Table 37-3. Colorectal Cancer (CRC) Screening and Surveillance Recommendations |
Congenital hypertrophy of the retinal pigment epithelium is an early benign manifestation of both FAP and
سندرم های پارانئوپلاستیک در آدنوکارسینومای معده:
A variety of paraneoplastic syndromes have been associated with gastric adenocarcinoma and warrant an investigation for a gastrointestinal malignancy. They include:
Trousseau's syndrome (thrombosis),
acanthosis nigricans (pigmented dermal lesions),
membranous nephropathy,
microangiopathic hemolytic anemia,
Leser-Trélat sign (seborrheic keratosis), and
dermatomyositis.
نئوپلاسمهای کبدی:
آدنوم های کبدی
Hepatic Adenomas:
found predominantly in women of childbearing age, are associated with estrogen and oral contraceptive use, and may enlarge during pregnancy. in Men use of anabolic steroids -- usually incidentally identified -- can spontaneously hemorrhage during menstruation or pregnancy or postpartum, causing shock and requiring surgical resection-- Consist of normal hepatocytes without portal tracts and Kupffer cells.
The diagnosis is suggested by the appearance of a cold spot on technetium-99m-sulfur colloid scans (resulting from absence of Kupffer cells) and of vascular lesions on angiography.
The appearance on ultrasonography, computed tomography, and magnetic resonance imaging is nonspecific, but a characteristic feature is the presence of a well-defined capsule.
همانژیوم های کبدی:
Hemangiomas
are the most common mesenchymal hepatic neoplasms -- prevalence in the general population of 2 to 5%-- usually discovered incidentally--most often solitary and located in the right lobe of the liver.
Right upper quadrant abdominal pain may occur in patients with large lesions (typically > 5 cm) owing to the development of intratumoral hemorrhage and thrombosis.
Diagnosisà readily made when a hyperechoic lesion on ultrasound evaluation corresponds to a peripheral enhancing lesion that eventually completely fills during dynamic computed tomography, when MRI reveals a high-intensity signal on T2-weighted images (most sensitive test), or when a technetium-99m red blood cell scan (most specific test) shows retention of the isotope in the tumor.
Treatment is usually not necessary in lesions less than 5 cm. In larger lesions, close monitoring and/or elective resection has been advocated. Symptomatic lesions may be treated with embolization, enucleation, resection, and, in extreme cases, transplantation (large unresectable lesions or multiple lesions).
Table 44-1. Hepatocellular Carcinoma |
Indeed, in 10 to 20% of patients, no cause for granulomas is found despite extensive investigation. A subset of these patients have a syndrome consisting of fever, hepatomegaly, and hepatic granulomas that responds to corticosteroids, described as hepatic granulomatous disease or "granulomatous hepatitis." These patients may possibly have a variant of sarcoidosis.
Liver biopsy (and culture, particularly for acid-fast bacteria) is of considerable value in the diagnosis of sarcoidosis, miliary tuberculosis, and disseminated histoplasmosis, because virtually all patients with these disorders have hepatic granulomas.
Characteristic granulomas are seen in many patients with primary biliary cirrhosis, and granulomas may be the first clue to Hodgkin's disease.
HEPATIC ENCEPHALOPATHYانسفالوپاتی کبدی
Ammonia, derived from both amino acid deamination and bacterial hydrolysis of nitrogenous compounds in the gut, has been implicated in the pathogenesis of hepatic encephalopathy, but its blood levels correlate poorly with the presence or degree of encephalopathy.
A number of potential contributors to hepatic encephalopathy have been investigated. These include γ-aminobutyric acid, mercaptans, short-chain fatty acids, benzodiazepine-like compounds, imbalance between plasma branched-chain and aromatic amino acids, altered cerebral metabolism (disturbed Na+, K+-ATPase activity), zinc deficiency, and deposition of manganese in the basal ganglia.
Treatment:
Protein restriction may be considered in patients with severe encephalopathy, but long-term restriction is associated with worsening malnutrition.
Nonabsorbable disaccharides (i.e., lactulose) are fermented to organic acids by colonic bacteria, lowering stool pH and trapping ammonia in the colon, and thereby preventing diffusion.
Reduction and elimination of nitrogenous compound substrates can be achieved by administration of enemas and the use of antibiotics that reduce colonic bacteria (i.e., neomycin and metronidazole).
Treatment with formulas rich in branched-chain amino acids has shown no benefit in improving encephalopathy or mortality.
HEPATOPULMONARY SYNDROMEسندرم هپاتوپولموناری
The pathophysiology of this syndrome involves intrapulmonary vascular dilation in the absence of architectural damage.
The vascular dilation leads to impaired oxygen transfer from alveoli to the central stream of red blood cells within capillaries, with a resulting "functional" intrapulmonary right-to-left shunt that improves with 100% oxygen!!!!
Intrapulmonary vascular dilation is detected by contrast echocardiography, which shows delayed visualization of microbubbles in the left heart chambers.
Table 45-1. Risk Factors for Cholelithiasis |
The pathophysiology of pigment stones is less well understood; however, increased production of bilirubin conjugates (hemolytic states), increased biliary Ca2+ and HCO3-, cirrhosis, and bacterial deconjugation of bilirubin to a less soluble form are all associated with pigment stone formation.
کوله سیستکتومی پروفیلاکتیک:
Asymptomatic patients should be followed expectantly. Prophylactic cholecystectomy is considered in groups at increased risk for developing complications:
(1) diabetics who have a greater morbidity and mortality from acute cholecystitis;
(2) persons with a calcified (porcelain) gallbladder or large gallbladder polyps, which are associated with an increased risk of carcinoma of the gallbladder;
(3) persons with sickle cell anemia, in whom hepatic crises may be difficult to differentiate from acute cholecystitis; and
(4) children with gallstones, because they frequently develop symptomatic disease.
Mirizzi syndrome is the occurrence of profound jaundice resulting from extrinsic compression of the common hepatic duct by an impacted stone in the cystic duct at the gallbladder neck.
BILIARY NEOPLASMS: Risk factors for development of these cancers include:
primary sclerosing cholangitis,
chronic ulcerative colitis,
choledochal cysts,
gallstones,
C. sinensis,
hepatolithiasis, and
α1-antitrypsin deficiency.
پانکراس:
Elevated serum pancreatic enzymes may occur in a variety of other conditions, including bowel perforation, intestinal obstruction, mesenteric ischemia, tubo-ovarian disease, and renal failure. Serum lipase is slightly more specific and remains normal in some conditions associated with an elevation of serum amylase, including macroamylasemia, parotitis, and tubo-ovarian disease.
Table 38-1. Etiology of Acute Pancreatitis |
Table 38-2. Signs Used to Assess Severity of Acute Pancreatitis |
Mortality is approximately 1% when there are fewer than three Ranson's signs, 10 to 20% when there are three to five signs, and greater than 50% when there are six or more Ranson's signs.
For removal of impacted gallstones or establishment of biliary drainage indicated for patients with evidence of biliary sepsisàEmergency ERCP à followed by elective cholecystectomy.
مصرف الکل و قهوه ریسک فاکتور برای کنسر پانکراس نیستند.