 Pain in the chest unrelated to swallowing (“heartburn”)

 Pain during swallowing (odynophagia)

 Difficulty swallowing (dysphagia)

THE ESOPHAGUS

Causes of dysphagia:

1. Incomplete occlusive esophageal obstruction (by extrinsic compression, intrinsic narrowing, foreign bodies)

2. Dysmotility (primary/idiopathic or secondary to systemic disease)

3. Inflammatory lesions without obstruction or dysmotility

Diagnostic aids:

1. Radiography

2. Endoscopy

3. Histology

4. Scintigraphy

5. Manometry

6. pH-metry

7. Intraluminal impedance

Diagnostic Aids:

a) ENDOSCOPY – allows direct visualization of esophageal mucosa & helps therapeutically in the removal of foreign bodies & treatment of varices.

b) SCINTIGRAPHY – evaluates efficiency of peristalsis & shows reflux episodes.

c) INTRALUMINAL IMPEDANCE – is a method for pH-independent detection of bolus movements in the esophagus & distinguishes between acid & nonacid liquid & gaseous reflux.

• 1 in 4,000 neonates; > 90% have TEF

• Type A – 87% most common

• Fifty per cent (50%) of infants have associated anomalies (VATER/VACTERL) – vertebral, anorectal, trachea, esophagus, cardiac, renal, radial, limb syndrome

• Frothing & bubbling at the mouth & nose, cough, cyanosis, respiratory distress

• Feeding exacerbates the symptoms, causes regurgitation & precipitate aspiration

• Diagnosis: inability to pass an NGT or OGT in the newborn is suggestive

• Management: maintain a patent airway

• Prone position

• Esophageal suctioning

• Surgical ligation of TEF & primary end-to-end anastomosis of the esophagus

• Premature babies: delay primary closure by temporizing with fistula ligation & gastrostomy tube placement

Gastroesophageal Reflux Disease

• Most common esophageal disorder in children of all ages

• Retrograde movement of gastric contents across the LES into the esophagus

• Physiologic vs. pathologic (frequent or persistent episodes, with respiratory complications)

Epidemiology: infants’ condition peak at 4 monthss & resolve mostly at 12 months of age & nearly all at 24 months old

Genetic predisposition: AD (chr 13q14 & chr 9)

Clinical manifestations:

a) infants: postprandial regurgitation, signs of esophagitis (irritability, arching, choking, gagging, feeding aversion), failure to thrive

b) Older children: regurgitation, abdominal & chest pain; respiratory manifestations related to asthma or sinusitis

Diagnosis: Barium study of esophagus & upper GIT

> Esophageal pH monitoring of distal esophagus: document acidic reflux episodes (normal value of distal esophageal acid exposure < 5-8% of total monitored time)

Endoscopy: erosive esophagitis, dilates reflux-induced strictures

Radionuclide scintigraphy with Tc – shows aspiration & delayed gastric emptying

Management: conservative therapy & lifestyle modification

Pathophysiology of GERD

Factors that determine the esophageal manifestations of reflux:

- Duration of esophageal exposure

- Causticity of the refluxate

- Susceptibility of the esophagus to damage

- LES, supported by the crura of the diaphragm at the GE junction with valve-like functions of the esophagogastric junction anatomy, form the anti-reflux barrier

- Transient LES relaxation is the major mechanism allowing reflux to occur.

- Gastric distention is the main stimulus for TLESR (straining, coughing, large volume or hyperosmolar meals).

Management of GERD

• Dietary measures: thicken the formula; avoid acidic/spicy foods, juices, alcohol, caffeinated & carbonated drinks

• Awake: prone or upright carried position

• Antacids, H2RAs, PPIs, prokinetic agents

• Fundoplication: for intractable GERD, refractory esophagitis & strictures, with morbidities from chronic pulmonary disease

FOREIGN BODIES IN THE ESOPHAGUS

• Coins – most frequently ingested

• Most lodge at the level of the cricopharyngeus (UES), the aortic arch or superior to the diaphragm at the LES

• Choking, gagging or coughing followed by excessive salivation, dysphagia food refusal, emesis, or pain in the throat or sternal notch

• Diagnosis: X-ray of neck, chest & abdomen (AP & lateral views)

• Flat surface of coin seen on AP view & the edge on lateral view; the reverse is true for coins lodged in the trachea

• Sharp objects, disc button batteries, or FBs with respiratory symptoms mandate urgent removal

• Asymptomatic blunt objects may be observed up to 24 hours in anticipation of passage into the stomach

• Glucagon (0.05 mg/kg IV) may be useful in facilitating passage of distal esophageal food boluses by decreasing the LES pressure.

