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Epidermal growth factor is a peptide that is a potent inhibitor of gastric acid secretion and a peptide that may control proliferation and migration of intestinal epithelial cells in the proximal small intestine gastritis symptoms pain back order gasex visa. A sulfated glycoprotein (Apolipoprotein J) also functions to gastritis food to eat order gasex 100caps with amex protect the mucosal barrier cells from surface-active components such as bile gastritis diet purchase gasex american express, in the luminal environment gastritis kronik aktif adalah generic 100 caps gasex with visa. Thus, incorporated within the mucus layer are factors that guard against the degradation of the mucus layer and underlying mucosa by pancreatic enzymes and other surface active agents associated with this region, as well as factors that promote cellular proliferation and differentiation. This plexus provides motor innervation for the muscularis mucosae and the slips of smooth muscle that enter villi or other regions of the mucosa and provide motility. The large mesenteric vessels pierce the muscularis externa at its attachment to the mesentery and then enter the submucosa, branch, and run around the circumference of the intestinal tube. The submucosal vessels supply and receive small tributaries from the overlying mucosa. The fibers in the outer layer form a more gradual helix, giving the impression of a longitudinal arrangement. Between the two layers of smooth muscle are the nerve fibers and parasympathetic ganglia of the myenteric plexus. This extensive plexus is found throughout alimentary canal and supplies the motor innervation to smooth muscle forming the muscularis externa of the entire gastrointestinal tract. The number of multipolar neurons within the myenteric plexus is substantial (in excess of 100 million neurons) and may exceed the number of neurons located within the spinal cord. Specialized cells known as the interstitial cells of Cajal also are found throughout the muscularis externa of the gastrointestinal tract and are essential for normal gastrointestinal motility. The interstitial cells of Cajal are divided into several subgroups of mesenchymal derived cells that are found in close association with elements of the enteric nervous system as well as smooth muscle cells. A subpopulation of these cells is regarded as the source of spontaneous slow peristaltic waves within the gastrointestinal musculature and function as pacemaker cells. Others of this family of cells are believed to be involved in the relaxation of smooth muscle triggered by nitric oxide. In addition to these movements, powerful contractions of the muscularis externa (migrating myoelectric contractions) also occur that move contents of the stomach and small intestine rapidly into the colon. The large intestine is continuous with the rectum and anal canal, the latter terminating as the anus. The lumen is lined by a simple columnar epithelium that consists of intestinal absorptive cells (enterocytes) and goblet cells. The latter increase in number toward the rectum so that in the distal region of the colon the epithelium consists mainly of goblet cells. Intestinal glands of the colon are longer and more closely packed than those in the small intestine, and they increase in length distally to reach their maximum depth (0. The glands contain numerous goblet cells, endocrine cells and in the basal half of the glands, proliferating and undifferentiated epithelial cells. Serosa the muscularis externa is invested by a thin layer of loose connective tissue covered by a layer of mesothelial cells of the visceral peritoneum. Where the mesentery attaches to the intestinal wall, the serosa becomes continuous with both sides of the mesentery and encloses connective tissue elements, blood vessels, and nerves. An adventitia is associated with the duodenum Ileocecal Junction the lumen of the ileum becomes continuous with that of the large intestine at the ileocecal junction. Here the lining is thrown into anterior and posterior folds called ileocecal valves, which consist of both the mucosa and submucosa surrounded by a thickening of the inner circular layer of the muscularis externa. The ileocecal valves act to prevent contents of the ileum from passing into the cecum prematurely and also prevent a backflow of fecal contents from the colon into the ileum. Large Intestine the large intestine is approximately 180 cm long and is divided into several regions.

