Breast abscess

Fibroadenoma

Abnormalities of normal development and involution (including breast pain and nodularity)

Nipple adenoma

Intraductal papilloma

Fat necrosis

Nipple adenoma

Nipple adenomas are non-malignant glandular tissue tumours of the nipple area, which vary in appearance. Nipple adenomas are surgically removed because they are sometimes, although not usually, associated with breast cancer.

Intraductal papilloma

Intraductal papillomas are small, relatively uncommon benign growths in the lining of the milk ducts near the nipple. They produce a discharge, which may be blood-stained. They are usually seen in women over 40. Breast cancer must be excluded by mammography and fine needle aspiration if required.

Intraductal papillomas are surgically removed before they grow big enough to block the milk ducts. The papilloma must be sent for histology to confirm that it is benign.

Although pintraduct papillomas are the commonest cause of bloody discharge of the nipple, cancer must always be ruled out.

Fat necrosis

Fat necrosis is damage to some of the fat tissue within the breast (for example following a motor vehicle accident or after being punched in the breast), which may then lead to the formation of a lump. Bruising occasionally occurs near the lump, and the area may be tender. The mass may be associated with skin or nipple retraction. A fat necrosis mass cannot always be distinguished from breast cancer without biopsy or fine needle aspiration. In a young woman with a history of injury to the breast, reassurance and follow-up examination are sufficient.

 

_Definition

Anemia is a condition characterized by abnormally low levels of healthy red blood cells or hemoglobin (the component of red blood cells that delivers oxygen to tissues throughout the body).

Description

The tissues of the human body need a regular supply of oxygen to stay healthy. Red blood cells, which contain hemoglobin that allows them to deliver oxygen throughout the body, live for only about 120 days. When they die, the iron they contain is returned to the bone marrow and used to create new red blood cells. Anemia develops when heavy bleeding causes significant iron loss or when something happens to slow down the production of red blood cells or to increase the rate at which they are destroyed.

Types of anemia

Anemia can be mild, moderate, or severe enough to lead to life-threatening complications. More than 400 different types of anemia have been identified. Many of them are rare.

IRON DEFICIENCY ANEMIA

Iron deficiency anemia is the most common form of anemia in the world. In the United States, iron deficiency anemia affects about 240,000 toddlers between one and two years of age and 3.3 million women of childbearing age. This condition is less common in older children and in adults over 50 and rarely occurs in teenage boys and young men.

The onset of iron deficiency anemia is gradual and, at first, there may not be any symptoms. The deficiency begins when the body loses more iron than it derives from food and other sources. Because depleted iron stores cannot meet the red blood cell’s needs, fewer red blood cells develop. In this early stage of anemia, the red blood cells look normal, but they are reduced in number. Then the body tries to compensate for the iron deficiency by producing more red blood cells, which are characteristically small in size. Symptoms develop at this stage.

FOLIC ACID DEFICIENCY ANEMIA

Folic acid deficiency anemia is the most common type of megaloblastic anemia (in which red blood cells are bigger than normal). It is caused by a deficiency of folic acid, a vitamin that the body needs to produce normal cells.

Folic acid anemia is especially common in infants and teenagers. Although this condition usually results from a dietary deficiency, it is sometimes due to inability to absorb enough folic acid from such foods as:

cheese

eggs

fish

green vegetables

meat

milk

mushrooms

yeast

Smoking raises the risk of developing this condition by interfering with the absorption of Vitamin C, which the body needs to absorb folic acid. Folic acid anemia can be a complication of pregnancy, when a woman’s body needs eight times more folic acid than it does otherwise.

VITAMIN B_{12 DEFICIENCY ANEMIA}Less common in this country than folic acid anemia, vitamin B12 deficiency anemia is another type of megaloblastic anemia that develops when the body doesn’t absorb enough of this nutrient. Necessary for the creation of red blood cells, B12 is found in meat and vegetables.

Large amounts of B12 are stored in the body, so this condition may not become apparent until as much as four years after B12 absorption stops or slows down. The resulting drop in red blood cell production can cause:

loss of muscle control

loss of sensation in the legs, hands, and feet

soreness or burning of the tongue

weight loss

yellow-blue color blindness

The most common form of B12 deficiency is pernicious anemia. Since most people who eat meat or eggs get enough B12 in their diets, a deficiency of this vitamin usually means that the body is not absorbing it properly. This can occur among people who have had intestinal surgery or among those who do not produce adequate amounts of intrinsic factor, a chemical secreted by the stomach lining that combines with B12 to help its absorption in the small intestine.

Pernicious anemia usually strikes between the ages of 50-60. Eating disorders or an unbalanced diet increases the risk of developing pernicious anemia. So do:

diabetes mellitus

gastritis, stomach cancer, or stomach surgery

thyroid disease

family history of pernicious anemia

VITAMIN C DEFICIENCY ANEMIA

A rare disorder that causes the bone marrow to manufacture abnormally small red blood cells, Vitamin C deficiency anemia results from a severe, long-standing dietary deficiency.

HEMOLYTIC ANEMIA

Some people are born with hemolytic anemia. Some acquire this condition, in which infection or antibodies destroy red blood cells more rapidly than bone marrow can replace them.

Hemolytic anemia can enlarge the spleen, accelerating the destruction of red blood cells (hemolysis). Other complications of hemolytic anemia include:

pain

shock

gallstones and other serious health problems

THALASSEMIAS

An inherited form of hemolytic anemia, thalassemia stems from the body’s inability to manufacture as much normal hemoglobin as it needs. There are two categories of thalassemia, depending on which of the amino acid chains is affected. (Hemoglobin is composed of four chains of amino acids.) In alpha-thalassemia, there is an imbalance in the production of the alpha chain of amino acids; in beta-thalassemia, there is an imbalance in the beta chain. Alpha-thalassemias most commonly affect blacks (25% have at least one gene); beta-thalassemias most commonly affect people of Mediterranean ancestry and Southeast Asians.

Characterized by production of red blood cells that are unusually small and fragile, thalassemia only affects people who inherit the gene for it from each parent (autosomal recessive inheritance).

AUTOIMMUNE HEMOLYTIC ANEMIA

Warm antibody hemolytic anemia is the most common type of this disorder. This condition occurs when the body produces autoantibodies that coat red blood cells. The coated cells are destroyed by the spleen, liver, or bone marrow.

Warm antibody hemolytic anemia is more common in women than in men. About one-third of patients who have warm antibody hemolytic anemia also have lymphoma, leukemia, lupus, or connective tissue disease.

In cold antibody hemolytic anemia, the body attacks red blood cells at or below normal body temperature. The acute form of this condition frequently develops in people who have had pneumonia, mononeucleosis, or other acute infections. It tends to be mild and short-lived, and disappears without treatment.

Chronic cold antibody hemolytic anemia is most common in women and most often affects those who are over 40 and who have arthritis. This condition usually lasts for a lifetime, generally causing few symptoms. However, exposure to cold temperatures can accelerate red blood cell destruction, causing fatigue, joint aches, and discoloration of the arms and hands.

SICKLE CELL ANEMIA

Sickle cell anemia is a chronic, incurable condition that causes the body to produce defective hemoglobin, which forces red blood cells to assume an abnormal crescent shape. Unlike normal oval cells, fragile sickle cells can’t hold enough hemoglobin to nourish body tissues. The deformed shape makes it hard for sickle cells to pass through narrow blood vessels. When capillaries become obstructed, a life-threatening condition called sickle cell crisis is likely to occur.

Sickle cell anemia is hereditary. It almost always affects blacks and people of Mediterranean descent. A child who inherits the sickle cell gene from each parent will have the disease. A child who inherits the sickle cell gene from only one parent carries the sickle cell trait, but does not have the disease.

APLASTIC ANEMIA

Sometimes curable by bone marrow transplant, but potentially fatal, aplastic anemia is characterized by decreased production of red and white blood cells and platelets (disc-shaped cells that allow the blood to clot). This disorder may be inherited or acquired as a result of:

recent severe illness

long-term exposure to industrial chemicals

use of anticancer drugs and certain other medications

ANEMIA OF CHRONIC DISEASE

Cancer, chronic infection or inflammation, and kidney and liver disease often cause mild or moderate anemia. Chronic liver failure generally produces the most severe symptoms.

Causes and symptoms

Anemia is caused by bleeding, decreased red blood cell production, or increased red blood cell destruction. Poor diet can contribute to vitamin deficiency and iron deficiency anemias in which fewer red blood cells are produced. Hereditary disorders and certain diseases can cause increased blood cell destruction. However, excessive bleeding is the most common cause of anemia, and the speed with which blood loss occurs has a significant effect on the severity of symptoms. Chronic blood loss is usually a consequence of:

cancer

gastrointestinal tumors

diverticulosis

polyposis

heavy menstrual flow

hemorrhoids

nosebleeds

stomach ulcers

long-standing alcohol abuse

Acute blood loss is usually the result of:

childbirth

injury

a ruptured blood vessel

surgery

When a lot of blood is lost within a short time, blood pressure and the amount of oxygen in the body drop suddenly. Heart failure and death can follow.

Loss of even one-third of the body’s blood volume in the space of several hours can be fatal. More gradual blood loss is less serious, because the body has time to create new red blood cells to replace those that have been lost.

Symptoms

Weakness, fatigue, and a run-down feeling may be signs of mild anemia. Skin that is pasty or sallow, or lack of color in the creases of the palm, gums, nail beds, or lining of the eyelids are other signs of anemia. Someone who is weak, tires easily, is often out of breath, and feels faint or dizzy may be severely anemic.

Other symptoms of anemia are:

angina pectoris (chest pain, often accompanied by a choking sensation that provokes severe anxiety)

cravings for ice, paint, or dirt

headache

inability to concentrate, memory loss

inflammation of the mouth (stomatitis) or tongue (glossitis)

insomnia

irregular heartbeat

loss of appetite

nails that are dry, brittle, or ridged

rapid breathing

sores in the mouth, throat, or rectum

sweating

swelling of the hands and feet

thirst

tinnitus (ringing in the ears)

unexplained bleeding or bruising

In pernicious anemia, the tongue feels unusually slick. A patient with pernicious anemia may have:

problems with movement or balance

tingling in the hands and feet

confusion, depression, and memory loss

Pernicious anemia can damage the spinal cord. A doctor should be notified whenever symptoms of this condition occur.

A doctor should also be notified if a patient who has been taking iron supplements develops:

diarrhea

cramps

vomiting

Diagnosis

Personal and family health history may suggest the presence of certain types of anemia. Laboratory tests that measure the percentage of red blood cells or the amount of hemoglobin in the blood are used to confirm diagnosis and determine which type of anemia is responsible for a patient’s symptoms. X rays and examinations of bone marrow may be used to identify the source of bleeding.

