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The total body water is highest in the new bom infant cheap viagra sublingual 100mg with visa, which constitutes 77 per cent of its body weight discount viagra sublingual 100mg otc. The water content falls rapidly during the first 6 months of life to below 65 per cent and more slowly during the next years to an average of 59 per cent viagra sublingual 100 mg low price. The ratio of total body water to surface area increases progressively upto about the age of 12 years, but the absolute volume of body water is highest in males between the ages of 1 to 40 years. Fat contains little water, so the thin individual has a greater proportion of water to total body weight than the obese person. The lower percentage of total body water in females correlates with the relatively large amount of subcutaneous fat and small muscle mass. An extremely obese individual may have 25 per cent to 30 per cent less body water than a thin individual of the same weight. The extracellular fluid, which represents 20 per cent of the body weight, is divided into (i) intravascular fluid (this represents 5 per cent of body weight) and (ii) interstitial or extracellular fluid (which represents 15 per cent of body weight). It should be remembered that intracellular fluid is larger subdivision and constitutes 70 per cent of total body water, whereas the extracellular water amounts to about 30 per cent of total body water and actually forms the suitable environment for the cells of the body. This water forms part of the protoplasm of the cells and is distributed in many small compartments or cells separated from each other by two cell membranes and layer of interstitial fluid. The largest portion of this intracellular water is within the skeletal muscle mass. As the females possess smaller muscle mass, the percentage of intracellular water is lower in females than in the males. If the chemical composition of the intracellular fluid is studied, it will be found that potassium and magnesium are the principal cations, whereas the phosphates and proteins are the principal anions. The intracellular concentration of potassium is approximately 125 mEq/L, magnesium is approximately 40 mEq/L and sodium is about 10 mEq/L. The concentration of phosphates is about 150 mEq/L in intracellular fluid, whereas protein constitutes 40 mEq/L of intracellular fluid. It can be divided into 3 subdivisions — (i) intravascular fluid (which is situated within the blood vessels) constitutes 7 per cent of total body water or 4 per cent of the body weight in normal adult; (ii) the interstitial or extravascular fluid (which lies outside the blood vessels and around the cells of the tissues of which it forms the immediate environment) constitutes 17 per cent of total body water or 7. The volume of the extracellular fluid can be measured by the dilution of a substance which passes freely through the walls of blood capillaries but does not enter into the cells of the body. The substances which have been used are inulin, thiocyanate, mannitol, thiosulphate, radioactive chlorine, bromine or sodium etc. Blood volume can be measured directly by dilution principle using red cells labelled with radioactive chromium (51Cr). The most important cation of extracellular fluid is sodium (which constitutes 140 mEq/L), whereas potassium (5 mEq/L), calcium (3 mEq/L) and magnesium (2 mEq/L) are the other cations available in the interstitial fluid. There are minor differences in ionic composition between the plasma and interstitial fluid due to difference in protein concentration. As the plasma contains higher protein content (organic anions), the total concentration of cations is higher in plasma than in the interstitial fluid. This intake is derived from two sources — (a) exogenous source and (b) endogenous source. About 1,200 ml water is drunk everyday from various beverages, whereas about 1,000 ml is derived from solid foods. During starvation this amount is supplemented by water released from the break down of body tissues. It must be remembered that water requirements of children are relatively greater than those of adults as (i) the water content is higher in respect to their total body weight, (ii) the metabolic activity is greater in children due to growth and (iii) the immature kidneys of the children are poor in concentrating ability. This amount of urine is excreted to get rid of the products of catabolism and end products of metabolism. In diarrhoea this amount is multiplied by the number of stools as also their fluidity. The insensible water loss through the skin is not from evaporation of water from sweat glands but from water vapour formed within the body and lost through the skin. The loss from the skin varies in accordance with the atmospheric temperature and humidity, muscular activity and body temperature. In case of hyperventilation and