Diseases, Disorders information

Symptoms of major depressive disorder include problems of sleep, interest, guilt, energy, concentration, appetite, psychomotor symptoms, and suicidal thoughts. Five symptoms of the criteria are needed to make a diagnosis. Commonly in depressive illness you see a lot of anxiety and a loss of libido(erectile dysfunction).

Another important point is what happens to REM sleep during a major depressive episode. REM increases; REM density increases. You are in REM quicker and you are in REM longer when you are depressed. Most antidepressants will decrease REM sleep. An old trick back before there were good antidepressants, a thing you could do for refractory patients was keep them up all night. You would just sleep deprive them and the depression would get better. Because depressed people are spending too much time in REM. But it really didn’t work. They would relapse fairly quickly after being kept awake.

When people get depressed, or manic, they can get psychotic. A thirty-five-year-old housewife comes in says the devil is punishing me. She’s not interested in doing anything anymore. She is sleeping two hours a night. She says she can’t get to sleep. She has a lot of psychomotor retardation, what’s going on? She doesn’t have schizophrenia. She has major depressive illness. When people get too high or too low they can get psychotic. But not everybody who is delusional or hallucinating is schizophrenic.

Histamine antagonists

Histamine2 (H2) receptor antagonists are moderately effective for treating GERD. These drugs are safe, with rare side effects. However, cimetidine may cause mental status changes, antiandrogenic activity (gynecomastia), and inhibition of the cytochrome P-450 system, which may alter levels of drugs metabolized by this pathway (eg, theophylline, warfarin, phenytoin).

The indicated oral doses for the treatment of reflux esophagitis are cimetidine (Tagamet), 800 mg twice daily; ranitidine (Zantac), 150 mg two to four times daily; famotidine (Pepcid), 20 mg to 40 mg twice daily; and nizatidine (Axid), 150 mg twice daily. The efficacy of all the H2 receptor antagonists is equivalent.

Proton pump inhibitors

The proton pump inhibitors (PPIs), omeprazole (Prilosec) and lansoprazole (Prevacid), are the most effective acid-suppressing medications available. These drugs inhibit the proton pump.

The usual dosage for treatment of reflux esophagitis is 20 to 40 mg of omeprazole (Prilosec) daily or 30 mg of lansoprazole (Prevacid) daily. At these doses, reflux symptoms are abolished in most patients. PPIs are safe and well tolerated. Side effects of headache, abdominal pain and diarrhea are rare.

Patients with classic symptoms who are less than 40 years old and who have had symptoms for less than 10 years do not require diagnostic studies. Indications for upper gastrointestinal endoscopy include onset of new symptoms in older patients with long-standing GERD, the presence of alarm symptoms, atypical or equivocal symptoms, and failure of full-dose H2 receptor antagonist therapy.

Alarm symptoms in patients with suspected GERD: Hematemesis Melena Dysphagia Unexplained weight loss Frequent vomiting.
PROTONIX helps to control NIGHTTIME heartburn and other symptoms associated with erosive Gastroesophageal Reflux Disease (GERD).

GERD Diagnosis
Esophageal endoscopy is the most popular test for initial evaluation of GERD symptoms. Barium swallow modified by a barium-coated test meal is the most sensitive test for evaluation of dysphagia. The observation of reflux of free barium into the esophagus establishes the diagnosis of GERD.

Ambulatory esophageal pH monitoring is the best test to establish the presence of abnormal acid esophageal reflux, although it provides no information about the esophageal structure or mucosa.

Treatment

Lifestyle modifications recommended for all patients with GERD:
Stop smoking cigarettes. Lose excess weight. Eat small meals Reduce consumption of caffeine, chocolate, fatty foods, alcohol, onions, peppermint, and spearmint. Elevate head of bed 6 to 9 in. Avoid tight-fitting garments

Antacids. Antacids work by neutralizing gastric acid and are indicated for treatment of occasional heartburn. Antacids have a very short duration of action, necessitating frequent dosing.

Gastroesophageal Reflux Disease
About 18% of the adult population in the United States have heartburn at least once a week. Gastroesophageal reflux describes the movement of gastric acid into the esophagus. The major antireflux barrier is the lower esophageal sphincter (LES), located at the esophagogastric junction. Patients with disordered esophageal motility from connective-tissue diseases or primary motility disorders and those with hyposalivation from chronic xerostomia, cigarette smoking, or anticholinergic medications are predisposed to increased severity of GERD.

Clinical evaluation

Heartburn, defined as a retrosternal burning sensation radiating to the pharynx, and acid regurgitation are classic symptoms of GERD. They usually occur postprandially, especially after large meals.

Symptoms may be exacerbated by recumbency, straining, and bending over and are usually improved by antacids. These symptoms are specific enough that their presence establishes the diagnosis of GERD without confirmatory tests.

Complications

Esophagitis with ulceration may result in gastrointestinal hemorrhage, which is reported in about 2% of patients with reflux esophagitis.

Esophageal strictures form in about 10% of patients with GERD. These patients are managed with periodic dilations and acid suppression with proton pump inhibitors.

Barrett’s esophagus. Metaplastic changes in the esophageal mucosa that result from GERD are referred to as Barrett’s esophagus. The presence of columnar-appearing epithelium more than 3 cm above the proximal gastric folds is a criterion for diagnosis. The reported incidence of adenocarcinoma in Barrett’s esophagus, which is considered a premalignant condition, is 1 in 52 patient-years.