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Vibrio vulnificus and other noncholera vibrios: bacteremic infections and sepsis after contaminated shellfish ingestion gastritis upper gi purchase 100caps gasex amex, typically in hosts with liver disease gastritis liquid diet cheap gasex 100 caps visa. Capnocytophaga canimorsus: septic shock in asplenic pts xanthomatous gastritis order gasex uk, typically after dog bite gastritis kronik generic gasex 100 caps with amex. Bacteremia, hypotension, physical findings minimal compared to degree of pain, fever, toxicity; infected area red, hot, shiny, exquisitely tender d. Progression to bullae, necrosis; decrease in pain due to peripheral nerve destruction an ominous sign. Mottled, bronze-colored overlying skin or bullous lesions; drainage with mousy or sweet odor; crepitus. Classic triad of headache, meningismus, and fever in one-half to twothirds of pts 1. Low-grade fever, dull sinus pain, diplopia, decreased mental status, chemosis, proptosis, hard-palate lesions that respect the midline Acute bacterial endocarditis a. Rapid valvular destruction, pulmonary edema, hypotension, myocardial abscesses, conduction abnormalities and arrhythmias, large friable vegetations, major arterial emboli with tissue infarction Inhalational anthrax: Bacillus anthracis, category A agent of bioterrorism a. Clotted central catheters producing this syndrome should be withdrawn, and anticoagulation therapy initiated. Most commonly seen in pts with lung or breast cancers, leukemias, or lymphomas; pericardial tamponade may also develop as a late complication of mediastinal radiation therapy. Pleural effusion, sinus tachycardia, jugular venous distention, hepatomegaly, and cyanosis are frequent physical findings. Echocardiography is diagnostic; pericardiocentesis may show serous or bloody exudate, and cytology usually shows malignant cells. On physical exam, pts have a loss of sensation below a horizontal line on the trunk, called a sensory level, that usually corresponds to one or two vertebrae below the site of compression. Hypoalbuminemia associated with malignancy may make symptoms worse for any given serum calcium level because more calcium will be free rather than protein bound. When serum sodium falls to 115 meq/L, pts may experience anorexia, depression, lethargy, irritability, confusion, weakness, and personality changes. If the patient has mental status changes with sodium levels 115 meq/L, normal saline infusion plus furosemide to increase free water clearance may provide more rapid improvement. Toxicity may be related either to the agents used to treat the cancer or from the response of the cancer to the treatment. When peripheral blood granulocyte counts are 1000/ L, the risk of infection is substantially increased (48 infections/100 pts). Any fluid collections should be tapped, and urine and/or fluids should be examined under the microscope for evidence of infection. If the pt remains febrile and neutropenic after 7 days, amphotericin B should be added to the antibiotic regimen. Manifestations include respiratory distress, pruritus, urticaria, mucous membrane swelling, gastrointestinal disturbances (including nausea, vomiting, pain, and diarrhea), and vascular collapse. Virtually any allergen may incite an anaphylactic reaction, but among the more common agents are proteins such as antisera, hormones, pollen extracts, Hymenoptera venom, foods; drugs (especially antibiotics); and diagnostic agents. Atopy does not seem to predispose to anaphylaxis from penicillin or venom exposures.

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Neutrophils also contain antioxidants to gastritis diet 7 up cake cheap gasex 100caps on-line destroy potentially toxic peroxides generated during lysosomal activity gastritis diet best gasex 100caps. These cells are phagocytic for specific molecules and have a special avidity for antigen-antibody complexes gastritis symptoms blood order 100caps gasex overnight delivery. Eosinophils also produce major basic protein which enhances the antibody mediated destruction of the larvae of some helminthic parasites gastritis diet 2000 buy genuine gasex. Lymphocytes belong to the class of leukocytes called mononuclear leukocytes and are characterized by a single, round, nonlobed nucleus. These cells form part of the immunologic defense system and may give rise to antibodyproducing cells (B lymphocytes) or elaborate nonspecific factors that destroy foreign cells (T lymphocytes). B and T lymphocytes cannot be distinguished morphologically using routine H&E preparations. They are few in number in normal connective tissue but increase markedly in areas of chronic inflammation. Once these cells have entered connective tissue, it is difficult, if not impossible, to distinguish them from macrophages. As monocytes leave the vasculature and become macrophages they receive further specific, molecular programing dependent on the microenvironment (spleen, lung, brain) within which they reside. Some macrophages have antigenpresenting functions and these specialized macrophages form a family of antigen presenting cells. This type of macrophage phagocytoses endogenous antigens that are degraded into antigen peptide fragments. It consists of a loose network of stellate and spindle-shaped cells embedded in an amorphous ground substance with thin, sparse fibers. The cells have multiple developmental potentials and can give rise to any of the connective tissues. The presence of mesenchymal cells in the adult often has been proposed to explain the expansion of adult connective tissue. However, fibroblasts, too, are capable of sequential divisions, and may fulfill this role. It resembles mesenchyme in that the constituent cells are stellate fibroblasts with long processes that often make contact with those of neighboring cells, and the intercellular substance is soft and jelly-like and contains thin collagen fibers. Areolar connective tissue is a loosely arranged connective tissue that is widely distributed in the body. It contains collagen fibers, reticular fibers, and a few elastic fibers embedded in a thin, almost fluid-like ground substance. This kind of connective tissue forms the stroma that binds organs and organ components together. It forms helices about the long axes of expandable tubular structures such as the ducts of glands, the gastrointestinal tract, and blood vessels. Reticular and collagenous fibers also extend around each fat cell to provide a delicate supporting framework that contains numerous capillaries. White fat is the more plentiful and is found mainly in the subcutaneous tissue (where it forms the panniculus adiposus), omenta, mesenteries, pararenal tissue, and bone marrow. White fat is an extremely vascular tissue and also contains many nerve fibers from the autonomic nervous system. In white fat, the cells are filled by a single, large droplet of lipid; thus, it is often referred to as unilocular fat. The materials within the fat droplet are in a constant state of flux and are not permanent entities. Adipocytes have receptors for insulin, thyroid hormone, glucocorticoids, and norepinephrine that modulates the release and uptake of lipid.