CAUSTIC INGESTIONS

• Ingestion results in esophagitis, necrosis, perforation & stricture formation

• Liquid alkali produce severe, deep liquefaction necrosis (acidic agents are bitter so less may be ingested – coagulation necrosis)

• Vomiting, drooling, refusal to drink, oral burns, dysphagia, abdominal pain

• Circumferential ulcers, white plaques, sloughing of mucosa

• Absence of oropharyngeal lesions does not exclude the possibility of significant esophagogastric injury!

• Endoscopy – rapidly identifies tissue damage

• Dilution by water/milk is recommended.

• Neutralization, induced emesis & gastric lavage are contraindicated.

• Surgical resection: SI or colon interposition

PYLORIC STENOSIS

• Most common cause of nonbilious vomiting (whites > Asians; M>F)

• Unknown cause; abnormal muscle innervation is implicated (3 wks-5 mos)

• Postprandial vomiting, hypochloremic metabolic alkalosis

• Diagnosis: firm, movable, olive-shaped mass; visible gastric peristaltic wave after feeding

• Ultrasound is confirmatory: pyloric thickness >4mm or length >14mm

• Barium: elongated pyloric channel, a bulge of the pyloric muscle into the antrum (shoulder sign) & streaks of barium in the narrowed channel (double tract sign)

• Surgery: Ramstedt pyloromyotomy

GASTRIC VOLVULUS

• Triad: sudden onset of severe epigastric pain, intractable retching with emesis & inability to pass a tube into the stomach

• Stomach rotates around itself when the ligaments are absent/stretched

• May advance to strangulation & perforation

• Diagnosis: plain abdominal X-ray: dilated stomach; double fluid level with a “beak” near the lower esophageal junction

• Treatment: emergent surgery

INTESTINAL OBSTRUCTION

• Partial vs. complete

• Simple (failure of progression of flow of luminal contents) vs. strangulating (impaired blood flow to the intestine in addition to obstruction of the flow of luminal contents)

• Accumulation of food, gas, intestinal secretions proximal to the point of obstruction-bowel distention-decreased intestinal absorption-inc. fluid & electrolyte secretion-isotonic intravascular depletion-inc.contractions then hypoactive bowel sounds-nausea/vomiting

• Intrinsic (atresia, stenosis, meconium ileus, aganglionic megacolon) vs. Extrinsic (malrotation, constricting bands, intra-abdominal hernias, duplications)

• Atresia – complete obstruction of the bowel lumen

• Stenosis – partial block of luminal contents

• Classic symptoms: nausea & vomiting, abdominal distention & obstipation

• High obstruction: large volume, frequent, bilious emesis; intermittent pain in the epigastrium or periumbilical area, relieved by vomiting

• Low obstruction: moderate/marked distention with emesis that is progressively feculent; diffuse pain over the entire abdomen

• Plain supine/upright/decubitus X-rays

• Upright/cross-table lateral view: distended bowel above the obstruction with fluid level and gas in the distended loops

• Pneumoperitoneum may be seen in perforation with free air in the subphrenic area or over the liver in the left lateral decubitus position

• Ground-glass appearance in the RLQ with trapped air bubbles seen in meconium ileus

• Ultrasound: stenosis, malrotation, volvulus, intussusception

• Contrast studies used when plain films or sonograms fail to identify the source of obstruction

• Water-soluble contrast enemas: useful in malrotation, meconium ileus/plug, intussusception (diagnostic & therapeutic)

