term, high dose steroid therapy is recommended in most cases that do not respond to the other methods of treatment. An initial dose of 15 to 30 mg per Kg body weight of methyl prednisolone or equivalent dose of dexamethasone is given intravenously in 5 to 10 minutes. The same dose may be repeated within 4 hours if the beneficial effects have not been achieved. It has been shown that this short term high dose steroid therapy has little effect on immunosuppression, but possesses the other possible benefits to outweigh this bad effect. Vasodilator drugs such as phenoxybenzamine are more popular particularly when combined with fluid administration. Isoproterenol has inotropic and chronotropic effects on the heart and produces mild peripheral vasodilatation. This may cause a slight fall in blood pressure due to vasodilatation which requires additional volume replacement. This type of injury is come across after earthquakes, mine injuries, air raids, collapse of a building or use of tourniquet for longer period. In this syndrome oligaemic shock occurs due to extravasation of blood into the muscles in the affected portion of the body. The muscles become crushed and myohaemoglobin enters the circulation and may cause acute renal tubular necrosis. As they are confined within a tough deep fascia in the inferior extremity and superior extremity, tension develops within the fascia. At this stage the limb fills tense and the patient complains of severe pain in the limb. Urine output will be obviously reduced if uraemia supervenes, the patient may show restlessness, apathy and mild delirium. Administration of intravenous fluid is required to combat hypovolaemic shock, but it should be remembered that in this condition kidney function is also jeopardized. Low molecular weight dextran (40000) or Rheomacrodex is particularly effective in this condition as it prevents sludging of red cells in small blood vessels and maintain circulation to the kidneys. This approximately corresponds to three infusions of 100 ml during and after operation. If the patient has bled considerable amount, blood transfusion is required after the urinary output has brought to normal level and chance of renal failure has been minimised. The total body water is highest in the new bom infant, which constitutes 77 per cent of its body weight. The water content falls rapidly during the first 6 months of life to below 65 per cent and more slowly during the next years to an average of 59 per cent. The ratio of total body water to surface area increases progressively upto about the age of 12 years, but the absolute volume of body water is highest in males between the ages of 1 to 40 years. Fat contains little water, so the thin individual has a greater proportion of water to total body weight than the obese person. The lower percentage of total body water in females correlates with the relatively large amount of subcutaneous fat and small muscle mass. An extremely obese individual may have 25 per cent to 30 per cent less body water than a thin individual of the same weight. The extracellular fluid, which represents 20 per cent of the body weight, is divided into (i) intravascular fluid (this represents 5 per cent of body weight) and (ii) interstitial or extracellular fluid (which represents 15 per cent of body weight). It should be remembered that intracellular fluid is larger subdivision and constitutes 70 per cent of total body water, whereas the extracellular water amounts to about 30 per cent of total body water and actually forms the suitable environment for the cells of the body. This water forms part of the protoplasm of the cells and is distributed in many small compartments or cells separated from each other by two cell membranes and layer of interstitial fluid. The largest portion of this intracellular water is within the skeletal muscle mass. As the females possess smaller muscle mass, the percentage of intracellular water is lower in females than in the males. If the chemical composition of the intracellular fluid is studied, it will be found that potassium and magnesium are the principal cations, whereas the phosphates and proteins are the principal anions. The intracellular concentration of potassium is approximately 125 mEq/L, magnesium is approximately 40 mEq/L and sodium is about 10 mEq/L. The concentration of phosphates is about 150 mEq/L in intracellular fluid, whereas protein constitutes 40 mEq/L of intracellular fluid. It can be divided into 3 subdivisions — (i) intravascular fluid (which is situated within the blood vessels) constitutes 7 per cent of total body water or 4 per cent of the body weight in normal adult; (ii) the interstitial or extravascular fluid (which lies outside the blood vessels and around the cells of the tissues of which it forms the immediate environment) constitutes 17 per cent of total body water or 7. The volume of the extracellular fluid can be measured by the dilution of a substance which passes freely through the walls of blood capillaries but does not enter into the cells of the body. The substances which have been used are inulin, thiocyanate, mannitol, thiosulphate, radioactive chlorine, bromine or sodium etc. Blood volume can be measured directly by dilution principle using red cells labelled with radioactive chromium (51Cr). The most important cation of extracellular fluid is sodium (which constitutes 140 mEq/L), whereas potassium (5 mEq/L), calcium (3 mEq/L) and magnesium (2 mEq/L) are the other cations available in the interstitial fluid.