Treatment

Anemia due to nutritional deficiencies can usually be treated at home with iron supplements or self administered injections of vitamin B12. People with folic acid anemia should take oral folic acid replacements. Vitamin C deficiency anemia can be cured by taking one vitamin C tablet a day.

Surgery may be necessary to treat anemia caused by excessive loss of blood. Transfusions of red blood cells may be used to accelerate production of red blood cells.

Medication or surgery may also be necessary to control heavy menstrual flow, repair a bleeding ulcer, or remove polyps (growths or nodules) from the bowels.

Patients with thalassemia usually do not require treatment. However people with a severe form may require periodic hospitalization for blood transfusions and/or bone marrow transplantation.

SICKLE CELL ANEMIA

Treatment for sickle cell anemia involves regular eye examinations, immunizations for pneumonia and infectious diseases, and prompt treatment for sickle cell crises and infections of any kind. Psychotherapy or counseling may help patients deal with the emotional impact of this condition.

VITAMIN B12 DEFICIENCY ANEMIA

A life-long regimen of B12 shots is necessary to control symptoms of pernicious anemia. The patient may be advised to limit physical activity until treatment restores strength and balance.

APLASTIC ANEMIA

People who have aplastic anemia are especially susceptible to infection. Treatment for aplastic anemia may involve blood transfusions and bone marrow transplant to replace malfunctioning cells with healthy ones.

ANEMIA OF CHRONIC DISEASE

There is no specific treatment for anemia associated with chronic disease, but treating the underlying illness may alleviate this condition. This type of anemia rarely becomes severe. If it does, transfusions or hormone treatments to stimulate red blood cell production may be prescribed.

HEMOLYTIC ANEMIA

There is no specific treatment for cold-antibody hemolytic anemia. About one-third of patients with warm-antibody hemolytic anemia respond well to large doses of intravenous and oral corticosteroids, which are gradually discontinued as the patient’s condition improves. Patients with this condition who don’t respond to medical therapy must have the spleen surgically removed. This operation controls anemia in about half of the patients on whom it’s performed. Immune-system suppressants are prescribed for patients whose surgery is not successful.

Self-care

Anyone who has anemia caused by poor nutrition should modify his or her diet to include more vitamins, minerals, and iron. Vitamin C can stimulate iron absorption. The following foods are also good sources of iron:

almonds

broccoli

dried beans

dried fruits

enriched breads and cereals

lean red meat

liver

potatoes

poultry

rice

shellfish

tomatoes

Because light and heat destroy folic acid, fruits and vegetables should be eaten raw or cooked as little as possible.

Alternative treatment

As is the case in standard medical treatment, the cause of the specific anemia will determine the alternative treatment recommended. If the cause is a deficiency, for example iron deficiency, folic acid deficiency, B12 deficiency, or vitamin C deficiency, supplementation is the treatment. For extensive blood loss, the cause should be identified and corrected. Other types of anemias should be addressed on a deep healing level with crisis intervention when necessary.

Many alternative therapies for iron-deficiency anemia focus on adding iron-rich foods to the diet or on techniques to improve circulation and digestion. Iron supplementation, especially with iron citrate (less likely to cause constipation), is used by alternative practitioners. This can be given in combination with herbs that are rich in iron. Some examples of iron-rich herbs are dandelion (Taraxacum officinale), parsley (Petroselinum crispum), and nettle (Urtica dioica). The homeopathic remedy ferrum phosphoricum can also be helpful.

An iron-rich herbal tonic can also me made using the following recipe:

soak 1/2 oz of yellow dock root and 1/2 oz dandelion root in 1 qt of boiled water for four to 8 hours

strain and simmer until the amount of liquid is reduced to 1 cup

remove from heat and add 1/2 cup black strap molasses, mixing well

store in refrigerator; take 1 tsp-2 Tbsp daily

Other herbal remedies used to treat iron-deficiency anemia aim to improve the digestion. Gentian (Gentiana lutea) is widely used in Europe to treat anemia and other nutritionally based disorders. The bitter qualities of gentian help stimulate the digestive system, making iron and other nutrients more available for absorption. This bitter herb can be brewed into tea or purchased as an alcoholic extract (tincture).

Other herbs recommended to promote digestion include:

anise (Pimpinella anisum)

caraway (Carum carvi)

cumin (Cuminum cyminum)

linden (Tilia spp.)

licorice (Glycyrrhiza glabra)

Traditional Chinese treatments for anemia include:

acupuncture to stimulate a weakened spleen

asian ginseng (Panax ginseng) to restore energy

dong quai (Angelica sinensis) to control heavy menstrual bleeding

a mixture of dong quai and Chinese foxglove(Rehmannia glutinosa) to clear a sallow complexion

Prognosis

Folic-acid and iron-deficiency anemias

It usually takes three to six weeks to correct folic acid or iron deficiency anemia. Patients should continue taking supplements for another six months to replenish iron reserves and should have periodic blood tests to make sure the bleeding has stopped and the anemia has not recurred.

Pernicious anemia

Although pernicious anemia is considered incurable, regular B12 shots will alleviate symptoms and reverse complications. Some symptoms will disappear almost as soon as treatment begins.

Aplastic anemia

Aplastic anemia can sometimes be cured by bone marrow transplantation. If the condition is due to immunosuppressive drugs, symptoms may disappear after the drugs are discontinued.

Sickle cell anemia

Although sickle cell anemia cannot be cured, effective treatments enable patients with this disease to enjoy longer, more productive lives.

Thalassemia

People with mild thalassemia (alpha thalassemia trait or beta thalassemia minor) lead normal lives and do not require treatment. Those with severe thalassemia may require bone marrow transplantation. Genetic therapy is is being investigated and may soon be available.

Hemolytic anemia

Acquired hemolytic anemia can generally be cured when the cause is removed.

Prevention

Inherited anemias cannot be prevented. Genetic counseling can help parents cope with questions and concerns about transmitting disease-causing genes to their children.

Avoiding excessive use of alcohol, eating a balanced diet that contains plenty of iron-rich foods, and taking a daily multivitamin can help prevent anemia.

Methods of preventing specific types of anemia include:

avoiding lengthy exposure to industrial chemicals and drugs known to cause aplastic anemia

not taking medication that has triggered hemolytic anemia and not eating foods that have caused hemolysis (breakdown of red blood cells)

receiving regular B12 shots to prevent pernicious anemia resulting from gastritis or stomach surgery

Aplastic

Exhibiting incomplete or faulty development.

Diabetes mellitus

A disorder of carbohydrate metabolism brought on by a combination of hereditary and enviornmental factors.

Hemoglobin

An iron-containing pigment of red blood cells composed of four amino acid chains (alpha, beta, gamma, delta) that delivers oxygen from the lungs to the tissues of the body.

Megaloblast

A large erythroblast (a red marrow cell that synthesizes hemoglobin).

 

AIDS (Acquired Immunodeficiency Syndrome) is caused by HIV (the Human Immunodeficiency Virus).

HIV is mainly transmitted through sexual intercourse.

Once infected, the virus remains in the body for life.

One can be HIV positive and feel completely well for many years.

When a mother is infected, there is a one in three chance of her baby becoming infected if no steps are taken to prevent this.

All people infected with HIV will eventually get AIDS.

AIDS is a fatal illness.

There is no drug that can cure HIV infection, but there are drugs that can control the virus and delay the onset of AIDS.

There is no preventative HIV vaccine available at the moment, however research is ongoing to find one.

Description

The Acquired Immune Deficiency Syndrome (AIDS) is caused by infection with the Human Immunodeficiency Virus (HIV). HIV attacks and gradually destroys the immune system, which protects the body against infections.

AIDS develops during the last stages of HIV infection. AIDS is not a single illness, but the whole clinical picture (a syndrome) that occurs when the immune system fails entirely. A person with a failing immune system is susceptible to a variety of infections that are very unlikely to occur in people with healthy immune systems. These are called opportunistic infections because they take advantage of the body’s weakened immune system. Certain types of cancers also occur when the immune system fails.

It may take years for a person’s immune system to deteriorate to such an extent that the person becomes ill and a diagnosis of AIDS is made. During this time (which can last as long as 15 years or possibly even longer), a person may look and feel perfectly well. This explains why so many people are unaware that they are infected. However, even though they feel healthy, they can still transmit the virus to others.

More than 90% of people living with HIV are in developing countries, with sub-Saharan Africa accounting for two thirds of all the HIV-infected people in the world. Unlike Western countries, where HIV has initially affected predominantly homosexual men, in Africa and developing countries HIV is usually spread by sex between men and women (heterosexual sex).

Research into HIV/AIDS is ongoing and new information is emerging rapidly. There are drugs that can dramatically slow down the disease in an infected person. These drugs need to be taken in various combinations in order to be effective and so treatment is generally quite expensive. Also, individuals on the drugs must be monitored by physicians trained in the use of antiretroviral therapy because these drugs can potentially cause serious side effects if not taken correctly and if the individual is not monitored properly. However, there is no cure for AIDS. There is also currently no preventative vaccine against HIV infection. At this time the only effective strategy for controlling the spread of HIV is prevention through individual behaviour change, spreading the correct information about preventing HIV infection and the use of condoms and other safe sex measures. Other measures, which should be taken by a country’s health system, are screening of blood products and the prevention of infection of patients through contaminated medical equipment. Mother to child infection can be reduced by a short course of an anti-HIV drug given to the mother and new-born baby at the time of delivery. (See “treatment”)

Cause

According to researchers, two viruses cause AIDS, namely HIV-1 and HIV-2. HIV-1 is the predominant virus in most parts of the world, whereas HIV-2 is most commonly found in West Africa. These viruses belong to a family called the retroviruses. They are unique viruses in that they are able to insert their genetic material into the genetic material (DNA) of cells of the person that they have infected. In this way they are able to persistently infect a person for the rest of that person’s life.

To understand how the virus eventually causes AIDS, see the section “Course of the disease”.

For detailed discussion of evidence that HIV causes AIDS, go to http://www.niaid.nih.gov/factsheets/evidhiv.htm

Viruses that are very closely related to HIV are found in other primates (apes and monkeys). These viruses are called Simian Immunodeficiency Viruses (SIV). HIV-2 is genetically almost indistinguishable from the SIV found in sooty mangabeys. A very close genetic relative of HIV-1 has been found in chimpanzees. Therefore most scientists accept that the human immunodeficiency viruses are recently derived from these primate viruses. The earliest blood sample found to contain HIV dates from 1959; this sample was collected in central Africa.

Based on molecular technology and the use of large computer programmes, scientists have been able to trace back the genetic origins of HIV-1 and HIV-2 and roughly pinpoint the time when these viruses first appeared in humans. The current theory is that sometime between 1930-1940 there was a “species-jump” of certain SIV’s into human populations, probably through the practise of slaughtering, preparing and consuming of “bush meat” from monkeys in parts of Central and West Africa.