• Management: fluid resuscitation; nasogastric decompression; cultures; antibiotics; surgery for strangulation; conservative measures for adhesions or strictures (if clinical signs of improvement are not evident

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II. REGURGITATION – effortless movement of stomach contents into the esophagus and mouth

III. ANOREXIA – appetite is affected by regulatory factors like hormones, plasma glucose, emotions

IV. VOMITING – highly coordinated reflex process in the medulla influenced directly by afferent innervation & indirectly by the chemoreceptor trigger zone & higher CNS centers

 If due to GI obstruction: mediated by intestinal visceral afferent nerves

 Cyclic vomiting – syndrome with numerous episodes with well intervals; onset between 3-5 y/o, lasts 2-3 days with 4 or more episodes per hour; stress & excitement are triggers

Differential Diagnosis of Vomiting

V. DIARRHEA – excessive loss of fluid & electrolyte in the stool; basis is disturbed intestinal solute transport

1. Secretory – decreased absorption; increased secretion; tend to be watery and voluminous; persists even when no feedings are given orally (ex: cholera, E. coli, Clostridium difficile)

2. Osmotic – occurs after ingestion of a poorly absorbed solute (lactose or glucose); transport defects; increased osmolality; stops with fasting

3. Motility – decreased transit time or defect in neuromuscular units or bacterial overgrowth (ex: IBS, postvagotomy dumping syndrome)

4. Mucosal inflammation – decreased mucosal surface area &/or colonic reabsorption, increased motility (Salmonella, Shigella, amebiasis, rotavirus, Campylobacter); WBCs & blood in stool

VI. CONSTIPATION – depends on stool consistency, frequency & difficulty in passing the stool; arise from defects either in filling or emptying the rectum

 Common causes during infancy:

1. Hirschsprung disease

2. Intestinal pseudo-obstruction

3. Congenital hypothyroidism

 Causes in childhood/adolescence:

1. Functional

2. Diet

VII. ABDOMINAL PAIN

 Children differ greatly in their perception of & tolerance for abdominal pain

 Functional vs. organic cause

 2 types of nerve fibers transmit painful stimuli:

1. A fibers – skin & muscle; sharp localized pain

2. C fibers – viscera, peritoneum & muscle; poorly localized, dull pain

• Pain is perceived in the cortex of the postcentral gyrus

• Visceral pain tends to be experienced in the dermatome from which the affected organ receives innervation.

 epigastrium: liver, pancreas, biliary tree, stomach, upper bowel

 umbilicus: distal small bowel, cecum, appendix, proximal colon

 suprapubic: distal large bowel, urinary tract, pelvic organs

VIII. GI HEMORRHAGE

• Erosive damage to the mucosa – most common cause of bleeding

• Hematemesis – bleeding from esophagus, stomach or duodenum

• Hematochezia – distal bleeding site or massive hemorrhage above the distal ileum

• Melena – blackened tarry stool due to bleeding from sites above the distal ileum

• Children may have iron deficiency anemia from chronic enteric blood loss

• May produce hypotension & tachycardia but rarely causes GI symptoms

Differential Diagnosis of GI Bleeding

 INFANCY

 Bacterial enteritis

 Milk protein allergy

 Intussusception

 Swallowed maternal blood

 Anal fissure

 CHILDHOOD

 Bacterial enteritis

 Anal fissure

 Polyps

 Swallowed epistaxis

 Peptic ulcer/gastritis

 ADOLESCENCE

-Inflammatory bowel disease

IX. ABDOMINAL DISTENTION & MASSES

 Enlargement of the abdomen can result from diminished tone of the wall musculature or from increased content: fluid, gas, or solid

 Ascites – accumulation of fluid in the peritoneal cavity

 Source of accumulated gas is swallowed air but endogenous flora may increase in malabsorptive states & produce excessive gas when substrate reaches the lower intestine

 Pneumoperitoneum – indicates a perforated viscus; (+)tympany even over solid organs

