Medicine (Abingdon, England : UK ed.)最新文献

One of the fundamental complications within toxicology is that patients may not know or disclose what they have been poisoned with. Consequently, a sound and considered general approach to identify potential harms and plan clinical management is necessary. This chapter aims to guide the reader through the initial approach and general principles to consider when managing a poisoned patient.

Irritable bowel syndrome (IBS) is a disorder of brain–gut interaction (formerly known as a functional gastrointestinal disorder) typically characterized by at least weekly abdominal pain associated with a change in frequency and form of the stool. IBS is common, with a population prevalence of around 5%. It is associated with a marked reduction in quality of life and significant healthcare expenditure. Its pathophysiology remains incompletely understood. IBS is subclassified according to the predominant bowel habit. Treatments are directed towards improving the predominant symptoms and include dietary/lifestyle modifications, medication and psychological interventions.

Crohn's disease is a chronic, relapsing and remitting inflammatory disease affecting any area of the gastrointestinal tract. It is becoming increasingly prevalent in western Europe, the USA and China, with the highest age-standardized prevalent rates in Norway. It is associated with modifiable risk factors such as smoking and diet, and non-modifiable risk factors including gene variants; however, there is no specific method to prevent its onset or effect a cure. Patients often complain of diarrhoea and abdominal pain, but symptoms can occur intermittently for many years before diagnosis. Diagnosis is usually made with ileo-colonoscopy and imaging. The key features on biopsy samples are transmural inflammation with granulomas. Early diagnosis, and thus early treatment, is key to reducing the risk of complications developing, such as strictures and fistulae. Treatments are aimed at reducing the inflammatory burden in the gut and can include enteral nutrition, drug therapy or surgical management. Drug therapy can be monitored by symptoms, using non-invasive stool tests (faecal calprotectin, radiological imaging), or ileo-colonoscopy. Up to 75% of patients require operative management in their lifetime; however, new drug therapies are likely to be licenced in the coming years and these will increase the options available for non-operative management.

Faecal incontinence and evacuation disorders are common conditions that cause significant morbidity. Patient-reported symptoms are poor predictors of underlying pathophysiology, so anorectal function testing is a key component of the clinical evaluation when initial management strategies fail. A number of investigations are available to assess anorectal structure (endoanal ultrasound, defaecography) and function (anorectal manometry, rectal sensory test, balloon expulsion test, defaecography). This review article outlines the usefulness and relevance of these investigations for investigating patients with faecal incontinence and/or evacuatory difficulty.

Squamous cell carcinomas of the oral cavity, oropharynx and oesophagus are relatively common and are classically associated with heavy alcohol and tobacco use. The dramatic increase in incidence of oropharyngeal cancers over the past three decades has been attributed to human papillomavirus (HPV) infection. These cancers often remain clinically silent until they are locally advanced, although many can still be treated radically with multimodality treatment. The prognosis depends upon the stage of the disease, and the age and fitness of the patient, their smoking history and whether or not the tumour is HPV driven. Surgery is often preferred in early-stage disease, while combined use of chemotherapy and radiotherapy, with or without surgery, is often required for advanced disease. Treatment is associated with significant morbidity, which requires intensive support from a multidisciplinary team.

Gastro-oesophageal reflux disease (GORD) is a common disorder with an increasing prevalence in the UK. The presence of a hiatus hernia is the strongest risk factor for developing GORD, although it is not essential. The most common symptoms experienced by patients with GORD are heartburn and acid regurgitation. The diagnosis of GORD is usually made from the clinical history. Endoscopy and ambulatory pH monitoring are adjunctive tests that can influence management decisions. The main goals of treatment are symptom control and the prevention of complications such as Barrett's oesophagus and peptic stricture. Treatment options include lifestyle interventions, proton pump inhibitors and, in selected patients, antireflux surgery.

Coeliac disease (CD) is a common, chronic, immune-mediated small bowel enteropathy resulting from gluten exposure in genetically susceptible individuals. Considerable clinical and immunopathological heterogeneity is seen in newly diagnosed patients, and the diagnosis is not always straightforward even for experienced physicians. Population screening using tissue transglutaminase-2 has revealed a higher prevalence of seropositivity than previously appreciated. There is a wide differential diagnosis for mucosal villous atrophy, crypt hyperplasia and increased intraepithelial lymphocyte concentrations. Life-long adherence to a gluten-free diet is currently the only recommended treatment for CD, although many newer approaches are being explored. CD is rightly described as a multisystem disorder and is associated with other gastrointestinal- and non-gastrointestinal-related disorders, numerous complications and possibly reduced survival. The landscape has recently expanded with the identification that some patients with symptoms suggestive of CD but without the mucosal changes seem to respond to a gluten-free diet. This group are currently labelled as having non-coeliac gluten sensitivity. Controversy exists over whether this is a separate disease entity. This review briefly discusses the important clinical, immunological and therapeutic aspects of CD.

Gastric tumours encompass adenocarcinoma, the most common type, as well as gastrointestinal stromal tumours, neuroendocrine tumours and gastric lymphoma. They are typically difficult to diagnose early as the ‘red flag’ features of gastric cancer tend to be associated with advanced disease. As a result, survival outcomes of gastric cancer are poor, with 5-year survival in the UK currently at 20%. There have been significant breakthroughs in systemic therapy and surgical technology to increase chances of cure and improve survival. These include immunotherapy and the introduction of robot-assisted surgery. Nevertheless, multimodal therapy and clear resection margins with radical lymphadenectomy remain the mainstay in trying to achieve a cure in gastric cancer.

Intestinal failure is a rare condition characterized by the inability of the gut to absorb sufficient nutrients and/or fluids and electrolytes to maintain health. These patients require parenteral (intravenous) supplementation. Short bowel syndrome is the most common cause and is typically secondary to extensive surgical resection. Intestinal failure requires management by a multidisciplinary team to provide nutritional support and facilitate intestinal rehabilitation. This involves surgery to restore intestinal continuity where possible, dietary modifications and medical therapies to modify motility and secretions, and increase intestinal absorptive capacity. Individuals requiring parenteral support are monitored for complications of chronic intestinal failure and home parenteral nutrition such as catheter infections and thrombosis, and liver and metabolic bone disease; rarely, they require referral for intestinal transplantation. Quality of life is an important consideration as patients could be on home parenteral support for extended periods, in some cases life-long.