HIV is not as contagious as is often believed. The virus does not survive long outside the body and can only be transmitted through the direct exchange of certain body fluids such as blood, semen and vaginal fluid. The virus can gain access to the body at its moist surfaces (”mucous membranes”) during sex or through direct injection into the blood stream. Sex is the major mode of transmission of HIV.

HIV can be transferred from one person to another (transmitted) through:

Unprotected vaginal or anal intercourse with an infected person

A mother’s infection passing to her child during pregnancy, birth or breastfeeding (called vertical transmission) – the risk of HIV passing from mother to child is approximately 30%

Injection with contaminated needles, which may occur when intravenous drug users share needles, or when health care workers are involved in needleprick accidents

Use of contaminated surgical instruments, for example during traditional circumcision

Blood transfusion with infected blood

Contact of a mucous-membrane surface with infected blood or body fluid, for example with a splash in the eye (Note that the virus cannot penetrate undamaged skin.)

If a person is exposed to HIV in one of the above ways, infection is not inevitable. The likelihood of transmission of HIV is determined by factors such as the concentration of HIV present in the body fluids. For example, although HIV has been detected in saliva, the concentration is thought to be too low for HIV to be transmitted through deep/wet kissing since it would require the exchange of almost one litre of saliva between individuals before there would be sufficient virus available for possible transmission. Additionally, a digestive protein in human saliva tends to inactivate the virus.

The risk of HIV transmission also depends on the stage of infection the HIV-positive sexual partner is in. Virus concentrations in blood and body fluids are highest when a person has very recently been infected with HIV, or otherwise very late in the disease, when AIDS has developed. Very early after infection the virus can multiply rapidly as the immune system has not had time to take control, and late in the disease the virus can multiply rapidly because it has destroyed the immune system altogether. However, it is important to note that once a person is infected with HIV, their blood, semen or vaginal fluids are always infectious, for the rest of their lives.

Vulnerability to HIV infection through sexual contact is increased if a person has sores on the genitals, mouth or around the anus/rectum. These sores can be caused by rough intercourse, other sexually transmitted diseases (STDs), gum disease or overuse of spermicides.

In heterosexual sex, women are more vulnerable to HIV infection because of the large mucous-membrane surface area of the vagina compared to that of the urethra (penile opening). Therefore, in regions where heterosexual sex is the main way HIV is transmitted (as in South Africa), approximately four women are infected for every three men that are infected.

Men who are circumcised have a slightly lower risk of being infected with HIV.

Fortunately, people can take action to reduce their risk of infection. For example, a person who uses a condom every time he or she has sex is at far lower risk of infection than someone who has unprotected sex.

The following outlines common sexual behaviours according to relative risk:

Very low risk

Kissing (if no blood is exchanged through cuts or sores)

Touching (such as stroking, hugging or massage)

Masturbation (including mutual masturbation)

Oral sex on a man with a condom

Oral sex on a woman with a barrier method (such as plastic wrap, dental dam or a condom cut open)

Low risk

Wet/deep kissing (when sores or gum disease, and therefore blood, are present)

Oral sex

Vaginal sex with a male or female condom

Anal sex with a male or female condom

High risk

Anal intercourse without a condom

Vaginal sex without a condom

How HIV is not transmitted

Unfortunately, there are still many myths around HIV. A person cannot be infected through:

Mosquito bites

Urine or sweat

Public toilets, saunas, showers or swimming pools

Sharing towels, linen or clothing

Going to school with, socialising or working with HIV-positive people

Sharing cutlery or crockery

Sneezes or coughs

Touching, hugging or dry kissing a person with HIV

(Sexual) contact with animals, since HIV is strictly a human virus and is not carried by animals

In South Africa, blood donated for transfusions or blood products is screened for antibodies to HIV and for the presence of one of the viral proteins. Any contaminated blood is discarded. The probability of HIV infection via blood transfusion in this country is therefore extremely low, but can still occur because the tests used do not detect very early HIV infection in a donor. (See “the window period” in the section on HIV tests.)

Symptoms

The majority of people will have some symptoms about three weeks after they have been infected with HIV. These symptoms are similar to those of glandular fever:

Fever and night sweats

Aching muscles and tiredness

Sore throat

Swollen glands

Diarrhoea

Skin rash and ulceration of the inside surface of the mouth and genitals

Headache, sore eyes and sensitivity to light

These early symptoms are called the HIV seroconversion illness. This is because the illness coincides with the start of the production of antibodies to the virus. (Antibodies are blood proteins made by the immune system that recognise and attach to organisms invading the body.) Consequently, seroconversion from HIV antibody negative to HIV antibody positive follows; these are the antibodies detected with HIV tests. The seroconversion illness is brief, lasting a week or two.

Thereafter most people remain symptom-free for a long time, on average ten years. Then symptoms associated with the advance of HIV disease, roughly in order of appearance, may include:

Unexplained weight loss (more than 10% of body weight)

Swelling of glands in the neck, armpit or groin

Easy bruising

A thick, white coating of the tongue or mouth (oral thrush) or vagina (vaginal thrush) which is severe and recurs

Ongoing vaginal discharge and pain in the lower abdomen

Sinus fullness and drainage

Recurrent herpes

Shingles

Persistent sore throat

Recurring fevers lasting more than 10 days without an obvious cause

Night sweats or chills

Persistent cough and/or shortness of breath

Persistent severe diarrhoea (longer than a month)

Changes in vision

Pain, loss of control and strength of muscles, paralysis

Discoloured or purplish growths on the skin or inside the mouth or nose

Difficulty with concentration, inability to perform mental tasks that have been done in the past, confusion, personality change

Symptoms are slightly different in children. Common symptoms include:

Persistent oral thrush

Recurrent bacterial infections, such as ear infections

Recurrent gastro-enteritis

Swollen salivary glands (parotitis)

Swollen lymph nodes in the neck, armpits or groin

Enlargement of the liver and spleen

Failure to grow or reach normal points in development at the right time (such as talking, walking)

Prevalence

Estimates published in the annual “UNAIDS Report on the Global HIV/AIDS Epidemic” in 2002 estimate that more than 40 million adults and children were infected with HIV around the world in 2001. Africa south of the Sahara desert accounts for 28 million of these adults and children. A recent study by the Human Sciences Research Council (HSRC) which was published in December 2002 estimated that 11.4% of South Africans (4.5 million people) are currently living with HIV/AIDS. This study also showed that HIV/AIDS in this country affects all races with 12.9% of Africans, 6.2% of whites, 6.1% of people of mixed race and 1.6% of Indians being infected. Also this study clearly demonstrated that young women in South Africa in the age group 25-29 are more at risk for HIV infection.

This data is also supported by the annual Department of Health Ante-natal clinic (ANC) surveys that showed about 24.8% of pregnant women were HIV positive in 2001. This in turn indicates that many thousands of babies would have been infected by their mothers in South Africa during 1999 to 2001. By the end of 1999, it is estimated that there were 370 000 AIDS orphans (mother or both parents lost to AIDS) under 15 years of age in South Africa. During 1999, 250 000 people died of AIDS in South Africa.

See “Epidemic Update” at http://www.UNAIDS.org

Course of the disease

The disease is best understood as a continuum from initial infection to terminal illness.

During sexual transmission, the virus penetrates the thin, moist surface of the vagina, urethra or rectum of another person during sex. Special protective white cells called macrophages usually patrol just beneath these surfaces and usually protect against invading organisms. Unfortunately, HIV is able to infect these exact cells or “defenders” called macrophages, which then carry the virus into the blood circulation.

Once in the blood, the virus has access to another type of white cell, called a T-helper lymphocyte. HIV gets into these cells by attaching to a specific protein on their surface, known as CD4 (so these cells are also called CD4 cells). T-helper lymphocytes circulate in the blood, but most of them are found in the lymph glands, where they stimulate other cells of the immune system to go into action.

In addition to the CD4 receptor, another co-receptor is required for the HIV virus to enter the CD4 cell successfully. The co-receptors are called CCR5 and CXCR4 and are also protein markers on the surface of these types of cells. Certain people have genetically defective CCR5 receptors that make them relatively resistant to HIV infection. CCR5 defects are common in Northern European populations but unfortunately are not common in South Africans.

HIV multiplies best inside T-helper lymphocytes and the infected lymphocytes eventually deteriorate and die, releasing more viruses to infect new lymphocytes.

The virus takes about two weeks to start multiplying efficiently in the body. At about three weeks after infection the immune system will recognise the “invasion” and start to produce antibodies to HIV. The battle between the virus and the immune response causes the symptoms of the seroconversion illness when antibodies are produced. Amazingly, the immune system will get the upper hand at this stage and limit multiplication of the virus, so that symptoms resolve in a week or two. Thereafter most people will have partial control over the virus with no symptoms of HIV infection for several years, 10 on average.

However, slowly but surely the virus hides out in an individual’s lymphocytes and evades the control measures of the immune system, mostly because it is genetically changeable and therefore keeps presenting a new appearance to the immune system which cannot keep up with the virus. All this time T-helper cells are not functioning properly or are destroyed whenever the virus multiplies. Initially the body is able to replace the T-helper cells as fast as they are destroyed and there is no significant effect on their numbers. However, after several years the body’s ability to replace the T-lymphocytes begins to fall off. T-helper cells play a crucial part in the proper functioning of the immune system and the depletion of these cells drastically reduces the effectiveness of the immune system.

AIDS is first diagnosed when an HIV-positive person gets a characteristic opportunistic infection or an AIDS-related tumour. Very common opportunistic infections in AIDS are Pneumocystis carinii pneumonia (PCP) now known as Pneumocystis jerovicii pneumonia and tuberculosis (TB), which can even occur in sites in the body outside the lungs, bones or gut. The common tumours in AIDS are Kaposi’s sarcoma, usually visible in the skin, and certain tumours of the lymph glands (lymphoma). Infection of the brain by HIV itself or other viruses and certain types of parasites, can cause dementia and stroke-like problems.

Some people progress to AIDS quickly within two years, whereas others remain symptom-free for 15 years or more. This latter group of people are known as “long-term non-progressors” and scientists are very interested in what advantage they have for withstanding HIV. In developing countries, where people may be malnourished and have many other illnesses to contend with as well, HIV disease tends to progress to AIDS more quickly than the 10-year average for people living in the better circumstances of the developing world.