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Inflammatorycarcinoma Inflammatory carcinoma of the breast is a clinical entity and does not constitute a histological type gastritis diet generic gasex 100 caps mastercard. The term has been used for breast cancers in which there is redness gastritis diet gasex 100caps with visa, oedema gastritis honey proven 100 caps gasex, tenderness and rapid enlargement gastritis juicing order gasex 100 caps without a prescription. Metaplastic carcinoma Rarely, invasive ductal carcinomas, besides epithelial elements, may have various components of metaplastic alterations such as squamous metaplasia, cartilaginous and osseous metaplasia, or their combinations. The nipple bears a crusted, scaly and eczematoid lesion with a palpable subareolar mass in about half the cases. Most of the patients with palpable mass are found to have infiltrating duct carcinoma, while those with no palpable breast lump are usually subsequently found to have intraductal carcinoma. G/A the skin of the nipple and areola is crusted, fissured and ulcerated with oozing of serosanguineous fluid from the erosions. These cells are larger than the epidermal cells, spherical, having hyperchromatic nuclei with cytoplasmic halo that stains positively with mucicarmine. In addition, the underlying breast contains invasive or non-invasive duct carcinoma which shows no obvious direct invasion of the skin of nipple. Histologic type of tumour Various microscopic types of breast cancer can be subdivided into 3 histologic grades: i) Non-metastasising-Intraductal and lobular carcinoma in situ. Microscopic grade Widely used system for microscopic grading of breast carcinoma is Nottingham modification of the Bloom-Richardson system. It is based on 3 features: i) tubule formation; ii) nuclear pleomorphism; and iii) mitotic count. Tumour size There is generally an inverse relationship between diameter of primary breast cancer at the time of mastectomy and long-term survival. Axillary lymph node metastasis More the number of regional lymph nodes involved, worse is the survival rate. In this regards, identification and dissection of sentinel lymph node followed by its histopathologic examination has attained immense prognostic value. Presence or absence of hormone receptors on the tumour cells can help in predicting the response of breast cancer to endocrine therapy. Later, however, distant spread by lymphatic route to internal mammary lymphatics, mediastinal lymph nodes, supraclavicular lymph nodes, pleural lymph nodes and pleural lymphatics may occur. Common sites for haematogenous metastatic spread from breast cancer are the lungs, liver, bones, adrenals, brain and ovaries. Breast carcinoma in situ Following factors act as determinants: i) Ductal carcinoma in situ (comedo and non-comedo subtypes) is diagnosed on the basis of three histologic features-nuclear grade, nuclear morphology and necrosis, while lobular neoplasia includes full spectrum of changes of lobular carcinoma in situ and atypical lobular hyperplasia. Invasive breast cancer these can be broadly divided into 3 groups: routine histopathology criteria; hormone receptor status; and biological indicators. Overall, taking the most important parameter of node-positive or nodenegative breast cancer, the prognosis varies- localised form of breast cancer without axillary lymph node involvement has a survival rate of 84% while survival rate falls to 56% with nodal metastases. Molecularclassification More recently, based on gene profiling of breast cancer by microarray, a molecular classification has been proposed. Out of all these, basal-like type has worst prognosis while luminal type A responds well to endocrine therapy and has good prognosis. After excision, about 25% cases develop ipsilateral invasive cancer in 10 years C. Soft and fleshy consistency Which of the following feature is not used in modified Bloom- Richardson grading system for breast cancer

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