Define the risk groups on which current recommendations for cervical carcinoma screening are based.
Recommendations concerning periodic screening of women in the U.S. using Pap smears (Papanicolaou-Traut smears) have been developed for the various risk groups. Low-risk groups are those women who have never had sexual activity, have had a hysterectomy for nonmalignant reasons, or have reached the age of 60 and have never had a positive Pap smear. High-risk patients are those who are sexually active early, have had many partners, or are in low socioeconomic groups.

What are the current recommendations for cervical carcinoma screening.
The American Cancer Society and the American College of Obstetricians and Gynecologists recommend that asymptomatic women over 18 years of age and those under age 18 who are sexually active have annual screening for at least 3 years initially. Some groups recommend that women then be screened every 2-3 years until age 65, while others suggest yearly screening as long as the patient is sexually active. High-risk patients should be screened yearly.

Sumarize the appropriate management of a patient with an abnormal Pap smear.
A persistently abnormal Pap smear should lead to colposcopy and/or biopsy.

What should be done if carcinoma in situ or dysplasia is found?
Cryotherapy, laser therapy, cone biopsy, or hysterectomy should be performed, depending on the size and extent of the lesion. Read the rest of this entry »

Who gets esophageal cancer?
Squamous cell cancer of the esophagus occurs in the 40- to 60-year-old age group and is seen mainly in men. The incidence is increased in Africa, China, Russia, Japan, Scotland, and the Caspian region of Iran. In the U.S. the nonwhite male population is at increased risk. Adenocarcinoma of the esophagus tends to occur in obese white men.

List the risk factors for esophageal cancer.

• Excessive alcohol and/or tobacco use
• Native Bantu beer (southern Africa)
• Chronic hot beverage ingestion
• Lye ingestion: > 30% of cases develop esophageal cancer
• Tylosis: > 40% of cases develop esophageal cancer
• Achalasia
• Plummer-Vinson syndrome
• Nontropical sprue
• Prior oral and pharyngeal cancer
• Occupational exposure to asbestos, combustion products, ionizing radiation
• Other occupational exposure: waiters, bartenders, metal workers, and construction workers
• Decreased dietary intake of fruits and vegetables throughout adulthood Read the rest of this entry »

How is potassium (K+) distributed between the intracellular fluid (ICF) and ECF compartments?
A 70-kg man contains approximately 3500 mEq of K+ (approximately 50 mEq/kg body weight). The vast majority of this (98%) is in the ICF space. Therefore, the amount in the ECF compartment (the portion that we routinely measure) represents only a small percentage of the total body K+.

How is the large chemical gradient between intracellular and extracellular K+ concentration maintained?
The Na+-K+ adenosine triphosphate (ATPase) pump actively extrudes Na+ from the cell and pumps K+ into the cell. This pump is present in all cells of the body. In addition, the cell is electrically negative compared to the exterior, which serves to keep K+ inside the cell.

Given the relatively small extracellular compared to intracellular concentration of K+, why are some electrical processes (cardiac conduction, skeletal and smooth muscle contraction) sensitive to changes in the ECF K+ concentration?
It is the ratio of the ECF to ICF K+ concentration more than the absolute level of either that determines the sensitivity of these electrical processes. Because the ECF concentration of K+ is small compared to the ICF concentration, a small absolute change in ECF K+ concentration results in a large change in the ECF to ICF K+ ratio. Read the rest of this entry »

How do you estimate a patient’s serum osmolality?
A close estimate can be derived from measurements of the serum sodium (Na+), glucose, and blood urea nitrogen (BUN), using the following equation:

What percentage of the adult human body consists of water? What percentage of the water content is intracellular versus extracellular?
Approximately 60% of the adult man and 50% of the adult woman are water. About two thirds of this volume is intracellular, and one third is extracellular. About 20% of the extracellular fluid volume is plasma water.

What are the sources and daily amounts of water gain and loss?
The average adult male gains and loses 2600 mL of water each day. The gains occur from direct fluid ingestion (1400 mL/day), from the fluid content of ingested food (850 mL/day), and as a product of water produced by oxidation reactions (350 mL/day). Water losses occur through urine (1500 mL/day), perspiration (500 mL/day), respiration (400 mL/day), and feces (200 mL/day).

List the factors necessary to allow the kidney to excrete free water.

1. A filtrate must be formed to allow renal excretion of free water.
2. Glomerular filtrate must escape reabsorption in the proximal tubule to reach the diluting segment (ascending loop of Henle), where free water is created.
3. An adequately functioning diluting segment must be present.
4. The free water formed by the diluting segment must leave the nephron without being reabsorbed by the collecting tubule. This nephron segment is intrinsically impermeable to water but is made permeable by antidiuretic hormone (ADH). Read the rest of this entry »

How is the entity eosinophilic gastroenteritis defined?
Eosinophilic gastroenteritis is a rare, nonparasitic inflammatory disease of the gastrointestinal tract with various degrees of eosinophilic infiltration anywhere in the tubular intestinal tract and the biliary tree in the absence of vasculitis or significant extraintestinal tissue eosinophilia. Peripheral blood eosinophilia is present in up to 80%.

Why should one know features of this rare disease?
Although it is a rare disease, it is a treatable condition mimicking several gastrointestinal diseases. It presents most often with abdominal pain, diarrhea, nausea, vomiting, dysphagia, and gastric outlet obstruction.

What is the differential diagnosis of eosinophilic gastroenteritis?
Patients with eosinophils on intestinal biopsy or any form of inflammation with peripheral eosinophilia should be evaluated for the possibility of eosinophilic gastroenteritis. Many other diseases, however, can produce similar findings.