If there is loss of viability of the small intestine best order phenergan anxiety symptoms when not feeling anxious, that portion of the intestine should be resected buy phenergan with amex anxiety symptoms lingering, the cyst is excised and end-to-end anastomosis of the small intestine is performed generic phenergan 25mg free shipping anxiety grounding. The caecum is bilaterally sacculated in early childhood with the appendix still at the inferior tip. Rapid growth of the right side and anterior aspects of the caecum rotate the appendix to its adult position on the posteromedial aspect below the ileocaecal valve. As the appendix varies considerably in length, the relation of the base of the appendix to the caecum is essentially constant. The vermiform appendix is present only in human beings and certain anthropoid apes. In many herbivorous animals there is a big caecal diverticulum in which bacteriolytic break down of cellulose takes place. Presence of lymphoid tissue in wall of the appendix is characteristic of human vermiform appendix. On longitudinal section the irregular lumen of the appendix is encroached upon by multiple longitudinal fold of mucous membrane. The longitudinal muscle is formed by coalescence of the three taeniae coli at the junction of the caecum and appendix. Thus the taeniae, particularly the anterior taenia may be used as a guide to locate an elusive appendix. Through this infection from the submucous coat directly comes to peritoneum and regional peritonitis occurs. Through these hiatus muscularis appendix may perforate when there is a rise in tension inside the organ. This number gradually increases to a pick of approximately 200 follicles between the ages of 12 and 20. After that the number is gradually reduced and reaches to about half at the age of 50 years and almost absence of lymphoid tissue at the age of 60 years. The mesoappendix passes behind the terminal ileum and joins with the mesentery of the small intestine. In early childhood the mesoappendix is very transparent and blood vessels may be seen through it. In adults it becomes laden with fat in the same proportion as the mesentery of the ileum. It is a branch of the lower division of ileocolic artery and passes behind the terminal ileum to enter the mesoappendix a short distance from the base of the appendix. Accessory appendicular artery supplies the base of the appendix and this artery should be properly ligated otherwise haemorrhage will continue after appendicectomy. Inflammatory thrombus may cause suppurative pylephlebitis in case of a gangrenous appendicitis. Lymphatic vessels draining the appendix travel along the mesoappendix to drain into the ileocaecal lymph nodes. Peritoneum reflects from the posterior surface of the caecum to the parietis at variable level of the caecum but usual|y opposite the ileocaecal junction. Only in case of long retrocaecal appendix the tip of the appendix remains in the retroperitoneal tissue close to the ureter. It should be appreciated that it is not a vestigeal organ and it does play a useful role in the defence mechanism of the body. Yet appendix is not indispensable in this regard and removal of the appendix produces no detectable defect in the functioning of the immunoglobulin system. These may occur in the form of (i) agenesis, (ii) duplication, (iii) diverticula and (iv) left sided appendix. Occasionally appendix may not be seen dur­ ing appendicectomy following acute appendicitis. In certain cases of non-rotation of the midgut the caecum and appendix may be seen as midline structure or on the left side. Acute appendicitis may occur at all ages, but is most commonly seen in the second and third decades of life. It must be noted that there is some relation between the amount of lym­ phoid tissue in the appendix and incidence of acute appendicitis. In children, appendicitis is not common as the configuration of the appendix makes obstruction of the lumen unlikely. There is hardly any difference of sex incidence, but this condition seems to be more commonly seen in teenaged girls. This may occur due to obstruction of the lumen, obstruction in the wall or obstruction from outside the wall. A faecolith is composed of inspis­ sated faecal material, epithelial debris, bacteria and calcium phosphates. Presence of a faecolith is so important that it even provides an indication for prophylactic appendicectomy. A stricture in the appendix usually indicates previous appendicitis which has resolved without surgery. Rise in incidence of appendi­ citis amongst the highly civilised society is mostly due to diet which is relatively rich with fish and meat and departure from simple diet rich in cellulose and high residue. May be, it is due to the peculiar position of the organ which predisposes to infection. In many cases of early appendicitis the appendix lumen is patent despite the presence of mucosal inflammation and lymphoid hyperplasia. Lymphoid hyperplasia ultimately narrows the lumen of the appendix leading to luminal obstruction. The sequence of events following obstruction of the appendix is probably as follows : A closed loop obstruction is produced continuing normal secretion of the appendicular mu­ cosa rapidly produces dis­ tension. This produces vague, | dull and diffuse pain in the Jp umbilical and lower epigas-.. Rapid multiplication of the resident bacteria of the appendix also increases distension. Oedema and mucosal ulceration may gradually develop, so that the bacteria may pass into the submucous layer. Resolution may occur at this stage either in the response to antibiotic therapy or spontaneously. If the intraluminal pressure increases further venules and capillaries are occluded, but arteriolar inflow continues resulting in engorgement and vascular congestion of the appendix. At this stage of distension, reflex nausea and vomit­ ing start, the visceral pain also becomes severe. Gradually the serosa is involved, more due to presence of hia­ tus muscularis and local peritonitis ensues. At this stage the greater omentum and loops of small bowel become adherent to the inflamed appendix preventing the spread of peritoneal contamination.