Risk factors

The following people are most at risk of HIV infection:

People who have unprotected vaginal or anal sex

People who have sex with many partners, thereby increasing the chance that they will encounter a partner who is HIV infected

People who share needles (for example for intravenous drug use, tattooing or body piercing)

Babies of mothers who are HIV infected

People who have another STD, especially STDs that cause open sores or ulcers such as herpes, chancroid or syphilis

Haemophiliacs and other people who frequently receive blood products (this risk is now very much diminished, but there are still countries where blood is not adequately screened)

Health care workers, where precautions are neglected or fail (for example through not wearing gloves or accidental needle injuries)

When to call a health professional

A health care professional should be seen if:

You have been at risk of HIV infection (for example through unprotected sex, rape or sharing of needles). Anti-HIV drugs taken within hours or days of exposure to HIV can decrease the risk of contracting the virus.

Your sexual partners engage in high-risk behaviour or are known to be HIV positive

You are pregnant or plan to have a child

Any of the symptoms listed above are present

An HIV-positive person develops shortness of breath, convulsions, weakness in a limb or one side of the body, or loses consciousness (they should receive emergency care)

Visit preparation

Before being tested for HIV, it is best to seek counselling. All clinics and doctors should insist on pre- and post-test counselling to help patients deal with the psychological stress and anxiety they are likely to experience while waiting for results or when they have to deal with the consequences of a positive result. Pre- and post-test counselling for HIV testing is a requirement by law in South Africa. Avoid sexual contact with others while waiting for test results.

Diagnosis

Diagnostic testing can only be done with your consent. Pre-employment testing is now illegal in South Africa. Testing by life insurance companies is still often required, but can only be done if the client gives consent.

Ordinary HIV tests do not detect the virus, but rather the specific antibodies that are produced by the immune system in response to HIV infection. Antibodies are produced from about three weeks after infection and usually become detectable by enzyme liked immunosorbent assay or ELISA testing by four to six weeks after infection. This four- to six-week period between infection and a positive test is called the window period. In some people the window period is longer; it may take up to three months for an antibody test to become positive after they have been infected, but this is unusual. People who think that they might have been exposed to infection are therefore usually asked to wait at least four weeks before having the HIV test. Also, even if the first test is negative (i.e., no antibodies detected), a follow-up test should be done three months after the suspected exposure.

The most widely used and best antibody test is called an ELISA test (ELISA is short for Enzyme-Linked Immunosorbent Assay). ELISA tests have to be done in a laboratory. If a positive result is obtained on an ELISA test, the laboratory will confirm the result by testing with at least one different type of ELISA test. As an additional check, a second blood specimen is usually taken from the person for repeat testing.

Testing can also be done with a rapid HIV test which can be carried out by any health care professional immediately on-site in a clinic. Two different rapid tests should be used to confirm a diagnosis of HIV infection. The advantage of rapid testing is that an HIV result is available within 30 minutes.

This sort of HIV testing is very accurate, with the statistics predicting approximately 1 in a 1000 false results, or even less. The modern HIV tests in use in South Africa do not give false positive results in persons who are pregnant, who have TB, malaria, or any other common disease.

Currently, home HIV tests are being sold in some chemists. Most health care professionals and the Department of Health are not in favour of this practice. One reason is that the quality of the test cannot be regulated, so that there may be a greater risk of false positive or negative results. Also, a person testing themselves or someone else, will probably not have the information or psychological support that is gained through pre- and post-test counselling.

HIV testing in babies:
In babies less than 18 months old, the mother’s antibodies in the baby’s blood can interfere with the HIV antibody test. Therefore, to test whether a baby is infected with HIV, it is necessary to detect the virus itself. This is commonly done with a PCR test.

Once a person has tested positive for HIV, a thorough medical examination should be done to evaluate their present state of health. As other STDs and TB are often present in someone who is HIV positive, additional screening tests for these diseases should be done, so that they can be treated straight away.

There are tests to monitor how advanced a person’s HIV disease is. A CD4 cell count indicates what reserves of T-helper lymphocytes the person has and therefore the remaining strength of their immune system. A normal CD4 count is 800 or more cells per microlitre of blood. HIV-infected people in the early stages of the disease have a count of 200 to 500 cells per microlitre and in late phases a count lower than 200. A viral load test measures the amount of virus in the blood, which shows how rapidly HIV is multiplying and therefore how quickly the disease is likely to progress.

Treatment

Home

Discuss your HIV status with your partner(s). While this may be difficult to do, it is important that they be tested so that they can also be treated if necessary. In addition, they in turn may be unknowingly putting others at risk of HIV.

Protect your partner(s) from HIV by practising safer sex.

Stay healthy to maintain a strong immune system: eat a healthy, balanced diet, get enough rest and exercise, and avoid cigarettes and alcohol.

Medication

Anti-retroviral drugs slow down the rate at which the virus multiplies. Even though these drugs cannot completely eliminate the virus, by slowing down its multiplication they can prolong the symptom-free period of the disease. The presence of symptoms of HIV disease, the CD4 count and viral load tests are all used to decide when to start anti-retroviral drugs. Even if there are no symptoms, according to international guidelines that are revised every year, a CD4 count lower than 250 or a viral load higher than 50 000 would indicate the need for drug treatment. These guidelines also give information on which drugs are suitable to start therapy with and how to monitor individuals on these drugs.

It is believed that it is best to start treatment as late as possible in order to decrease the possibility of viral resistance developing to certain important groups of drugs and to minimise the drug side effects to an individual.

Anti-retroviral drugs include:

Nucleoside reverse transcriptase inhibitors (NRTIs) such as zidovudine (AZT) and lamivudine (3TC)

Non-nucleoside reverse transcriptase inhibitors (NNRTIs) such as nevirapine

Protease inhibitors (PIs) such as indinavir

The two groups of reverse transcriptase inhibitors handicap (inhibit) the viral enzyme that allows the virus to repeatedly copy itself into the DNA of T-helper lymphocytes.

The protease inhibitors handicap the viral enzyme that allows young viruses to mature to the state in which they can infect new cells.

In the best circumstances a person is given a combination of these drugs. This is because the drugs assist each other against the virus, and it takes longer for the virus to become resistant to any one drug. Ultimately a person’s virus becomes resistant to these drugs so that they are no longer effective, in the same way that insects become resistant to a pesticide and bacteria become resistant to a frequently used antibiotic.

These drugs are very expensive and in South Africa the state does not pay for a person’s treatment. Laboratory monitoring while on the drugs which can also be costly. If you do not have medical aid, it may be possible to get drug treatment by participating in a drug trial at a large hospital. In a drug trial new drugs or new combinations of drugs are tried out on a group of patients. These trials are closely monitored to ensure that those participating benefit from the drugs, and are not harmed or exploited.

HIV drugs and mother to child transmission (MTCT)

Pregnant women who are HIV positive can reduce the risk of infecting their babies by using anti-retroviral drugs during pregnancy and labour. In addition, the baby may be given an anti-retroviral drug for a few weeks after birth to counteract exposure to the virus during labour. There are different drugs and treatment approaches that can be used in this situation, but the most world-wide experience has been obtained with the drug AZT, and more recently, nevirapine. Infection of babies can be reduced by approximately 50% by using a short course of either of these drugs. A planned caesarean section will also reduce the risk of HIV being transmitted to the baby, as most infections occur during labour itself.

New data from studies conducted in Soweto, South Africa, using only one dose of drug (nevirapine) to the mother during labour and one dose of nevirapine to the infant after delivery has shown to decrease transmission by almost 60%. This is a very easy and short schedule that can easily be implemented in this country to prevent mother to child transmission of HIV.

However, babies can still be infected through breastfeeding, so most specialists strongly recommend that mothers who are HIV positive should bottle feed their babies. The recently implemented Department of Health MTCT programme in South Africa provides a nevirapine dose for a mother and her infant as well as a 12 month supply of formula milk at a reduced subsidised cost. Most antenatal clinics in the country also have a “training” programme to show mothers how to use this milk properly. So although the benefits of breast milk are unfortunately lost in these infants, receiving formula or bottle milk at least ensures they are not exposed to HIV.

MTCT is a very complex problem. If you are HIV positive and pregnant you would need to discuss the issues at length with a health care professional knowledgeable in the area.

Health care workers who are accidentally exposed to HIV through, for example, a needleprick accident should start one or more anti-retroviral drugs (usually AZT and 3TC) as soon as possible after the incident and preferably within 72 hours. The drugs are usually taken for one month. From analysing thousands of such accidental exposures to health care wokers, it has been calculated that even though the risk of getting HIV infection from such an accident is quite low (0.03% of cases), taking anti-retroviral drugs reduces the risk of infection by about 80%.

Women who have been raped should also start anti-retroviral drugs as soon as possible. Most specialists believe that this is highly likely to reduce the risk of HIV infection, just as the drugs reduce infections after needleprick accidents and reduce transmission of HIV from a mother to her newborn baby. Recently some experimental work in monkeys and data from rape clinics have confirmed this theory, and showed that the drugs must be taken early (definitely before 72 hours, and preferably within 36 hours) to be effective.

Currently it is not the policy of the South African government to fund anti-retroviral drugs in the context of MTCT or rape. There are certain centres where treatment is nevertheless available, such as Baragwanath Hospital in Gauteng and Groote Schuur Hospital in the Western Cape.

Preventative treatment for opportunistic infections

Preventative treatment for opportunistic infections covers primary prevention (preventing illness before it occurs) and secondary prevention (preventing a disease that a person has already had from coming back).

Children should receive their routine vaccinations, but if they already have AIDS, they should not get the vaccine against TB. Extra vaccinations may be recommended in both adults and children. All children, as well as adults who have started to show the signs of HIV disease, should take an antibiotic called co-trimoxazole continuously. This antibiotic prevents Pneumocystis jerovici pneumonia. Adults or children who have had TB or who have contact with people with TB (especially at home) should take anti-TB drugs as well.

Boosting the immune system

A third aspect of treatment focuses on boosting the immune system. In general one should take care of one’s health and immune system. In addition, get treatment for any infections early on before they become too serious. Recently, researchers at the University of Stellenbosch have developed a drug called Moducare, which is made from the African potato plant. Moducare has been shown to boost the immune system and may help, along with other measures, to slow down HIV disease.

Follow-up

Follow-up treatment and examinations will include regular visits to a doctor to monitor the progress of HIV disease, to diagnose and treat other infections and to keep up to date with new treatments.

Regular dental examinations are necessary, because people with HIV have a higher rate of mouth problems, including gum disease.

Other

HIV-positive people often have to deal with being treated differently by others (discrimination) or even shunned because they carry an infectious disease that is transferred by sex. There is also the anxiety about the threat of illness and death. It may therefore be important to get emotional support from a psychologist or a support group.

It may happen that, when it is known that people have HIV, their colleagues do not want to work with them or their employer will want to fire them. Information on legal and human rights for people living with HIV/AIDS may be obtained from an AIDS service organisation.

Prevention

How to protect yourself from getting HIV:

Reduce the number of sexual partners.