 Masses may occur in the lumen, wall, or mesentery

 Constipated child: mobile, nontender fecal masses found or palpated

 Diffuse enlargement of the liver

 Anomalies, cysts, or inflammatory disease can affect the wall of the gut

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Anatomy

a. Anterior abdominal wall

i. 4 abdominal quadrants formed byTUP (transumbilical plane) and midsagittal plane – RUQ, RLQ, LUQ, and LLQ.

ii. 9 abdominal regions formed by TPP (transpyloric plane), TTP (transtubercular plane), and midclavicular planes, of which the three central regions are most important (from top to bottom): Epigastric (T6-8), Umbilical (T9-11), and suprapubic (or hypogastric, T12-L1). Referred pain from foregut, midgut, and hindgut, are referred to these three regions respectively.

iii. Body wall components, gubernaculum, and inguinal canal:

1. The gubernaculum is a cord of connective tissue and smooth muscle which connects the skin near the pubic symphisis to the gonads near the posterior abdominal wall in the embryo.

2. A defect in the anterior abdominal wall passing obliquely from lateral to medial and deep to superficial, is present so that the gubernaculum can reach the skin. This becomes the inguinal canal. During development, the gubernaculums shrinks and pulls the testes through the inguinal canal.

3. Layers of the anterior abdominal wall (from superficial to deep):

a. Skin

b. Superificial fascia (Camper’s fascia (fatty, superficial) and Scarpa’s fascia (thin and fibrous, deep). Scarpa’s is continuous with Darto’s (penis and scrotum) and Colle’s (perineum) fascias.

c. Trilaminar muscle sheet (abdominal muscles) plus rectus abdominus muscle.

d. Transversalis fascia

e. Parietal Peritoneum

4. Urethral injury can result in urinary extravasation, which can potentially fill all of the space between Scarpa’s fascia and the aponeuroses of the abdominal muscles (like a half-underwear on the front).

5. The 3 anterior abdominal muscles are homologous to the intercostal muscles:

a. External abdominal oblique muscle (EAO)

b. Internal abdominal oblique muscle (IAO)

c. Transversus abdominus muscle (TA)

6. Arcuate line:

a. The point at which the aponeuroses of the transversus abdominus and internal abdominal oblique muscles merge with the anterior layer of the rectus sheath, leaving a free edge on the posterior aspect of the rectus abdominus muscle inferior to the arcuate line.

7. Inguinal canal:

a. Walls of:

i. Floor – inguinal ligament

ii. Roof – arching fibers of IAO and TA laterally, conjoint tendon medially.

iii. Posterior aspect – transversalis fascia

iv. Anterior aspect – aponeuroses of EAO

b. Contents:

i. The round ligament of the uterus in the female.

ii. The spermatic cord in the male.

iii. The ilioinguinal nerve in both.

c. Layers surrounding the testes which were derived from the anterior abdominal wall:

i. Internal spermatic fascia (from transversalis fascia)

ii. Cremaster muscle (from arching fibers of IAO muscle)

iii. External spermatic fascia (from aponeuroses of EAO)

The processus vaginalis (peritoneum in the inguinal canal) degenerates (normally) and only leaves a small sac on the anterior of the testes called the tunica vaginalis.

d. Components of the spermatic cord:

i. Vas deferens

ii. Testicular artery and vein (pampiniform plexus).

iii. Lymphatics

iv. Internal spermatic fascia

v. Cremaster muscle

vi. External spermatic fascia

vii. Genital branch of genitofemoral nerve.

b. Inguinal region/hernia

i. How do you get an inguinal hernia?

1. Increased intra-abdominal pressure (chronic cough, constipation, heavy lifting, straining on urination due to prostate enlargement, etc.

2. Decreased abdominal muscle tone (old age)

ii. Types of inguinal hernias:

1. Indirect inguinal hernia:

a. Projection of gut through the inguinal canal (potentially right into the scrotum).

b. More common in males

c. Note during surgery: The neck of the hernial sac will be lateral to the inferior epigastric vessels.

2. Direct inguinal hernia:

a. Projection of gut through Hesselbach’s triangle (weak region b/w rectus abdominus, inferior epigastric’s, and inguinal ligament).

b. More common in elderly (due to weak musculature).

c. Note during surgery: The neck of the hernial sac will be medial to the inferior epigastric vessels.

