•What are the signs of active acromegaly?

-Signs of activity:
1-Progressive increase in the size of the body
2-Excessive sweating
3-Increasing visual field defect
4-Large skin tags (Molluscum fibrosum)
5-Presence of glycosuria (diabetes mellitus)
6-Hypertension
7-Progressive headache
8-Enlarging thyroid.

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•What are causes of death in acromegaly?

1-Heart failure
2-Complications of hypertension
3-Complications of DM
4-Coronary artery disease
5-Tumor expansion (mass effect) 6-There is an increased death due to neoplasia, especially colon tumor
7-Pituitary apoplexy.

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•ACUTE GASTRIC DILATATION

-It is an enormous acute dilatation of stomach with atonic gastric wall without peristalsis.
-Stomach distends enormously occupying most of the abdomen and pelvis causing sequestration of lots of fluid resulting in hypovolaemia.

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•Causes of Acute Gastric dilatation:

1-After major surgery (abdomen,. neurosurgery).
2-Trauma, burns.
3-Retroperitoneal haematoma.
4-Electrolyte imbalance.
5-Other causes: Anorexia nervosa, bulimia, polyphagia, drug abuse, diabetes, anaesthesia, debilitating diseases, spinal cord diseases, muscle dystrophy.

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#Stomach

•COMPLICATIONS OF GASTRIC SURGERY:

1-Haemorrhage.
2-Stomal obstruction.
3-Biliary fistula.
4-Injury to CBD.
5-Duodenal blow out—on 4th postoperative day.
6-Pancreatitis.
7-Recurrent ulcer/stomal ulcer.
8-Gastrojejunocolic fistula.
9-Dumping syndrome (Postcibal syndrome).
10-Nutritional disturbances, diarrhoea.
11-Pulmonary tuberculosis.
12-Carcinoma in gastric remnant (after 10–15 years).
13-Gallstone formation.
14-Alkaline gastritis.
15-Afferent and efferent loop. syndrome.
16-Afferent loop obstruction-common.
17-Efferent loop obstruction.

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•HYPERTROPHIC PYLORIC STENOSIS

-There is increased risk of developing the condition if new- born gets erythromycin or azithromycin in first 14 days after birth.

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•Ultrasound abdomen (very useful) in PS:

-Doughnut sign.
-Pyloric muscle 4 mm or more in thickness.
-Length of pyloric canal >14 mm.
-Cervix sign on long avis, target sign on short axis.

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•Precancerous lesions of Gastric Cancer:

1•H. pylori infection, chronic gastritis
2•Pernicious anaemia
3•Intestinal metaplasia
4•Adenomatous polyps more than 2 cm
5•Agammaglobulinaemia
6•Benign gastric ulcer
7•Previous gastric surgery
8•Stomach remnant (stump carcinoma)
9•Menetrier’s disease.
10•Benign gastric ulcer.

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DUODENAL BLOW-OUT 5%:

-It is a very serious complication of Billroth II gastrectomy, occurs usually on 4–5th day after surgery.

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#Stomach

DUMPING SYNDROME(Post-cibal Syndrome):

-It is common in females, seen after Billroth II surgery.

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•EARLY DUMPING SYNDROME:

-It is common and more severe type Incidence is 10% Vasomotor symptoms appear immediately after food, lasts for 30-40 minutes, aggravated by bulky food.
-It is relieved by lying down, aggravated by more food.

-Clinical features: Sweating, tachycardia, colicky pain and diarrhoea, Hypotension and features of hypovolaemia.

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•LATE DUMPING SYNDROME:

-It is of less severe type Incidence is 5% It usually occurs 2 hours after meal.
-It is relieved by glucose and aggravated by exercise.

-Pathogenesis: Due to initial hyperglycaemia insulin secretion is stimulated which in turn leads to hypoglycaemia.

-Clinical features: Tremor, fainting, nausea, Features of hypoglycaemia.

-Treatment: Symptoms are less severe and so treated conservatively, by giving glucose and food.

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In case of Cushing syndrome:

-CBC shows
1-High Neutrophils & RBC, but decrease all other cells (Lymphopenia, Esinopenia).

-Biochemistry shows:
1-Hyperglycemia
2-Hypernatremia.
3-Hypokalemia.
4-Metabolic alkalosis
5-Hypocalcemia.

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•In case of Primary Adrenal insufficiency"Addison's disease ":


-CBC: neutropenia, lymphocytosis and eosinophilia.

-Decrease Aldosterone,
-Hyponatremia,
-Hyperkalemia,
-Metabolic acidosis.
-Hypercalcemia.
-Hypoglycemia.
Urea is increased in primary disease but decreased or Normal in secondary diseas.


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•Causes of anaemia in malaria infection:

1-Haemolysis of infected red cells
2-Haemolysis of non-infected red cells(black water fever) 3-Dyserythropoiesis
4-Splenomegaly and sequestration
5-Folate depletion.

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#Infections

•What are the mechanisms of anemia in kala-azar?

1-Hypersplenism (which causes sequestration and splenic pooling, destruction of RBC in spleen).
2-Short lifespan of RBC
3-Hemolysis
4-Ineffective erythropoiesis ,infiltration of marrow by parasite
5-Bleeding, hemodilution.

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•What are the causes of anemia in CKD?

-Anemia is common in CKD, correlates with the severity of renal failure.
-It is usually normocytic and normochromic.
-The mechanisms are:
1-Erythropoietin deficiency (most significant)
2-Diminished erythropoiesis due to toxic effects of uremia on bone marrow suppression. Also by PTH, ACE inhibitor
3-Reduced dietary intake and absorption of hematinics (iron, vitamin B12, folic acid).
4-Increased red cell destruction (may also be during hemodialysis due to mechanical, oxidant and thermal damage)
5-Increased blood loss due to capillary fragility, poor platelet function, occult gastrointestinal bleeding and blood loss during hemodialysis.
6-Erythropoietin alpha therapy may cause anemia (by pure red cell aplasia).

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•What are the causes of anemia in hypothyroidism?

-Causes of anemia:
1)Anemia of chronic disorder
2)Iron deficiency
3)Vitamin B12 deficiency
4)Folate deficiency
5)Other factors responsible menorrhagia in female, anorexia.

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•What are the types of anemia in hypothyroidism?

-Anemia may be:
1-Usually normocytic normochromic
2-Iron deficiency, if menorrhagia (in female)
3-May be macrocytic due to associated pernicious anemia (due to deficiency of vitamin B12).

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What are the mechanisms of anemia in rheumatoid arthritis?

Multiple factors are responsible:
1-Anemia of chronic disorder
2-Megaloblastic anemia (because of either folate deficiency or vitamin B12 deficiency, if associated with pernicious anemia)
3-Hypersplenism (in Felty’s syndrome)
4-Hemolytic anemia (Coombs’ test may be positive)
5-GIT bleeding (due to NSAID or vasculitis causing iron deficiency anemia)
6-Marrow suppression (gold and penicillamine—though less or no use now a days).

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•In Ulcerative colitis ; several types of anemia could be found , most commonly iron deficiency anemia due to repeated blood loss but occasionally Anemia of chronic disease and autoimmune haemolytic anemias .

•In Crohn's disease: however it's mostly a megaloblastic anemia due to the frequent affection of the terminal ileum .

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