Always practice safer sex:

Use condoms from start to finish during anal or vaginal sex. Male latex condoms as well as female condoms provide protection against infection.

Always use male condoms when performing oral sex on a man.

For oral sex on a woman, cover the vaginal area with plastic wrap (cling wrap), a condom cut open or dental dams.

Never use oil-based lubricants with male condoms.

Engage in non-penetrative sex practices such as kissing, massaging, hugging, touching, body rubbing and masturbation.

Avoid alcohol and drugs, which can impair judgement and motivation to practice safer sex.

Do not share needles/syringes when using intravenous drugs - preferably don’t use recreational or illegal drugs at all!

Make sure all medical and surgical instruments, including those used for tattooing, body piercing or circumcision, are completely sterilised before re-use or are safely discarded.

Be tested regularly and get treatment for other STDs (women and men with open sores from herpes, syphilis or chancroid are more susceptible to HIV than other people).

 

Abdominal pain is a frequent manifestation of disorders of the abdominal organs, but it may also result from disorders in which the primary problem lies outside the abdomen.

The cause of abdominal problems can be hard to pinpoint. Sometimes serious and minor abdominal problems start with the same symptoms.

Any sudden, severe, unfamiliar stomach or abdominal pain lasting longer than 30 minutes requires immediate attention.

When the problem is in your abdomen

The abdomen contains various organs and other structures and disease processes in many of these give rise to pain.

The site, character, relieving and aggravating factors of the pain are taken into consideration in the diagnostic process.

Accompanying symptoms such as vomiting, constipation, rectal bleeding and jaundice are evaluated in conjunction with the pain.

Various special investigations may be indicated to make a final diagnosis.

The treatment of abdominal pain will be determined by the underlying disease process.

Facts about the intra-abdominal organs

The liver is one of the largest organs in the body, representing 2% of the total body weight with 1,5L of blood entering this organ every minute

The gallbladder holds about 50ml of bile but as much as 1,5L of bile is produced every day by the liver cells

Although the pancreas is only 12-15cm long and weighs about 100g, it produces 1-2L of secretions per day containing digestive enzymes

An amazing 250-350L of blood flow through the spleen every day with each red blood cell averaging 1 000 passes through this 12 by 7 cm organ each day

The volume of the empty stomach is only 50 ml but by a process of active relaxation, the stomach can accommodate about 1 000 mls before pressure in the lumen starts to rise

It is estimated that stool contains up to 400 different species of bacteria which participates in numerous physiological processes

The small intestine in an adult is 5-6m long and the principal function is absorbing nutrients from the food that we eat

Each kidney contains over 1 million functioning units called nephrons responsible for maintaining homeostasis of body fluids.

When the problem is

 

outside of your abdomen

This is classified as abdominal pain due to diseases of extra abdominal organs. There are two types of pain due to diseases of extra abdominal organs:

Disease processes in organs outside of the abdomen (with referred pain to the abdomen)

Systemic diseases with abdominal pain as a manifestation

Disease processes in organs outside of the abdomen -

Diseases of the vertebral column such as vertebral collapse, prolapsed intervertebral disc or spinal tumour affecting the nerves running onto the anterior (front) abdominal wall, can give rise to abdominal pain. Myocardial infarction (heart attack) can occasionally present with abdominal pain.

Systemic diseases with abdominal pain as a manifestation -

Systemic diseases such as diabetic ketoacidosis, acute intermittent porphyria, lead poisoning and sickle cell anaemia can all present with abdominal pain. This may misdirect the investigative pathway and lead to a delay in diagnosing the underlying condition.

It should be borne in mind that abdominal pain, sometimes of a severe nature, may result from disorders in which the alimentary system (the organs of digestion) is not primarily at fault.

Cause

Site of the pain

The abdomen can be divided into four quadrants: upper right, upper left, lower left and lower right quadrants. Various regions are also present such as the epigastric region (in the centre just below the rib cage), periumbilical region (around the umbilicus) and pelvic region (in the centre just above the pelvic bone).

Pain that occurs in half or more of the abdomen is called generalised pain. Generalised pain can occur with many different illnesses, most of which will go away without medical treatment. Indigestion and the stomach flu (gastroenteritis) are common problems that can cause generalised abdominal pain.

Examples of more localised pain and the possible causative problems are as follows:

Epigastric Pain:

peptic ulcers, pancreatitis, gastroesophageal reflux disease Right Upper Quadrant Pain

: gallbladder inflammation (cholecystitis), hepatitis, liver abscess Left Upper Quadrant Pain

: diseases of the spleen (infarction, infiltration, abscess) Periumbilical Pain

: bowel obstruction, early appendicitis Right Lower Quadrant Pain:

late appendicitis, female genital tract diseases (ectopic pregnancy, ovarian cyst, infection, Mittelschmirtz (pain of ovulation)) Left Lower Quadrant Pain:

female genital tract diseases (as above), diverticular disease Pelvic Region Pain

: urinary tract infection, bladder obstruction.The exact site of the pain is important and can point to the diagnosis of the underlying problem

Abdominal pain may also radiate. For example the pain of pancreatitis, felt in the epigastrium, often radiates to the back. So does the pain related to a dissecting abdominal aneurysm. Disease entities irritating the diaphragm, such as cholecystitis (gallbladder inflammation) often radiates to the shoulder. The pain of oesophageal reflux can radiate to the neck and that of kidney stones to the groin.

Abdominal pain in children

This is a common childhood complaint ranging from mild discomfort to a life-threatening emergency requiring immediate attention. If a child has severe or persistent abdominal pain, get medical care without delay.

In most cases, surgery will not be required, but children with such symptoms should have a thorough checkup to make sure there is not a serious underlying problem.

What causes abdominal pain in children?

In infancy, the most common cause of abdominal pain is colic, which usually clears by age three months. As the child grows older, abdominal pain may be associated with minor disruptions of normal body functions (such as constipation) or with a variety of organic disorders or emotional problems. The abdominal pain associated with emotional problems usually occurs in the age group 5-10 years.

Organic pain (pain due to a physical disease process) is often due to diseases of the abdominal organs, such as the intestines, liver, pancreas and stomach, but it may be relayed from other, more distant parts of the body. Pneumonia and streptococcal throat infection, for example, sometimes cause abdominal symptoms. Hernias, testicular torsion (in boys) and Hirschsprung’s disease are other possible causes. Urinary tract infections also causes abdominal pain and can be indicative of a structural abnormality of the urinary tract. Milk intolerance, due to lactose intolerance, results in abdominal pain associated with diarrhoea.

One of the most common emergency causes of abdominal pain in infancy is intussusception, a telescope-like folding of the intestines. In childhood, appendicitis is the most common cause of abdominal pain requiring surgery.

Symptoms

Character of the pain

Dull, burning pain relieved by antacids or food, is classical of peptic ulcer disease.

Colicky pain, pain which comes and goes in waves, is related to obstruction of a hollow part of a organ seen in renal stone obstruction of an ureter and bowel obstruction. The accompanying irritable bowel syndrome is often described as cramping.

The lower abdominal pain of an urinary tract infection is burning in nature.

Accompanying symptoms and signs

Often the importance of abdominal pain can only be determined when other symptoms are evaluated. Abdominal pain without other symptoms is usually not a serious problem.

The patient with acute cholecystitis is often jaundiced (yellow discolouration of sclera and mucous membranes) and vomits intermittently.

The ureteric colic of a passing renal stone is usually accompanied by blood in the urine.

Diarrhea and/or vomiting are frequent complaints in a patient with abdominal pain related to gastroenteritis.

Alternating constipation and diarrhea is commonly found in irritable bowel syndrome.

Constipation and eventually the absence of any bowel actions can be a feature of colonic obstruction caused by a growing tumour.

Abnormal bleeding that accompanies abdominal pain is almost always an ominous sign. Vomiting of blood can indicate the presence of a peptic ulcer whereas blood passed per rectum can be related to diverticulitis or a tumour of the colon.

The relieving and aggravating factors

These factors also point the clinician in the right diagnostic direction.

The pain of irritable bowel syndrome is often relieved by passing stool or flatus and that of peptic ulcer disease is often relieved by eating food.

Ingestion of alcohol aggravates the pain of pancreatitis, but sitting up straight and leaning forward will relieve this type of pain.

The pain of an inflamed abdominal organ (appendicitis or gallbladder disease) may increase with movement or coughing. Generalised abdominal pain usually does not. Pain that increases with movement or coughing and does not appear to be caused by strained muscles is more likely to mean there is a serious problem.

Duration of the pain

The duration of pain can be divided into two broad categories: acute and chronic pain. This aspect of your abdominal pain also provides clues as to the cause of the pain.

Acute onset pain (pain of quick onset) in the epigastric area can be due to perforation of a peptic ulcer, cholecystitis or acute pancreatitis. In the periumbilical area, acute pain can be due to small bowel obstruction, appendicitis or infarction of the intestines (insufficient blood supply to the intestines with resultant gangrene). Acute pain in the lower quadrants can denote dissecting aortic aneurysm, diverticulitis and obstruction of the colon.

Pain of a slower and often recurrent nature is termed chronic pain. Chronic pain in the epigastric area can be due to reflux oesophagitis or a chronic peptic ulcer. In the periumbilical region, chronic pain can point to the presence of inflammatory bowel disease and in the lower quadrants to inflammatory bowel disease.

Specialised investigations

After the clinician has taken all the above into account, further special investigations may be indicated in order to make a diagnosis.Diagnostic tests that may be performed include:

Blood, urine and stool tests

X-rays of the abdomen

Upper gastrointestinal endoscopy

Colonoscopy

Upper gastrointestinal tract and small bowel series

Barium enema

Ultrasound of the abdomen

Blood, urine and stool tests

Various tests are performed on the above samples in a patient with abdominal pain. The white blood cell count in blood is elevated in appendicitis, a positive culture result is obtained in urinary tract infections and blood can be detected in the stools of a patient with bowel cancer.

X-rays of the abdomen

X-rays are a form of electromagnetic radiation (like light). They are of higher energy, however, and can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black and other structures will be shades of gray.

The test is performed in a hospital radiology department or in the health care provider’s office by an X-ray technician. You lie on your back on the X-ray table. The X-ray machine is positioned over your abdominal area. You hold your breath as the picture is taken so that the picture will not be blurry. You may be asked to change position to the side or to stand up for additional pictures.