increased respiratory rate this loss is increased. Salt is also excreted by sweat which represents a hypotonic solution of salt with an average sodium concentration of 15 mEq/L. The sodium concentration in sweat however is exceeded to 60 mEq/L in unacclimatized individuals. The insensible fluid lost from skin and lungs is in fact pure water and does not contain any salt. Various gastrointestinal secretions contain various amounts of salts which of course are reabsorbed, except a small amount which is excreted with faeces. Sweat is a major source of loss of salt in tropical countries and this amount varies considerably according to the temperature and humidity of the environment. Whether sweating is noticeable depends on how rapidly it evaporates, which in turn is related to the humidity as well as to the temperature of the environment. But such high rate of sweating cannot be maintained for long and the rate falls down even if the individual is exposed to heat for more time. The sweat glands are partly under the influence of adrenal cortical hormones and the composition of sweat varies greatly, so much so that average figures cannot be given. Sodium concentration may vary from 6 to 85 mEq/L but is always lower than the plasma concentration. But the potassium concentration varies from 5 to 21 mEq/L and is always higher than that of the plasma. Concentrations of sodium and chloride in sweat are related also to the intake of these ions and usually decline when their body contents fall. When the salt intake increases, the concentrations of sodium and chloride in the sweat rise. About 100 mEq of sodium is excreted in the ur ine in normal individuals in temperate climate. This amount varies considerably according to the circumstances and normal kidneys have the power to reduce sodium excretion to less than 1 mEq/day. Excretion of urine and of sodium depends on glomerular filtration, which depends on the renal blood flow. Desoxycorticosterone acetate causes sodium retention by the tubules regardless of the sodium concentration in the plasma. The most powerful conservation of sodium is effected by aldosterone which is about 30 times as effective as desoxycorticosterone acetate.

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Sometimes it is very easy to find out the appendix viagra sublingual 100 mg fast delivery, when the appendix is more or less exposed as soon as the peritoneum is incised to ask the surgeon ‘How do you do’ order viagra sublingual 100 mg otc, so it is called ‘How do you do’ appendix trusted viagra sublingual 100mg. In other cases, it may be very difficult to find the appendix out which may be fixed in the retroperitoneal tissue behind the caecum. In this case the peritoneum on the lateral side of the caecum has to be incised to lift the caecum and appendix with it. The mesoappendix is pierced at its base with a mosquito artery forceps and the appendicular artery is secured with a ligature through this hole. One must be careful about the presence of accessory appendicular artery which should be held with ligature. By this process only the mucous and the muscular coats are crushed and curled inwards to occlude the lumen but the peritoneal coat remains unaffected. A seromuscular purse-string or figure of N-suture is inserted in the caecal wall around the base of the appendix. The intervening lumen is emptied before­ hand by momentary pressure with an artery forceps. A swab is placed beneath the base of the appendix and the appendix is divided close to the forceps. The stump is cauterised with pure carbolic acid and is invaginated while the purse-string suture is tightened. The appendix, the knife, the swab and other instruments which have come in contact with the contaminated mucosa of the appendix are placed in a bowl and removed from the field of operation. Nature has already localised the lesion and it is better not to disturb such localisation. Surgery at this stage is difficult and dangerous as it is difficult to find appendix due to adhesions and ultimately faecal fistula may form. When 48 hours have passed since commencement of the disease, presence of lump may be felt on careful palpation. A close watch is kept on the patient while he undergoes the conservative treatment. The followings are the conditions which should stop the conservative treatment and immediate appendicectomy should be carried out. This means, the nature is failing to control the disease and there is a chance that the appendix may perforate any moment The conditions in favour of stopping the conservative treatment are: (a) A rising pulse rate; (b) Vomiting or increase in gastric aspiration; (c) Increase in the abdominal pain — suggesting an impending spreading peritonitis; (d) Increase in the size of the lump. Conservative treatment should make the patient better by decreasing the pain, decreasing the amount of gastric aspiration (which indicates the return of peristalsis), temperature is lowering down and pulse rate is becoming normal and the size of the lump is reducing considerably and ultimately disappears. The patient is kept under observation for further 4 to 5 days after resolution of the lump. He is instructed to have appendicectomy done (interval appendicectomy) 6 to 8 weeks after his discharge. The incision for drainage is made just medial to the anterior superior iliac spine at the level of the most prominent portion of the appendicular abscess. The peritoneum is pushed medially so that the mass surrounding the appendix is approached from its lateral peritoneal aspect. Otherwise a finger should be slowly introduced into the abscess and its loculations are broken down by blunt dissection. Care is taken not to breakdown adhesions walling-off the medial aspect of the abscess mass. If the appendicular abscess is situated more medially the same incision for appendicectomy is made. When after opening the peritoneum one sees appendicular abscess, it is better to drain the abscess and come out. Appendicectomy is usually avoided during draining of the abscess, lest a faecal fistula may result due to injury to the inflamed caecum and inflamed coils of small intestine. Appendicectomy is only performed in case of infants, if it becomes very easy, as there is a chance of continued drainage of faeces from caecum through perforation of the appendix due to broad lumen of the appendix in infant. The subcutaneous tissue and skin incision are kept open as should be done in case of gangrenous appendicectomy to avoid wound infection. When the drainage has been stopped a sinogram may be performed to know that the abscess cavity has been obliterated. Rectal examination should be made almost daily to detect developing pelvic abscess. A pelvic abscess may be drained in the female into the vagina and in the male into the rectum. If the appendix is not removed when the abscess is drained, interval appendicectomy should be done 6 to 8 weeks after the wound has healed. Subphrenic or intra-abdominal abscess — may occur following gangrenous or perforated appendicitis. All that is required is to ensure that the tract remains open until the drainage ceases, (i) If the bowel beyond the fistula is obstructed or (ii) the mucous membrane of (he gut is continuous with the skin, closure of the fistula will require an operation. Intestinal obstruction, initially paralytic but occasionally may go on to true mechanical obstruction may occur with slowly resolving peritonitis. Intestinal obstruction due to adhesion formation is not uncommon after 2 months of operation. Right inguinal hemia — is said to be more common following the gridiron incision for appendicitis due to injury to the iliohypogastric nerve. The greatest advantage of laparoscopic appendicectomy is probably to confirm the diagnosis before appendicectomy. Many surgeons use open technique to establish pneumoperitoneum rather than using a Verress needle for greater safety. A moderate trendelenburg tilt of the operating table is made to keep the loops of small bowel away from pelvis for better visualisation of the appendix. The surgeon stands on the left side of the patient and faces the video monitor placed at patient’s right foot. The operating ports are placed according to surgeon’s choice depending on previous abdominal scars. Laparoscopic tissue holding forceps is used to catch hold of the appendix, which is lifted to display the mesoappendix. A dissecting forceps is used to create a window in the mesoappendix and the appendicular vessels are ligated or coagulated. The appendix is made free from its mesoappendix and its base is now ligated with an absorbable loop ligature. The base of the appendix is divided and the appendix is removed through one of the ports.

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Traction on the stomach is made to reduce the hernia and to facilitate division of phreno-oesophageal ligaments which constitute the sac of the hernia generic 100 mg viagra sublingual fast delivery. If only too much adhesion of the oesophagus is antici­ pated order 100mg viagra sublingual fast delivery, a thoracic approach is worthwhile generic viagra sublingual 100mg line. If there is a good gap in the oe­ sophageal hiatus, this should be repaired anterior or posteriorly with non-absorbable material. Now the fundus of the stomach is exposed and upper short gastric vessels are divided. The fundus of the stomach is brought posteriorly around the oesophagus and sutured. Sutures are placed through the anterior fun­ dus, the wall of the oesophagus and the fundus brought posteriorly and sutured. It must be remembered that the fundus should be anchored to the intra-abdominal oesophagus securely, lest it should slip down on to the body of the stomach and cause obstruction to the stomach. This technique involves full 