Inflammatory breast cancer is also one of the few times where radiation is added following a total mastectomy order on line phenergan anxiety yawning. It mimics mastitis but is not an infectious process buy 25mg phenergan fast delivery anxiety while driving, and antibiotics do not play a role in treatment purchase phenergan 25 mg amex anxiety hot flashes. Since it is confined to the ducts, it cannot metastasize (thus no axillary sampling is needed). Total mastectomy is recommended for multicentric lesions throughout the breast, many practitioners add a sentinel node biopsy in those patients, in the event that invasive cancer is found following the mastectomy, as a sentinel node cannot be identified after the breast has been removed. Lumpectomy with or without radiation is used if the lesion(s) are confined to a limited portion of the breast. Inoperable cancer of the breast is breast cancer that is not amenable to surgical resection. Treatment for inoperable breast cancer can include any combination of chemotherapy, hormone therapy (if hormone receptor positive), or radiation, and is often considered palliative. Anti- estrogen hormonal therapy is an option for adjuvant systemic therapy if the tumor is estrogen receptor-positive. Premenopausal women receive tamoxifen Postmenopausal women receive an aromatase-inhibitor (e. Large Calcification Located within a Case of Overt Breast Cancer Noted on Mammography visualsonline. The need for further surgery is determined by the histologic diagnosis given from a frozen section. A total thyroidectomy should be performed in follicular cancers, so that if needed, radioactive iodine can be used in the future to treat blood-borne metastases. Thyroid nodules in hyperthyroid patients are almost never cancer, but they may be the source of the hyperfunction (“hot adenomas”). Clinical signs of hyperthyroidism include include weight loss in spite of strong appetite; palpitations; heat intolerance; moist skin; hyperactive behavior; tachycardia; and occasional atrial fibrillation or flutter. Most hyperthyroid patients are treated with radioactive iodine, but those with a “hot adenoma” have the option of surgical excision of the affected lobe. Hyperparathyroidism is most commonly found by serendipitous discovery of high serum calcium in blood tests (rarely seen in the full florid “disease of stones, bones, and abdominal groans”). Repeat calcium determinations, look for low phosphorus, and rule out cancer with bone metastases. Asymptomatic patients become symptomatic at a rate of 20% per year; thus elective intervention is justified. Removal is curative (sestamibi scan may help localize the culprit gland before surgery). Cushing’s syndrome is the constellation of clinical signs which accompany elevated cortisol: fat deposits in the face, a ruddy complexion, hirsutism, interscapular fat (“buffalo hump”), truncal obesity with abdominal striae, and thin weak extremities, classically in a patient with a previously normal appearance. If no suppression, measure 24-hour urine-free cortisol; if elevated, move to a high-dose suppression test. No suppression at higher dose identifies adrenal adenoma (or paraneoplastic syndrome). Zollinger-Ellison syndrome (gastrinoma) shows up as virulent peptic ulcer disease, resistant to all usual therapy (including eradication of Helicobacter pylori), and more extensive than it should be (several ulcers rather than one, ulcers extending beyond first portion of the duodenum). Differential diagnosis is with reactive hypoglycemia (attacks occur after eating), and with self-administration of insulin. In the latter the patient has reason to be familiar with insulin (some connection with the medical profession, or with a diabetic patient), and in plasma assays has high insulin but low C-peptide. Glucagonoma produces severe migratory necrolytic dermatitis, resistant to all forms of therapy, in a patient with mild diabetes, mild anemia, glossitis, and stomatitis. In both cases the key finding is hypokalemia in a hypertensive (usually female) patient who is not on diuretics. Appropriate response to postural changes (more aldosterone when upright than when lying down) suggests glandular hyperplasia (idiopathic form, which is treated medically), whereas lack of response (or inappropriate response) is diagnostic of adenoma. Pheochromocytoma is seen in thin, hyperactive women who have attacks of pounding headache, perspiration, palpitations, and pallor (i. By the time patients are seen, the attack has subsided and blood pressure may be normal, leading to a frustrating lack of diagnosis. Surgery requires careful pharmacologic preparation with alpha-blockers, followed by beta-blockers. Meticulous intraoperative monitoring and anesthesia care are also an essential part of surgical resection. Coarctation of the aorta may be recognized at any age, but patients are typically young and have hypertension in the arms, with normal pressure (or low pressure, or no clinical pulses) in the