Possible abnormal findings include:

abdominal masses

an accumulation of fluid in the abdominal area

kidney stones

some types of gallstones

intestinal blockage

foreign bodies in the intestines

trauma to the abdominal tissue with rupture or haemorrhage of certain organs

perforation of the stomach or intestines

Upper gastrointestinal endoscopy

This test involves examining the lining of the esophagus, stomach and upper duodenum with a flexible fiberoptic endoscope. An endoscope is a device consisting of a tube and an optical system. In upper GIT endoscopy, this device is introduced through the mouth to view the interior of the body. The operator can visualise the area being examined by looking into the proximal part of the scope.You may be given a sedative and/or an analgesic in order to relax you. A local anesthetic will be sprayed into your mouth to suppress the need to cough or gag when the endoscope is inserted. (The gag and cough reflexes are natural protective reflexes initiated by the presence of a foreign body in the upper airway).

A mouth guard will be inserted to protect the endoscope from an involuntary biting action by the patient. Dentures will be removed as they may dislodge and get in the way of the scope. An IV may be inserted to administer medications during the procedure.

The procedure is performed with the patient lying on his or her left hand side. After the gag reflex has been suppressed by the anesthetic spray, the endoscope will be advanced through the mouth into the oesophagus and to the stomach and duodenum. Air will be introduced through the endoscope to enhance viewing by gently pushing away any excess tissue.

The inner mucosal surface of the said structures are examined and biopsies can be obtained through the endoscope. The biopsies are sent to the laboratory for various tests. When the area has been viewed and any biopsies taken, the endoscope will be removed and you will be asked to cough to expel the extra air.

The intake of food and liquids are restricted until your cough reflex returns. The test lasts about 30 to 60 minutes.

Possible abnormal findings can indicate the presence of one or more of the following:

ulcers (acute or chronic)

inflammation of the stomach and duodenum

tumours and masses

diverticulae

Mallory-Weiss syndrome (tear of the oesophagus)

esophageal rings

strictures

obstruction

gastric erosion

dilated oesophageal veins

the presence of foreign bodies

Colonoscopy

A colonoscopy is a procedure of viewing the interior lining of the large intestine (colon) using a colonoscope, a flexible fiber-optic tube.

You will have to prepare your colon in order to clear out as much of the faeces as possible to improve the visibility of the operator. This is done with various laxatives and enemas.

You lie on your left side with your knees drawn up toward the abdomen and your lower body exposed. After administration of an intravenous sedative and analgesic, the lubricated scope is inserted through the anus and gently advanced under direct vision to the terminal small bowel. Air will be inserted through the scope to provide a better view by gently pushing away any excess tissue. Suction may be used to remove secretions.

Since better views are obtained during withdrawal than during insertion, a more careful examination is done during withdrawal of the scope. Tissue samples may be taken with tiny biopsy forceps inserted through the scope, polyps can be removed with electrocautery snares and photographs can be taken. All tissue removed will be sent to the laboratory for analysis. Specialised procedures, such as laser therapy, can also be done via the scope.

Possible abnormal findings include:

lower gastrointestinal (GI) bleeding

polyps (which can be removed through the colonoscope during the exam)

tumours can be visualized and biopsied

inflammatory bowel disease

diverticulitis

Upper gastrointestinal tract and small bowel series

X-rays to examine the esophagus, stomach and small intestine. X-ray pictures are taken after one has swallowed a barium suspension (contrast medium). The contrast medium better defines the structures that are being examined by X-rays.

This test may be done in an office or a hospital radiology department. You will be given a milky substance to drink that has barium in it. The passage of the barium through the esophagus, stomach, and small intestine is monitored by X-ray images. Pictures are taken with you in a variety of positions. The test takes 30 minutes to 1 hour to complete.

In the esophagus, abnormal results may mean:

esophageal cancer

esophageal stricture

hiatus hernia (a portion of the stomach protrudes through the esophageal opening)

diverticula (a pouch-like sac that protrudes from the walls of an organ)

ulcers (open sores)

achalasia (esophagus fails to relax)

In the stomach, abnormal results may mean:

stomach ulcers

cancer of the stomach

polyps (a tumour that is usually noncancerous that grows on the inner lining of the stomach)

pyloric stenosis (a narrowing of the opening from the stomach)

In the small intestines the test may reveal:

tumours

inflammation of the small intestines

obstruction

Barium enema

An X-ray examination of the large intestines. Pictures are taken after rectal instillation of barium sulfate (a radio opaque - contrast medium).

This test may be done in an office or a hospital radiology department. You lie on the X-ray table and an initial X-ray is taken before the administration of the contrast medium. You are asked to lie on the side while a well lubricated enema tube is inserted gently into your rectum via your anus. The barium, a radio opaque (shows up on X-ray) contrast medium, is then allowed to flow into the colon through the enema tube. A small balloon at the tip of the enema tube may be inflated to help keep the barium inside your bowel. The flow of the barium is monitored by the health care provider on an X-ray fluoroscope screen (like a TV monitor). X-ray pictures are taken at various levels as the contrast medium flows through your colon.

Possible abnormal findings include:

Cancer

Diverticulitis (small pouches formed on the colon wall that can become inflamed)

Polyps (a tumour, usually noncancerous, that grows on the inner lining of the colon)

Inflammation of the inner lining of the intestine (ulcerative colitis)

Irritable colon

Acute appendicitis

Twisted loop of the bowel

Ultrasound of the abdomen

Ultrasound examination uses high-frequency sound waves to echo off the internal structures of the body and create a picture of these structures.

The test is done in the ultrasound or radiology department. You will be lying down. A conducting and lubricating gel is applied to the skin of your abdomen. The transducer (a hand-held instrument) is then moved over your abdomen. You may be asked to move to other positions or hold your breath at times during the procedure.

Various conditions can be diagnosed with an ultrasound investigation. These include:

A liver abscess

Gallstones

Malignant secondaries in the liver

Obstruction of one or both kidneys can be seen

An aneurysm of the aorta (abnormal dilation of the large artery running trough the abdomen)

Pathology in the pelvic organs such as an ectopic pregnancy and uterine fibroids

The exact location of palpable abdominal masses can be determined.

Diagnosing abdominal pain in children

Look for the following common signs of abdominal pain in babies and toddlers:

Crying

Irritability

Restlessness

A sudden refusal to eat.

The symptoms of intussusception include a cycle of screaming fits, with or without vomiting, alternating with quiet periods.

Crying may exacerbate the pain of appendicitis so greatly that a suffering infant will not cry. Instead, look for irritability and flexing of the hips (pulling the legs up to the stomach), as well as a general appearance of illness and signs that moving is painful.

Older children who can talk will usually complain of “a sore tummy”.

Abdominal pain is a frequent manifestation of disorders of the abdominal organs, but it may also result from disorders in which the primary problem lies outside the abdomen.

The cause of abdominal problems can be hard to pinpoint. Sometimes serious and minor abdominal problems start with the same symptoms.

Any sudden, severe, unfamiliar stomach or abdominal pain lasting longer than 30 minutes requires immediate attention.

When the problem is in your abdomen

The abdomen contains various organs and other structures and disease processes in many of these give rise to pain.

The site, character, relieving and aggravating factors of the pain are taken into consideration in the diagnostic process.

Accompanying symptoms such as vomiting, constipation, rectal bleeding and jaundice are evaluated in conjunction with the pain.

Various special investigations may be indicated to make a final diagnosis.

The treatment of abdominal pain will be determined by the underlying disease process.

Facts about the intra-abdominal organs

The liver is one of the largest organs in the body, representing 2% of the total body weight with 1,5L of blood entering this organ every minute

The gallbladder holds about 50ml of bile but as much as 1,5L of bile is produced every day by the liver cells

Although the pancreas is only 12-15cm long and weighs about 100g, it produces 1-2L of secretions per day containing digestive enzymes

An amazing 250-350L of blood flow through the spleen every day with each red blood cell averaging 1 000 passes through this 12 by 7 cm organ each day

The volume of the empty stomach is only 50 ml but by a process of active relaxation, the stomach can accommodate about 1 000 mls before pressure in the lumen starts to rise

It is estimated that stool contains up to 400 different species of bacteria which participates in numerous physiological processes

The small intestine in an adult is 5-6m long and the principal function is absorbing nutrients from the food that we eat

Each kidney contains over 1 million functioning units called nephrons responsible for maintaining homeostasis of body fluids.

When the problem is

 

outside of your abdomen

This is classified as abdominal pain due to diseases of extra abdominal organs. There are two types of pain due to diseases of extra abdominal organs:

Disease processes in organs outside of the abdomen (with referred pain to the abdomen)

Systemic diseases with abdominal pain as a manifestation

Disease processes in organs outside of the abdomen -

Diseases of the vertebral column such as vertebral collapse, prolapsed intervertebral disc or spinal tumour affecting the nerves running onto the anterior (front) abdominal wall, can give rise to abdominal pain. Myocardial infarction (heart attack) can occasionally present with abdominal pain.

Systemic diseases with abdominal pain as a manifestation -

Systemic diseases such as diabetic ketoacidosis, acute intermittent porphyria, lead poisoning and sickle cell anaemia can all present with abdominal pain. This may misdirect the investigative pathway and lead to a delay in diagnosing the underlying condition.

It should be borne in mind that abdominal pain, sometimes of a severe nature, may result from disorders in which the alimentary system (the organs of digestion) is not primarily at fault.

Cause

Site of the pain

The abdomen can be divided into four quadrants: upper right, upper left, lower left and lower right quadrants. Various regions are also present such as the epigastric region (in the centre just below the rib cage), periumbilical region (around the umbilicus) and pelvic region (in the centre just above the pelvic bone).

Pain that occurs in half or more of the abdomen is called generalised pain. Generalised pain can occur with many different illnesses, most of which will go away without medical treatment. Indigestion and the stomach flu (gastroenteritis) are common problems that can cause generalised abdominal pain.

Examples of more localised pain and the possible causative problems are as follows:

Epigastric Pain:

peptic ulcers, pancreatitis, gastroesophageal reflux disease Right Upper Quadrant Pain

: gallbladder inflammation (cholecystitis), hepatitis, liver abscess Left Upper Quadrant Pain

: diseases of the spleen (infarction, infiltration, abscess) Periumbilical Pain

: bowel obstruction, early appendicitis Right Lower Quadrant Pain:

late appendicitis, female genital tract diseases (ectopic pregnancy, ovarian cyst, infection, Mittelschmirtz (pain of ovulation)) Left Lower Quadrant Pain:

female genital tract diseases (as above), diverticular disease Pelvic Region Pain

: urinary tract infection, bladder obstruction.The exact site of the pain is important and can point to the diagnosis of the underlying problem

Abdominal pain may also radiate. For example the pain of pancreatitis, felt in the epigastrium, often radiates to the back. So does the pain related to a dissecting abdominal aneurysm. Disease entities irritating the diaphragm, such as cholecystitis (gallbladder inflammation) often radiates to the shoulder. The pain of oesophageal reflux can radiate to the neck and that of kidney stones to the groin.

Abdominal pain in children

This is a common childhood complaint ranging from mild discomfort to a life-threatening emergency requiring immediate attention. If a child has severe or persistent abdominal pain, get medical care without delay.