3. Femoral hernia:

a. Projection of gut beneath the inguinal ligament into the upper thigh.

b. More common in women due to wider pelvis and smaller vessels creating more room.

c. Abdominal referred pain:

i. See lecture slides for a nice review of the nervous system.

ii. Important abdominal dermatomes:

1. T4 – nipple

2. T7 – xiphoid process

3. T10 – umbilicus

4. L1 – suprapubic

iii. Abdominal pain can be:

1. Somatic:

a. Sharp and precisely localized

b. Referred somatic pain is relatively uncommon. Arises from a common pathway of nerve fiber travel.

2. Visceral:

a. Dull, aching, and poorly localized.

b. Caused by stretch, distention, ischemia, or trauma to abdominal organs.

c. Accompanied by reflex sweating, salivation, nausea, vomiting, increased HR, etc.

3. Referred:

a. Referred visceral pain is common. Referred visceral pain is referred to body wall dermatomes which make up the splanchnic nerves the visceral pain is coming from (eg. pain in the stomach is transmitted up the greater splanchnic nerves to cause pain in dermatomes T5-9 (epigastric region)).

b. If the diaphragm is contacted the pain can be referred to the C3-C5 region (shoulder and neck).

iv. Divisions of the abdomen:

1. Foregut:

a. Lower esophagus to descending duodenum, including liver, gallbladder, pancreas and spleen.

b. Blood supply is from the celiac trunk.

c. Innervation:

i. Sympathetic: Greater splanchnic nerve (T5-T9).

ii. Parasympathetic: Vagus nerve.

2. Midgut:

a. Descending duodenum to transverse colon (includes first 2/3rds).

b. Blood supply is from superior mesenteric artery.

c. Innervation:

i. Sympathetic: Lesser and least splanchnic nerves (T10-11, T12). And some L1.

ii. Parasympathetic: Vagus nerve.

3. Hindgut:

a. Last 1/3 of transverse colon to anal canal.

b. Blood supply is from inferior mesenteric artery.

c. Innervation:

i. Sympathetic: Lumber splanchnic nerves (L1 and L2).

ii. Parasympathetic: Pelvic splanchnic nerves (S2-S4).

d. Peritoneum/Abdominal Viscera

i. Arrangement of Abdominal Viscera

1. Supracolic (above transverse mesocolon)

a. Abdominal esophagus

b. Stomach

i. Variable in shape

c. Spleen

i. An enlarged spleen is palpable (otherwise not)

d. Upper ½ of duodenum

i. C-shaped

ii. Divided into 4 parts: superior, descending, horizontal, ascending. All but superior are retroperitoneal.

iii. D-J flexure is supported by the ligament of Treitz.

e. Liver

i. Superior extent: 4th or 5th intercostal space (just below nipple)

ii. Bare area on posterior aspect contacts diaphragm, IVC, and right kidney.

f. Gallbladder

g. Upper ½ of pancreas

i. Retroperitoneal

ii. Splenic vein is postero-superior to majority of pancreas

2. Infracolic (below transverse mesocolon)

a. Small intestine

i. Jejunum (LUQ)

1. larger, thicker wall, pinker, few arcades, long vasa recta, scant fat

ii. Ileum (RLQ)

1. smaller, thinner wall, darker, many arcardes, short vasa recta, abundant fat.

b. Root of mesentery

i. Approx 15 cm from LUQ to RLQ

ii. Rest of small intestine highly folded and fan-shaped projections from the root.

c. Large intestine

i. Cecum

1. Base of appendix is posteromedial on cecum

2. Found on surface by McBurney’s point

ii. Appendix

1. Average 9 cm in length

2. Abundant lymphoid tissue

3. Suspended by mesoappendix – mobile.

a. Retrocecal position most common

iii. Colon

1. Left (splenic) flexure is higher than right (hepatic) flexure, and is suspended from the diaphragm by the phrenicocolic ligament.