lower extremities. Chest x-ray shows scalloping of the ribs (erosion from large collateral intercostals). Renovascular hypertension is seen in 2 distinct groups: young women with fibromuscular dysplasia, and old men with arteriosclerotic occlusive disease. In both groups hypertension is resistant to the usual medications, and a telltale faint bruit over the flank or upper abdomen suggests the diagnosis. Therapy is imperative in the young women—usually balloon dilatation and stenting—but it is much more controversial in older patients with atherosclerotic disease, many of whom have short life expectancy from the other manifestations of the arteriosclerosis. Esophageal atresia presents with excessive salivation noted shortly after birth or with choking spells when first feeding is attempted. If there is normal gas pattern in the bowel, the baby has the most common form of the 4 types, in which there is a blind pouch in the upper esophagus and a fistula between the lower esophagus and the tracheobronchial tree. For the imperforated anus itself, look for a fistula nearby (to vagina or perineum). If present, repair can be delayed until further growth (but before toilet training time). If not present, do a colostomy for high rectal pouches (and definitive repair at a later date). The level of the pouch is determined with x-rays taken upside down (so the gas in the pouch goes up), with a metal marker taped to the anus. Congenital diaphragmatic hernia is always on the left and resulting defects permit the bowel to herniate into the chest. The fundamental problem arises not from the displacement of the bowel, but from the under-developed hypoplastic lung that also retains its fetal-type circulation. Congenital Diaphragmatic Hernia with Bowel Contents in the Thoracic Cavity Copyright 2007 Gold Standard Multimedia Inc. In gastroschisis, the location of the umbilical cord is normal (it reaches the baby), the defect is to the right of the cord (lateral), there is no protective membrane, and the bowel looks inflamed and matted. In omphalocele, the cord goes to the defect (central), which has a thin membrane under which one can see a normal-looking bowel and small slice of liver. Small defects can be closed primarily, but large ones require construction of a prosthetic “silo” to house and protect the bowel. The contents of the silo are then squeezed into the belly, a little bit every day, until complete closure can be done in about a week. Babies with gastroschisis also need vascular access for parenteral nutrition, because the inflamed bowel will not work for about 1 month. If the skin can be closed but not the fascia, then the patient is left with a ventral hernia repaired at a later date.

Carcinoma arising from or involving the lower part of the anal canal below the pectinate line commonly spreads to the inguinal group of lymph nodes and these are easily palpable best 25 mg phenergan anxiety from weed. The instrument is introduced at first in the direction of the axis of the anal canal buy 25 mg phenergan overnight delivery 8 tracks anxiety, i discount phenergan 25mg without a prescription anxiety keeps me from sleeping. Now the obturator is withdrawn and the interior of the rectum and anal canal is seen with the help of a light. The piles will prolapse into the proctoscope as this instrument is being withdrawn. The main three branches are situated in the left lateral, right anterior and right posterior positions. By this instrument whole of the rectum and a large part of the sigmoid colon can be examined. The instrument is well lubricated and passed through the anus along the direction of the anal canal i. As soon as the anal and the light-carrier are fitted and the bellow is canal is passed, the instrument is then depressed attached. Now the instrument is pushed posteriorly and pushed towards the sacrum along the rectum (B). While within the rectum, by circumduction movement the interior of the rectum is thoroughly inspected. As it comes nearer the pelvic-rectal junction the instrument will be directed more anteriorly on one side or the other (usually the left side). Introduction of the instrument into the pelvic colon is the most difficult part of the operation. By gentle inflation of the bowel under direct vision the lumen can be made to open out in advance of the instrument. By continuing in the same manner the sigmoidoscope can be passed up to its full extent so that the greater part of the pelvic colon can be examined. This instrument is mainly used to detect presence of any growth, ulcer, diverticula etc. The growth can be biopsied and a smear may be taken from ulcer for bacteriological examination through this instrument. The proliferative type of carcinoma has an irregular nodular surface which is friable and bleeds easily. A sessile benign growth is often difficult to distinguish from carcinoma without biopsy. Just by seeing a polyp through sigmoidoscopy one should not be content in removing it. If there be a carcinoma