In most cases, surgery will not be required, but children with such symptoms should have a thorough checkup to make sure there is not a serious underlying problem.

What causes abdominal pain in children?

In infancy, the most common cause of abdominal pain is colic, which usually clears by age three months. As the child grows older, abdominal pain may be associated with minor disruptions of normal body functions (such as constipation) or with a variety of organic disorders or emotional problems. The abdominal pain associated with emotional problems usually occurs in the age group 5-10 years.

Organic pain (pain due to a physical disease process) is often due to diseases of the abdominal organs, such as the intestines, liver, pancreas and stomach, but it may be relayed from other, more distant parts of the body. Pneumonia and streptococcal throat infection, for example, sometimes cause abdominal symptoms. Hernias, testicular torsion (in boys) and Hirschsprung’s disease are other possible causes. Urinary tract infections also causes abdominal pain and can be indicative of a structural abnormality of the urinary tract. Milk intolerance, due to lactose intolerance, results in abdominal pain associated with diarrhoea.

One of the most common emergency causes of abdominal pain in infancy is intussusception, a telescope-like folding of the intestines. In childhood, appendicitis is the most common cause of abdominal pain requiring surgery.

Symptoms

Character of the pain

Dull, burning pain relieved by antacids or food, is classical of peptic ulcer disease.

Colicky pain, pain which comes and goes in waves, is related to obstruction of a hollow part of a organ seen in renal stone obstruction of an ureter and bowel obstruction. The accompanying irritable bowel syndrome is often described as cramping.

The lower abdominal pain of an urinary tract infection is burning in nature.

Accompanying symptoms and signs

Often the importance of abdominal pain can only be determined when other symptoms are evaluated. Abdominal pain without other symptoms is usually not a serious problem.

The patient with acute cholecystitis is often jaundiced (yellow discolouration of sclera and mucous membranes) and vomits intermittently.

The ureteric colic of a passing renal stone is usually accompanied by blood in the urine.

Diarrhea and/or vomiting are frequent complaints in a patient with abdominal pain related to gastroenteritis.

Alternating constipation and diarrhea is commonly found in irritable bowel syndrome.

Constipation and eventually the absence of any bowel actions can be a feature of colonic obstruction caused by a growing tumour.

Abnormal bleeding that accompanies abdominal pain is almost always an ominous sign. Vomiting of blood can indicate the presence of a peptic ulcer whereas blood passed per rectum can be related to diverticulitis or a tumour of the colon.

The relieving and aggravating factors

These factors also point the clinician in the right diagnostic direction.

The pain of irritable bowel syndrome is often relieved by passing stool or flatus and that of peptic ulcer disease is often relieved by eating food.

Ingestion of alcohol aggravates the pain of pancreatitis, but sitting up straight and leaning forward will relieve this type of pain.

The pain of an inflamed abdominal organ (appendicitis or gallbladder disease) may increase with movement or coughing. Generalised abdominal pain usually does not. Pain that increases with movement or coughing and does not appear to be caused by strained muscles is more likely to mean there is a serious problem.

Duration of the pain

The duration of pain can be divided into two broad categories: acute and chronic pain. This aspect of your abdominal pain also provides clues as to the cause of the pain.

Acute onset pain (pain of quick onset) in the epigastric area can be due to perforation of a peptic ulcer, cholecystitis or acute pancreatitis. In the periumbilical area, acute pain can be due to small bowel obstruction, appendicitis or infarction of the intestines (insufficient blood supply to the intestines with resultant gangrene). Acute pain in the lower quadrants can denote dissecting aortic aneurysm, diverticulitis and obstruction of the colon.

Pain of a slower and often recurrent nature is termed chronic pain. Chronic pain in the epigastric area can be due to reflux oesophagitis or a chronic peptic ulcer. In the periumbilical region, chronic pain can point to the presence of inflammatory bowel disease and in the lower quadrants to inflammatory bowel disease.

Specialised investigations

After the clinician has taken all the above into account, further special investigations may be indicated in order to make a diagnosis.Diagnostic tests that may be performed include:

Blood, urine and stool tests

X-rays of the abdomen

Upper gastrointestinal endoscopy

Colonoscopy

Upper gastrointestinal tract and small bowel series

Barium enema

Ultrasound of the abdomen

Blood, urine and stool tests

Various tests are performed on the above samples in a patient with abdominal pain. The white blood cell count in blood is elevated in appendicitis, a positive culture result is obtained in urinary tract infections and blood can be detected in the stools of a patient with bowel cancer.

X-rays of the abdomen

X-rays are a form of electromagnetic radiation (like light). They are of higher energy, however, and can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black and other structures will be shades of gray.

The test is performed in a hospital radiology department or in the health care provider’s office by an X-ray technician. You lie on your back on the X-ray table. The X-ray machine is positioned over your abdominal area. You hold your breath as the picture is taken so that the picture will not be blurry. You may be asked to change position to the side or to stand up for additional pictures.

Possible abnormal findings include:

abdominal masses

an accumulation of fluid in the abdominal area

kidney stones

some types of gallstones

intestinal blockage

foreign bodies in the intestines

trauma to the abdominal tissue with rupture or haemorrhage of certain organs

perforation of the stomach or intestines

Upper gastrointestinal endoscopy

This test involves examining the lining of the esophagus, stomach and upper duodenum with a flexible fiberoptic endoscope. An endoscope is a device consisting of a tube and an optical system. In upper GIT endoscopy, this device is introduced through the mouth to view the interior of the body. The operator can visualise the area being examined by looking into the proximal part of the scope.You may be given a sedative and/or an analgesic in order to relax you. A local anesthetic will be sprayed into your mouth to suppress the need to cough or gag when the endoscope is inserted. (The gag and cough reflexes are natural protective reflexes initiated by the presence of a foreign body in the upper airway).

A mouth guard will be inserted to protect the endoscope from an involuntary biting action by the patient. Dentures will be removed as they may dislodge and get in the way of the scope. An IV may be inserted to administer medications during the procedure.

The procedure is performed with the patient lying on his or her left hand side. After the gag reflex has been suppressed by the anesthetic spray, the endoscope will be advanced through the mouth into the oesophagus and to the stomach and duodenum. Air will be introduced through the endoscope to enhance viewing by gently pushing away any excess tissue.

The inner mucosal surface of the said structures are examined and biopsies can be obtained through the endoscope. The biopsies are sent to the laboratory for various tests. When the area has been viewed and any biopsies taken, the endoscope will be removed and you will be asked to cough to expel the extra air.

The intake of food and liquids are restricted until your cough reflex returns. The test lasts about 30 to 60 minutes.

Possible abnormal findings can indicate the presence of one or more of the following:

ulcers (acute or chronic)

inflammation of the stomach and duodenum

tumours and masses

diverticulae

Mallory-Weiss syndrome (tear of the oesophagus)

esophageal rings

strictures

obstruction

gastric erosion

dilated oesophageal veins

the presence of foreign bodies

Colonoscopy

A colonoscopy is a procedure of viewing the interior lining of the large intestine (colon) using a colonoscope, a flexible fiber-optic tube.

You will have to prepare your colon in order to clear out as much of the faeces as possible to improve the visibility of the operator. This is done with various laxatives and enemas.

You lie on your left side with your knees drawn up toward the abdomen and your lower body exposed. After administration of an intravenous sedative and analgesic, the lubricated scope is inserted through the anus and gently advanced under direct vision to the terminal small bowel. Air will be inserted through the scope to provide a better view by gently pushing away any excess tissue. Suction may be used to remove secretions.

Since better views are obtained during withdrawal than during insertion, a more careful examination is done during withdrawal of the scope. Tissue samples may be taken with tiny biopsy forceps inserted through the scope, polyps can be removed with electrocautery snares and photographs can be taken. All tissue removed will be sent to the laboratory for analysis. Specialised procedures, such as laser therapy, can also be done via the scope.

Possible abnormal findings include:

lower gastrointestinal (GI) bleeding

polyps (which can be removed through the colonoscope during the exam)

tumours can be visualized and biopsied

inflammatory bowel disease

diverticulitis

Upper gastrointestinal tract and small bowel series

X-rays to examine the esophagus, stomach and small intestine. X-ray pictures are taken after one has swallowed a barium suspension (contrast medium). The contrast medium better defines the structures that are being examined by X-rays.

This test may be done in an office or a hospital radiology department. You will be given a milky substance to drink that has barium in it. The passage of the barium through the esophagus, stomach, and small intestine is monitored by X-ray images. Pictures are taken with you in a variety of positions. The test takes 30 minutes to 1 hour to complete.

In the esophagus, abnormal results may mean:

esophageal cancer

esophageal stricture

hiatus hernia (a portion of the stomach protrudes through the esophageal opening)

diverticula (a pouch-like sac that protrudes from the walls of an organ)

ulcers (open sores)

achalasia (esophagus fails to relax)

In the stomach, abnormal results may mean:

stomach ulcers

cancer of the stomach

polyps (a tumour that is usually noncancerous that grows on the inner lining of the stomach)

pyloric stenosis (a narrowing of the opening from the stomach)

In the small intestines the test may reveal:

tumours

inflammation of the small intestines

obstruction

Barium enema

An X-ray examination of the large intestines. Pictures are taken after rectal instillation of barium sulfate (a radio opaque - contrast medium).

This test may be done in an office or a hospital radiology department. You lie on the X-ray table and an initial X-ray is taken before the administration of the contrast medium. You are asked to lie on the side while a well lubricated enema tube is inserted gently into your rectum via your anus. The barium, a radio opaque (shows up on X-ray) contrast medium, is then allowed to flow into the colon through the enema tube. A small balloon at the tip of the enema tube may be inflated to help keep the barium inside your bowel. The flow of the barium is monitored by the health care provider on an X-ray fluoroscope screen (like a TV monitor). X-ray pictures are taken at various levels as the contrast medium flows through your colon.

Possible abnormal findings include:

Cancer

Diverticulitis (small pouches formed on the colon wall that can become inflamed)

Polyps (a tumour, usually noncancerous, that grows on the inner lining of the colon)

Inflammation of the inner lining of the intestine (ulcerative colitis)

Irritable colon

Acute appendicitis

Twisted loop of the bowel

Ultrasound of the abdomen

Ultrasound examination uses high-frequency sound waves to echo off the internal structures of the body and create a picture of these structures.

The test is done in the ultrasound or radiology department. You will be lying down. A conducting and lubricating gel is applied to the skin of your abdomen. The transducer (a hand-held instrument) is then moved over your abdomen. You may be asked to move to other positions or hold your breath at times during the procedure.