360° plica­ tion of stomach around the oesophagus and causes a higher intraluminal pressure in the abdominal oesophagus which is the sole objective of anti-reflux operation and in this respect this operation seems to be the most effective of all anti-reflux procedures. The only complication is that it may be a too tight repair and thus causes oesophageal obstruction. Postoperative barium swallow examination should be done to exclude such complication. The oesophagus is mobilised above upto the aortic arch to allow a sufficient long intra­ abdominal oesophagus. The fundus of the stomach is fixed firmly around 2/3rds of the circumference of the oesophagus along its lower 3 to 5 cm. Post-operative barium swallow should demonstrate a 4 cm segment of intra-abdominal oesophagus. As it is not a total fundoplication recurrence rate is more in long-term follow up. The oesophagus is mobilised extensively through the hiatus, but the phreno-oe- sophageal membranes are kept intact. The opening of the hiatus is narrowed by inserting sutures anterior to the oesopha­ gus, so that only one finger can Fig. Now the stomach is wrapped around the entrance of the oesopha­ gus into stomach by placing sutures on both anterior and posterior aspects of the gastro-oesophageal junction. These sutures are also passed through the median arcuate ligament for posterior gastropexy. Manometric pressure readings before, during and after this procedure indicate a rise in sphincter pressure to a level of 40 to 50 mmHg. The lower oesophagus and the car­ dia are separated from the diaphragmatic hiatus. The fundus of the stomach is drawn up behind the oesophagus and then sutured in front of the oesophagus. The diaphragmatic hiatus is now narrowed with sutures placed behind the oesophagus. In Nissen fundoplication, the fundus is sutured as explained encircling the oesophagus completely. Toupet (a surgeon from France) partial fundoplication used in which the fundus is sutured on each side of the oesophagus, leaving the anterior aspect of oesophagus exposed. In any case if the laparoscopic method fails, the abdomen is opened with upper midline incision and the procedure is completed as open operation. It mainly involves the distal oesophagus, but occasionally the middle of oesophagus may be involved and these are examples of Barrett’s oesophagus when the lower part of the oesophagus has columnar epithelium. The treatment of reflux oesophagitis with stricture is difficult, so every effort should be made to prevent such stricture formation and to perform anti-reflux surgery before stricture develops. If the stric­ ture cannot be dilated and there is extensive shortening of the oesophagus, Collis gastro­ plasty is ad­ vised. The vagi may be sacrificed in the process and may need pyloroplasty to be performed. When the stricture has caused too much narrowing of the oesophagus, Thai fundic patch operation alongwith a fundoplication should be performed. In this operation the nar­ rowed part of the oesophagus is incised longitudinally across the stricture allow­ ing the opening in the oesophagus to gape widely. After this the fundus of the stomach is used for a full 360° degree fundoplication of Nissen type. When recurrence develops after above-mentioned operations, it is un­ likely that further attempts at repair will be successful. In such cases, resection of the damaged oesophagus alongwith in­ testinal interposition using either jeju­ Fig. To minimise reflux oesophagitis and further stricture formation it is better to interpose an intes­ tinal segment from the oesophageal remnant through the diaphragm upto the stomach. This abnormal oesophageal lining may extend upto the level of the aortic arch or above. This columnar epithelium is mainly mucus secreting with only sparse parietal cells. When the squamous epithelium of the oesophagus is eroded by chronic reflux, replacement may occur with columnar epithelium. Yet it is very difficult to mention with certainty that all cases of Barrett’s oe­ sophagus is due to reflux oesophagitis. A few cases may be congenital — due to cephalad growth of columnar epithelium from the gastric cardia. Stricture may also develop but this stricture is always situated at the junction of columnar and squamous epithelium which may be in the middle of the oesophagus. The columnar epithelium of the Barrett’s oesophagus may undergo dysplasia or neoplastic change and the risk of adenocarcinoma developing in patients with Barrett’s oesophagus is greater than in general population. In such patients long term observation with repeated endoscopy and biopsy should be performed. Left figure shows large sliding hiatus hemia with cardia well above the diaphragm and is incompetent allowing gastric juice to enter the oesophagus. Right figure shows a large para-oesophageal hemia in which almost the whole stomach has entered the thorax where it lies upside down.