Extraesophageal manifestations of GERD may include noncardiac chest pain, chronic hoarseness and cough, and asthma

Alport’s syndrome has glomerular lesions, hematuria and decreased GFR. Underline anterior lenticonus, cataracts, sensorineural deafness. First, lets look at prune-belly syndrome. Here is the prune-belly. Lacks abdominal musculature. Testes are not palpable. Renal abnormalities. Prune-belly syndrome. By the way, what do you notice? Is this a boy or a girl? Boy. Prune-belly syndromes are almost always in boys. And we can talk at some point about why that is, but it’s almost always in boys. Write it down. There are only about five reported cases in girls. And if they ask you that, tell them you want your money back. Prune-belly syndrome, boy, cryptorchidism, absence of abdominal musculature, renal problems. Hearing. Sensorineural high tone hearing loss. Cataract. This is the only condition, the only condition, that gives you anterior lenticonus. Everything else is posterior lenticonus in ophthalmology. This plus the characteristic glomerular lesion is Alport’s syndrome. I’ll go back and remind you, Alport’s syndrome; anterior lenticonus, cataracts, glomerular lesions, hematuria, decreased GFR.

Okay, we have a few more to go. This is a sort of characteristic … you see this little bulls-eye when you do your funduscopic? This is pretty characteristic. This is the lenticonus because what’s happening is you are looking in and the conical-shaped lens is like this, so you are going in and making your cuts in and I’ve never seen it described anywhere, but I’ve seen it a zillion times. And this is what it looks like. It almost looks circumferential. Bulls-eye in nature.

Tuberous sclerosis; you’ve heard about tuberous sclerosis. The renal abnormalities, renal angiomyolipoma, cystic kidneys and renal cell carcinoma. An important clinical link and association. Other features, underline adenoma sebaceae, underline CNS tubers, retinal phacoma and of course some of the skin, the shagreen patches, the White Mountain ash spots. We’ll talk about Drash syndrome, which is diffuse mesangial sclerosis, nephrotic syndrome in end-stage renal disease. The association here is Wilms tumor and male pseudohermaphroditism. So let’s first … looks like I have Drash syndrome up here first. Here’s mesangial sclerosis, diffuse mesangial sclerosis and ambiguous genitalia. If you get a patient, a case, with nephrotic syndrome and ambiguous genitalia like this, what study do you want to do? A renal ultrasound because you want to look for Wilms tumor. And that’s the link and association, a very important link and association here. This is named after Alan Drash, the first person. It’s also called Denny’s Drash syndrome, nephrotic syndrome in childhood, diffuse mesangial sclerosis, Wilms tumor, male pseudohermaphroditism. So these are males that have ambiguous genitalia. The females do not.

Finally, what is this? Recognizable? Anaphylactoid purpura, right. Remember, it is usually classically over the lower limbs and buttocks. It is alliterative, palpable purpura. Write down, as a link and association, palpable purpura. Because you can feel it. Little lumps. Palpable purpura on the lower extremities, crampy abdominal pain, arthralgia, peak at 4-5 years of age. It’s mediated by IgA immune complexes. Histology in the kidney, mesangial proliferation and/or epithelial crescents. The worse the biopsy the worse the prognosis. If you have nephrotic syndrome and nephritis, that is the worst outcome. We biopsy them and if we see crescents, that’s the issue.

I have included in your syllabus a list of syndromes that have renal disease in them and I’m going to highlight some of them here, not all of them, but highlight a few of them and show you some pictures. One or two of them you may see in the photo-quiz outside. I wonder how they got there? So we’ll just go through a few syndromes that will both help you clinically and might help you on the Boards.
A few words about medications. I recommend Cheap Canadian Pharmacy
Anti-Acidity Medications:
Canadian Pharmacy Nexium – NEXIUM works by decreasing the acid produced by acid pumps. NEXIUM deactivates some of the pumps to keep acid production under control. By reducing acid production in the stomach, NEXIUM reduces the amount of acid backing up into the esophagus and causing reflux symptoms.
Achipex – ACIPHEX is used for the treatment of persistent, frequent heartburn and other symptoms associated with acid reflux disease. Persistent and frequent occurrences are classified as 2 or more days a week.
Prevacid – Prevacid works by reducing the amount of acid produced in the stomach.
Syndrome number one, which I don’t have a picture of, is branchio-otorenal syndrome, BOR syndrome. You get dysplasia; unilateral renal agenesis is the renal anomalies, and other findings are branchial fistulas and in particular, preauricular pits and hearing losses. Those are underlined because those are the associations that you want to make. If you see somebody with a little pit in front of their ear and hearing loss, look for renal problems. Potter’s syndrome: renal failure, oligohydramnios. Remember that oligohydramnios tends to be associated with pulmonary hypoplasia. Because there’s not enough amniotic fluid to expand the lungs. You also get small posterior-set ears, micrognathia, beaked nose, wide set eyes. Here is a picture of Potter’s facies. These babies are usually stillborn. Micrognathia, look at the ears. Look how low set they are. This is what the kidneys look like; cystic dysplasia. Another picture of Potter’s facies. Ears are low set, not so low set, beaked nose, micrognathia. Pulmonary hypoplasia is the association.

Prune-belly syndrome; the renal abnormalities, dilated urinary tract, dysplastic, aplastic, multicystic and hydronephrotic kidneys. Underline absence of abdominal musculature, cryptorchidism. That’s called the triad because there are three of them. Cryptorchidism, absence of abdominal musculature, renal abnormalities. The triad.