Various conditions can be diagnosed with an ultrasound investigation. These include:

A liver abscess

Gallstones

Malignant secondaries in the liver

Obstruction of one or both kidneys can be seen

An aneurysm of the aorta (abnormal dilation of the large artery running trough the abdomen)

Pathology in the pelvic organs such as an ectopic pregnancy and uterine fibroids

The exact location of palpable abdominal masses can be determined.

Diagnosing abdominal pain in children

Look for the following common signs of abdominal pain in babies and toddlers:

Crying

Irritability

Restlessness

A sudden refusal to eat.

The symptoms of intussusception include a cycle of screaming fits, with or without vomiting, alternating with quiet periods.

Crying may exacerbate the pain of appendicitis so greatly that a suffering infant will not cry. Instead, look for irritability and flexing of the hips (pulling the legs up to the stomach), as well as a general appearance of illness and signs that moving is painful.

Older children who can talk will usually complain of “a sore tummy”.

 

Definition

Vitamins are organic components in food that are needed in very small amounts for growth and for maintaining good health. The vitamins include vitamin D, vitamin E, vitamin A, and vitamin K, or the fat-soluble vitamins, and folate (folic acid), vitamin B_{12, biotin, vitamin B6, niacin, thiamin, riboflavin, pantothenic acid, and vitamin C (ascorbic acid), or the water-soluble vitamins. Vitamins are required in the diet in only tiny amounts, in contrast to the energy components of the diet. The energy components of the diet are sugars, starches, fats, and oils, and these occur in relatively large amounts in the diet.}

Most of the vitamins are closely associated with a corresponding vitamin deficiency disease. Vitamin D deficiency causes rickets, a disease of the bones. Vitamin E deficiency occurs only very rarely, and causes nerve damage. Vitamin A deficiency is common throughout the poorer parts of the world, and causes night blindness. Severe vitamin A deficiency can result in xerophthalamia, a disease which, if left untreated, results in total blindness. Vitamin K deficiency results in spontaneous bleeding. Mild or moderate folate deficiency is common throughout the world, and can result from the failure to eat green, leafy vegetables or fruits and fruit juices. Folate deficiency causes megaloblastic anemia, which is characterized by the presence of large abnormal cells called megaloblasts in the circulating blood. The symptoms of megaloblastic anemia are tiredness and weakness. Vitamin B12 deficiency occurs with the failure to consume meat, milk or other dairy products. Vitamin B12 deficiency causes megaloblastic anemia and, if severe enough, can result in irreversible nerve damage. Niacin deficiency results in pellagra. Pellagra involves skin rashes and scabs, diarrhea, and mental depression. Thiamin deficiency results in beriberi, a disease resulting in atrophy, weakness of the legs, nerve damage, and heart failure. Vitamin C deficiency results in scurvy, a disease that involves bleeding. Specific diseases uniquely associated with deficiencies in vitamin B6, riboflavin, or pantothenic acid have not been found in the humans, though persons who have been starving, or consuming poor diets for several months, might be expected to be deficient in most of the nutrients, including vitamin B6, riboflavin, and pantothenic acid.

Some of the vitamins serve only one function in the body, while other vitamins serve a variety of unrelated functions. Hence, some vitamin deficiencies tend to result in one type of defect, while other deficiencies result in a variety of problems.

Purpose

People are treated with vitamins for three reasons. The primary reason is to relieve a vitamin deficiency, when one has been detected. Chemical tests suitable for the detection of all vitamin deficiencies are available. The diagnosis of vitamin deficiency is often aided by visual tests, such as the examination of blood cells with a microscope, the x ray examination of bones, or a visual examination of the eyes or skin.

A second reason for vitamin treatment is to prevent the development of an expected deficiency. Here, vitamins are administered even with no test for possible deficiency. One example is vitamin K treatment of newborn infants to prevent bleeding. Food supplementation is another form of vitamin treatment. The vitamin D added to foods serves the purpose of preventing the deficiency from occurring in persons who may not be exposed much to sunlight and who fail to consume foods that are fortified with vitamin D, such as milk. Niacin supplementation prevents pellagra, a disease that occurs in people who rely heavily on corn as the main source of food, and who do not eat much meat or milk. In general, the American food supply is fortified with niacin.

A third reason for vitamin treatment is to reduce the risk for diseases that may occur even when vitamin deficiency cannot be detected by chemical tests. One example is folate deficiency. The risk for cardiovascular disease can be slightly reduced for a large fraction of the population by folic acid supplements. And the risk for certain birth defects can be sharply reduced in certain women by folic acid supplements.

Vitamin treatment is important during specific diseases where the body’s normal processing of a vitamin is impaired. In these cases, high doses of the needed vitamin can force the body to process or utilize it in the normal manner. One example is pernicious anemia, a disease that tends to occur in middle age or old age, and impairs the absorption of vitamin B12. Surveys have revealed that about 0.1% of the general population, and 2-3% of the elderly, may have the disease. If left untreated, pernicous anemia leads to nervous system damage. The disease can easily be treated with large oral daily doses of vitamin B12 (hydroxocobalamin) or with monthly injections of the vitamin.

Vitamin supplements are widely available as over-the-counter products. But whether they work to prevent or curtail certain illnesses, particularly in people with a balanced diet, is a matter of debate and ongoing research. For example, vitamin C is not proven to prevent the common cold. Yet, millions of people take it for that reason. Ask a physician or pharmacist for more information on the appropriate use of multivitamin supplements.

Precautions

Vitamin A and vitamin D can be toxic in high doses. Side effects range from dizziness to kidney failure. Ask a physician or pharmacist about the correct use of a multivitamin supplement that contains these vitamins.

Description

Vitamin treatment is usually done in three ways: by replacing a poor diet with one that supplies the recommended dietary allowance, by consuming oral supplements, or by injections. Injections are useful for persons with diseases that prevent absorption of fat-soluble vitamins. Oral vitamin supplements are especially useful for persons who otherwise cannot or will not consume food that is a good vitamin source, such as meat, milk or other dairy products. For example, a vegetarian who will not consume meat may be encouraged to consume oral supplements of vitamin B12.

Treatment of genetic diseases which impair the absorption or utilization of specific vitamins may require megadoses of the vitamin throughout one’s lifetime. Megadose means a level of about 10-1,000 times greater than the RDA. Pernicious anemia, homocystinuria, and biotinidase deficiency are three examples of genetic diseases which are treated with megadoses of vitamins.

Preparation

The diagnosis of a vitamin deficiency usually involves a blood test. An overnight fast is usually recommended as preparation prior to withdrawal of the blood test so that vitamin-fortified foods do not affect the test results.

Aftercare

The response to vitamin treatment can be monitored by chemical tests, by an examination of red blood cells or white blood cells, or by physiological tests, depending on the exact vitamin deficiency.

Risks

Few risks are associated with vitamin treatment. Any possible risks depend on the vitamin and the reason why it was prescribed. Ask a physician or pharmacist about how and when to take vitamin supplements, particularly those that have not been prescribed by a physician.

Essential VitaminsVitaminWhat It Does For The Body Vitamin A (Beta Carotene)Promotes growth and repair of body tissues; reduces susceptibility to infections; aids in bone and teeth formation; maintains smooth skinVitamin B-1 (Thiamin)Promotes growth and muscle tone; aids in the proper functioning of the muscles, heart, and nervous system; assists in digestion of carbohydratesVitamin B-2 (Riboflavin)Maintains good vision and healthy skin, hair, and nails; assists in formation of antibodies and red blood cells; aids in carbohydrate, fat, and protein metabolismVitamin B-3 (Niacinamide)Reduces cholesterol levels in the blood; maintains healthy skin, tongue, and digestive system; improves blood circulation; increases energyVitamin B-5Fortifies white blood cells; helps the body’s resistance to stress; builds cellsVitamin B-6 (Pyridoxine)Aids in the synthesis and breakdown of amino acids and the metabolism of fats and carbohydrates; supports the central nervous system; maintains healthy skinVitamin B-12 (Cobalamin)Promotes growth in children; prevents anemia by regenerating red blood cells; aids in the metabolism of carbohydrates, fats, and proteins; maintains healthy nervous systemBiotinAids in the metabolism of proteins and fats; promotes healthy skinCholineHelps the liver eliminate toxinsFolic Acid (Folate, Folacin)Promotes the growth and reproduction of body cells; aids in the formation of red blood cells and bone marrowVitamin C (Ascorbic Acid)One of the major antioxidants; essential for healthy teeth, gums, and bones; helps to heal wounds, fractures, and scar tissue; builds resistance to infections; assists in the prevention and treatment of the common cold; prevents scurvyVitamin DImproves the absorption of calcium and phosphorous (essential in the formation of healthy bones and teeth) maintains nervous systemVitamin EA major antioxidant; supplies oxygen to blood; provides nourishment to cells; prevents blood clots; slows cellular agingVitamin K (Menadione)Prevents internal bleeding; reduces heavy menstrual flow

_{Key Terms}

Genetic disease

A genetic disease is a disease that is passed from one generation to the next, but does not necessarily appear in each generation. An example of genetic disease is Down’s syndrome.

Plasma

Blood consists of red and white cells, as well as other components, that float in a liquid. This liquid is called plasma.

Recommended dietary allowance (RDA)

The Recommended Dietary Allowances (RDAs) are quantities of nutrients of the diet that are required to maintain human health. RDAs are established by the Food and Nutrition Board of the National Academy of Sciences and may be revised every few years. A separate RDA value exists for each nutrient. The RDA values refer to the amount of nutrient expected to maintain health in the greatest number of people.

Serum

Serum is blood plasma with the blood clotting proteins removed. Serum is prepared by removing blood from the subject, allowing the blood naturally to form a blood clot, and then using a centrifuge to remove the red blood cells and the blood clot. The blood clot takes the form of an indistinct clump.

Vitamin status

Vitamin status refers to the state of vitamin sufficiency or deficiency of any person. For example, a test may reveal that a patient’s folate status is sufficient, borderline, or severely inadequate.

 

Definition

Vitamin K deficiency exists when chronic failure to eat sufficient amounts of vitamin K results in a tendency for spontaneous bleeding or in prolonged and excessive bleeding with trauma or injury. Vitamin K deficiency occurs also in newborn infants, as well as in people treated with certain antibiotics. The protein in the body most affected by vitamin K deficiency is a blood-clotting protein called prothrombin.

Description

Vitamin K is a fat-soluble vitamin. The recommended dietary allowance (RDA) for vitamin K is 80 mg/day for the adult man, 65 mg/day for the adult woman, and 5 mg/day for the newborn infant. The vitamin K present in plant foods is called phylloquinone; while the form of the vitamin present in animal foods is called menaquinone. Both of these vitamins are absorbed from the diet and converted to an active form called dihydrovitamin K.

Spinach, lettuce, broccoli, brussels sprouts, and cabbage are good