higher in the colon, this will implant cancer cells in the rectal wound. With the advent of fibreoptic colonoscope, the whole of the colon upto the caecum can be viewed for practical purposes. Colonoscopy is never done under general anaesthesia, but it may be done after satisfactory analgesia by injecting intravenously diazepam (Valium) 5-20 mg. It is extremely important for the endoscopist to pay attention to any pain being experienced because of excessive stress on the bowel wall or on the attachments of the colon. When the barium enema report is at hand, the strong indications of a diagnostic endoscopic examination following the contrast study are listed below : (i) X-ray study negative, but the symptoms persist including occult blood and anaemia; (ii) X-ray study positive yet for confirmation; (iii) X-ray study positive for cancer, but for taking biopsy; (iv) X-ray study positive for cancer yet to exclude synchronous cancer or associated polyps; (v) X-ray study positive for polyp, but to exclude malignant change or for additional polyps; (vi) X-ray study positive for inflammatory disease, but to know the extent of disease and for biopsy. There are certain clinical conditions in which an attempt at endoscopic examination appears unwise. These are (i) acute toxic dilatation of the colon, (ii) acute severe ulcerative colitis, (iii) acute diverticulitis, (iv) radiation necrosis, (v) recent bowel anastomosis and (vi) in uncooperative patients. Endoscopic polypectomy has drastically reduced the need for the abdominal approach. Even in most instances malignant polyps can be controlled entirely by polypectomy via the colonoscope. Straight X-ray of the abdomen may indicate evidence of intestinal obstruction due to annular growth at the rectosigmoid junction. Chest X-ray is performed in an established case of carcinoma of the rectum to exclude pulmonary metastasis. In any case of internal haemorrhoid barium enema X-ray must be performed to exclude any carcinoma above the rectum to be the cause of this condition. In case of rectal polyp, this polyp may be one of the multiple polyps in the colon which should be excluded by barium enema. This tumour is firmly fixed to the coccyx and occasionally to the last piece of the sacrum. Though congenital such a cyst often remains symptomless till adult life, until and unless it becomes infected or becomes burst outside forming a sinus. The cyst however if exceptionally of big size may give rise to difficulty in defaecation. The cyst is easily palpable by rectal examination and may be discovered accidentally by this examination. So internal haemorrhoid is covered by mucous membrane whereas the external haemorrhoid is covered with skin. Internal haemorrhoids are the varicosities of the internal haemorrhoidal plexuses. These could be divided into two main types : (a) Vascular haemorrhoids in which there is extensive dilatation of the terminal superior haemorrhoidal venous plexus — commonly found in younger individuals particularly men; (b) Mucosal haemorrhoids in which there is sliding down of the thickened mucous membrane whcih conceals the underlying veins. Piles may occur at all ages, but are uncommon below the age of 20 years barring piles secondary to vascular malformations which may occur in children. For practical purposes internal haemorrhoids can be divided into three degrees :— First degree haemorrhoids are those in which hypertrophy of the internal haemorrhoidal plexus remains entirely within the anal canal as the mucosal suspensory ligaments remain intact. Patients in this stage usually present with rectal bleeding and discomfort or irritation. Second degree haemorrhoids occur when with further hypertrophy the mucosal suspensory ligaments become lax and piles will descend so that they prolapse during defaecation but spontaneous reduction takes place afterwards. In third degree haemorrhoids, they remain prolapsed after defaecation and require replacement. Secondary haemorrhoids occur between the three primary ones, the most common being the mid-posterior position. They are urethral stricture, an enlarged prostate, a big pelvic tumour pressing on the superior rectal veins. Pregnancy not only presses on the superior rectal veins but also excess progesterone during this period relaxes the smooth muscles on the walls of the said veins. Rectal examination is usually not fruitful, as uncomplicated piles cannot be felt with finger unless they are thrombosed or fibrosed. After the proctoscope has been fully introduced the obturator is taken out and with good light interior of the anal canal is seen. Sigmoidoscopy should always be performed to exclude any serious rectal pathology (such as carcinoma). Bright streak of blood with the passage of stool and pain after defaecation are the characteristic features. As the fissure is mainly situated in the lower anal canal it is highly painful and associated with spasm of the sphincters.

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