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This spreads by lymphatic channel in the early phase generic viagra sublingual 100 mg fast delivery, so enlargement of regional lymph nodes is early order 100mg viagra sublingual visa. Presenting symptoms are similar to those of papillary carcinoma purchase viagra sublingual 100mg mastercard, but the age of the patient is more and there may be pain in the bones due to metastasis. The lump is slightly tender, hard, irregular and the margins are diffused due to infiltration. Dyspnoea, pain in the ear, hoarseness of voice are the complaints due to infiltration of surrounding structures. Thyroid may not move up during deglutition due to fixity to the surrounding structures. Though lymph nodes are almost always enlarged and hard, yet such enlargement may be obscured by the primary mass. Duration of symptoms is much less (months) than the preceding varieties of carcinoma. The common presentation is firm, smooth and distinct lump in the neck, indistinguishable from any other form of thyroid solitary nodule. Diarrhoea is an important symptom which is complained of by at least 1 /3 of the patients. These patients may also have phaeochromocytoma, parathyroid tumour, neuromas of the skin or mucous membrane etc. Lymph node metastasis is found in half the patients and blood borne metastasis is not very rare. This tumour is very difficult to differentiate from anaplastic carcinoma without biopsy. Secondary growths — are rare and may be involved from local infiltration from adjacent organs or from blood borne metastasis from kidney, lung, breast, colon or melanoma of any site. Four autoantigens have been detected — thyroglobulin, thyroid cell microsomes, nuclear component and non-thyroglobulin colloid. The thyroid is symmetrically enlarged, soft, rubbery and firm in consistency in 80% of cases. The enlargement may be asymmetric, lobulated and even nodular in rest of the cases. Though the disease is focal in the beginning yet it extends to involve one or both lobes and the isthmus. The most frequent complaints are enlargement of the neck with slight pain and tenderness in that region. Shortness of breath, increasing fatigue and increase in weight are more related to hypothyroid state. Diagnosis is confirmed by demonstrating high titres of thyroid antibodies in the serum. Biopsy may be indicated in case of asymmetric and nodular goitres to rule out carcinoma. Firm and irregular enlargement of the thyroid with adhesion to surrounding tissues is quite common. Needle biopsy is quite helpful in diagnosis as enlargement of the follicles with infiltration by large mononuclear cells, lymphocytes, neutrophils and foreign body type of giant cells containing many nuclei can be detected easily. Slight enlargement of the gland with difficulty in swallowing and hoarseness are usual symptoms. The H commonest position is the subhyoid p^K (just below the hvoid bone) and next common is the suprahyoid (just above the hvoid bone) position. In case of suprahyoid position one must carefully differentiate this cyst from the sublingual dermoid cyst. The least common position is at the level of the cricoid cartilage when it may mimic an adenoma of the isthmus of the thyroid. The cyst is usually too small or the content is too tense to exhibit definite fluctuation. Primary hyperparathyroidism is due to increased secretion of parathyroid hormone which mobilizes calcium from bone, increases Fig. Such overactivity of the parathyroid usually result from an adenoma (90% of cases), or due to hyperplasia (9%) or rarely due to carcinoma (1%). Patients may present with symptoms of hypercalcaemia or the case may remain asymptomatic only to be revealed on routine serum analysis. There are certain gastrointestinal symptoms — features of peptic ulceration due to hypercalcaemia-induced gastrin secretion. Bone manifestation is more common histologically and is not often clinically evident. Radiological appearances resembling rickets may occur in children from resorption of metaphyseal bones. Osteitis fibrosa cystica (brown tumour) arises from a process of subperiosteal bone resorption with patchy fibrous replacement. Mental disturbances with psychosis, dementia and behavioural changes are often noticed. Calcification may occur in other tissues such as cartilage resulting in pseudogout, in the cornea there may be a band — keratopathy. This condition must be differentiated from sarcoidosis, milk-alkali syndrome, disseminated malignancy and excessive vitamin-D ingestion, all of which cause hypercalcaemia. In type lib in addition there are features of neurological complications with the presence of neuromas of the lips and eyelids and ganglioneuromatosis together with even megacolon. Secondary hyperparathyroidism is a reactive hyperplasia of the parathyroid glands in response to chronic calcium-losing conditions, chronic renal failure or malabsorption. It is rather impossible to palpate an enlarged parathyroid gland be it a case of hypertrophy or adenoma. But a systemic palpation should always be made to discover enlarged parathyroid gland. One thing must be remembered that even in presence of hyperparathyroidism if one finds a swelling at the posterior aspect of a thyroid lobe, very often it is a thyroid adenoma rather than parathyroid adenoma.