How is irritable bowel syndrome (IBS) differentiated from eosinophilic gastroenteritis?
Peripheral eosinophilia is absent in 20% of the patients with eosinophilic gastroenteritis, reinforcing the need to examine mucosa with biopsies. Careful review of the colonic histology can usually distinguish IBS by its lack of mucosal eosinophils. Read the rest of this entry »

What is ulcerative colitis?
Ulcerative colitis (UC) is a chronic inflammatory disease of the colon. It is distinct from Crohn’s disease (CD) of the colon in that the inflammation is restricted mostly to the mucosa and involves only the colon. The rectal segment is almost always involved, whereas in CD of the colon the rectum is usually spared.

Define backwash ileitis.
Backwash ileitis refers to unusual cases of ulcerative colitis that involve the terminal ileum. The endoscopic, histologic, and radiologic appearances of backwash ileitis is the same as those of ulcerative colitis. When deep linear ulcers and strictures are seen in the ileum, Crohn’s ileitis is the more likely diagnosis.

What is indeterminate colitis?
As more information is gathered about the pathogenesis of ulcerative colitis and CD, the distinction between them at times can be unclear. In about 7% of patients, when the inflammatory process is limited to the colon (no ileal involvement), the endoscopic, histologic, or radiologic findings are insufficiently distinct to separate the two diseases. The colitis is then referred to as “indeterminate.” Other patients carry the diagnosis of UC for many years until a change in signs and symptoms, consistent with CD, influences a change in diagnosis. In some patients, the diagnosis of CD of the colon is recognized only after colectomy and the development of recurrent ileitis in the ileostomy or ileoanal pouch performed for what was thought to be UC. Read the rest of this entry »

What are the usual symptoms and signs suggestive of Crohn’s disease?
The symptoms of Crohn’s disease are determined by the site and type of involvement, that is, inflammatory, stenotic, or fistulizing. The most common site of involvement is ileocolitis. These patients present with diarrhea; abdominal pain that is usually insidious in the right lower quadrant, triggered or aggravated frequently after meals; weight loss; and an association with a tender, inflammatory mass in the right lower quadrant. The diarrhea is usually nonbloody, and this may be one of the clues in clinical history that helps differentiate Crohn’s disease from ulcerative colitis, where bloody diarrhea is almost universal. Patients frequently have fever, weight loss, perianal fistulas and/or fissures, and extra-intestinal manifestations, such as aphthous stomatitis, arthritis, and erythema nodosum. Patients with isolated colonic disease present usually with diarrhea, abdominal pain, and weight loss.
Perianal skin tags are very common and, at times, mistaken for external hemorrhoids; it is not until these are excised and the course is complicated by a nonhealing wound that the diagnosis of Crohn’s disease is entertained. At times the main symptoms are related to perianal fistulas and/or abscess, even though most of these patients have other areas of involvement by Crohn’s disease. Gastroduodenal Crohn’s disease is less common and can mimic complicated peptic ulcer disease with abdominal pain, early gastric satiety, or symptoms of duodenal obstruction.
Patients can present with mild, moderate, or severe disease. This is a clinical judgment based on factors such as the severity of diarrhea, abdominal pain, the presence or absence of dehydration, anemia, malnutrition, and tachycardia. For clinical trials, the Crohn’s Disease Activity Index (CDAI) has been developed. Calculation of the CDAI combines weighted scores of clinical and laboratory variables. CDAI scores less than 150 indicate a clinical remission, and scores over 450 indicate severely active disease. Even though the CDAI is subjective and cumbersome, it is currently the standard measure of disease activity for all clinical trials.

How is the diagnosis of Crohn’s disease established?
The diagnosis of Crohn’s disease is established by history, physical examination, endoscopy, biopsies, x-rays, and laboratory tests. Crohn’s disease presents more commonly between ages 15 and 25 years. The diagnosis should be suspected in patients with chronic diarrhea, finding characteristic intestinal ulcerations and excluding alternative diagnoses. The ulcerations of Crohn’s disease may be aphthoid but could be deep and serpiginous along the longitudinal axis of the bowel. Skip areas, cobblestoning, and rectal sparing are characteristic findings. Air contrast barium enema, small bowel series with or without a per-oral pneumocolon, or colonoscopy each may demonstrate these typical lesions. On a small bowel series, Crohn’s disease often leads to separation of bowel loops, a narrowed and ulcerated terminal ileum and, in advanced cases, the so-called string sign. The biopsies of involved areas have architectural distortion and a chronic inflammatory infiltrate, and in about 10-30% of cases of Crohn’s colitis there are noncaseating granulomas that are usually diagnostic. Typical lesions of Crohn’s disease may also be seen in the upper gastrointestinal tract. The inflammation is localized to the ileocecal region in approximately 50% of cases, the small bowel in approximately 25% of cases, the colon in 20% of cases, and the upper gastrointestinal tract or perirectum in 5%.

Which diseases can mimic the symptoms and signs of Crohn’s disease?
The differential diagnosis of Crohn’s disease is long. The most common mimics of Crohn’s colitis are ulcerative colitis, ischemic colitis, diverticulitis, or colorectal cancer. For Crohn’s ileitis, infection with Yersinia enterocolitica or Mycobacterium tuberculosis may mimic disease. In immunosuppressed patients, viral infections such as cytomegalovirus (CMV) can mimic Crohn’s disease. Other important diseases in the differential diagnosis of Crohn’s disease include the irritable bowel syndrome, intestinal lymphoma, celiac sprue, radiation enteropathy, and nonsteroidal anti-inflammatory drug-induced enteropathy. Read the rest of this entry »