2. Intraperitoneal parts:

a. Transverse colon (in transverse mesocolon)

b. Sigmoid colon (in sigmoid mesocolon)

d. Paracolic gutters

i. On either side (medial and lateral) of ascending and descending colon (visceral peritoneum dips dorsally to become continuous with parietal peritoneum)

ii. Right paracolic gutter allows surgical access

iii. Gutters can also allow percolation of fluid and spread of infection.

e. Blood supply of intestines:

i. Arterial

1. Superior mesenteric artery (midgut). Branches:

a. Inferior pancreaticoduodenal

b. Jejunal and ileal branches (12-15)

c. Middle colic

d. Right colic

e. Ileocolic

2. Inferior mesenteric artery (hindgut). Branches:

a. Left colic

b. Sigmoid

c. Superior rectal

3. Arteries anastamose around the margin of colon as the marginal artery of Drummond (variable, but can be important collateral channel).

ii. Venous

1. Portal vein tributaries:

a. Splenic

b. Superior mesenteric

c. Inferior mesenteric

f. Porto-systemic anastomoses (Chronic portal hypertension can show up in these locations):

i. Esophageal (varices)

ii. Anorectal (hemorrhoids)

iii. Paraumbilical (engorged umbilical veins)

iv. Retroperitoneal

e. Retroperitoneal Structures:

i. Kidney Review:

1. Layers surrounding the kidney:

a. Kidney fibrous capsule

b. Perirenal fat

c. Renal fascia (also separates from adrenals)

d. Pararenal fat

ii. Adrenal Glands:

1. Location: superomedial edge of kidney

2. Structure:

a. Cortex (mesoderm): mineralocorticoids, glucocorticoids, and sex steroids.

b. Medulla:

i. Preganglionic SNS neuron reaches via splanchnic nerves.

ii. Chromaffin cells are essentially modified post-ganglionic SNS neurons that secrete E/NE into bloodstream instead of into a synapse.

c. Blood supply:

i. Rich and variable

ii. From inferior phrenic artery, abdo. aorta, and renal artery.

iii. Diaphragm:

1. Function:

a. Chief muscle of inspiration

b. Increase intra-abdominal pressure

2. Structure:

a. Central tendon surrounded by peripheral musculature.

b. Peripheral musculature is discontinous posteriorly:

i. Median, medial, and lateral arcuate ligaments.

c. Ligament of Treitz (supports the duodenum) is partly formed by muscle from the right crus.

d. Vertebrocostal triangle: diaphragmatic attachment of lateral arcuate ligament is weak – site for diaphragmatic hernia.

3. Openings:

a. Vena Cava – T8

b. Esophagus – T10

c. Aorta – T12

d. Plus other vessels and nerves

4. Blood supply – rich. From superior and inferior surfaces.

5. Nerve supply – C3,4,5 keep the diaphragm alive.

iv. Blood Supply:

1. Unpaired arteries:

a. Abdominal aorta

b. Celiac trunk

c. Superior Mesenteric

d. Inferior mesenteric

e. Median sacral

2. Paired arteries:

a. Inferior phrenic

b. Middle suprarenal

c. Renal

d. Gonadal

e. Lumbar

f. Iliac

g. Deep iliac circumflex

h. Inferior epigastric

v. Lymphatics:

1. Pre-aortic nodes – anterior to the abdo. aorta

a. Celiac

b. Superior mesenteric

c. Inferior mesenteric

i. Same locations (and names) as the pre-aortic nerve plexi

2. Para-aortic nodes – lateral to abdo. aorta

a. Para-aortic

b. Common iliac

c. External iliac

d. Internal iliac

3. Everything drains into the cisterna chyli, just below the diaphragm.

vi. Muscles:

1. See table in lecture notes

vii. Fascia:

1. Thickening of the fascia covering the muscles of the posterior abdominal wall form the arcuate ligaments inferiorly.

viii. Nerves:

1. Lumbar Plexus (L1 to L5) – See diagram in notes

NERVE ORIGIN INNERVATION

Iliohypogastric nerve L1 Suprapubic region

Ilioinguinal nerve L1 Groin

Genitofemoral nerve

Femoral branch L1,2 Cremaster muscle

Superior thigh

Lateral Femoral Cutaneous nerve L2,3 Lateral thigh

Femoral nerve L2,3,4 Quadriceps and iliopsoas

Obturator nerve L2,3,4 Thigh adductors

Lumbosacral trunk L4,5 Joins lumbosacral plexus – rest of lower limb

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About 1% of the world’s population is afflicted by rheumatoid arthritis, women three times more often than men. Onset is most frequent between the ages of 40 and 50, but people of any age can be affected. It can be a disabling and painful condition, which can lead to substantial loss of functioning and mobility if not adequately treated. It is a clinical diagnosis made on the basis of symptoms, physical exam, radiographs (X-rays) and labs, although the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) publish diagnostic guidelines. Diagnosis and long-term management are typically performed by arheumatologist, an expert in joint, muscle and bone diseases.^[1]

Various treatments are available. Non-pharmacological treatment includes physical therapy, orthoses, occupational therapy and nutritional therapy but do not stop progression of joint destruction. Analgesia (painkillers) and anti-inflammatory drugs, including steroids, are used to suppress the symptoms, while disease-modifying antirheumatic drugs (DMARDs) are required to inhibit or halt the underlying immune process and prevent long-term damage. In recent times, the newer group of biologics has increased treatment options.^[1]

The name is based on the term “rheumatic fever”, an illness which includes joint pain and is derived from the Greek word ῥεύμα-rheuma (nom.), ῥεύματος-rheumatos (gen.) (“flow, current”). The suffix -oid (“resembling”) gives the translation as joint inflammation that resembles rheumatic fever. The first recognized description of rheumatoid arthritis was made in 1800 by Dr. Augustin Jacob Landré-Beauvais (1772–1840) of Paris.^[2]

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Rheumatologists treat arthritis, certain autoimmune diseases, musculoskeletal pain disorders and osteoporosis. There are more than 200 types of these diseases, including rheumatoid arthritis, osteoarthritis, gout, lupus, back pain, osteoporosis, and tendinitis. Some of these are very serious diseases that can be difficult to diagnose and treat. They treat soft tissue problems related to musculoskeletal system sports related soft tissue disorders and the specialty is also interrelated with physiotherapy, physical medicine and rehabilitation of disabled patients. Patient education programs and occupational therapy also go hand in hand with this specialty.

There are many international organizations representing rheumatologists all over the world. The American College of Rheumatology ( ACR), the Association of Rheumatology Health Professionals (ARHP), the European League Against Rheumatism (EULAR), Asia Pacific League of Associations for Rheumatology (APLAR), International League of Associations for Rheumatology (ILAR) are the main international organizations established and organizing many activities related to this specialty, these organizations strive to propagate and consolidate Rheumatology endeavors internationally , furthermore, there are associations and colleges of Rheumatology representing Rheumatologists from each and every nation scattered throughout the world which represent the above mentioned organizations from each nation. Rheumatologists are physicians specialized in rheumatic diseases.

For example, there are approximately 480 consultant rheumatologists in the UK. Rheumatologists are increasing in numbers in all countries, as there is an increasing demand for specialists on this field with an increasing population of aging patients who need specialized treatment.

WHAT KIND OF TRAINING DO RHEUMATOLOGISTS HAVE?

After four years of medical school and three years of training in either internal medicine or pediatrics, rheumatologists devote an additional two to three years in specialized rheumatology training. Most rheumatology who plan to treat patients choose to become board certified. Upon completion of their training, they must pass a rigorous exam conducted by the American Board of Internal Medicine or the American Board of Pediatrics to be certified. Rheumatologists who are certified by these boards after 1990 are required to complete an extensive recertification process every ten years.

WHAT DO RHEUMATOLOGISTS TREAT?

Rheumatologists treat arthritis, certain autoimmune diseases, musculoskeletal pain disorders and osteoporosis. There are more than 100 types of these diseases, including rheumatoid arthritis, osteoarthritis, gout, lupus, back pain, osteoporosis, fibromyalgia and tendonitis. Some of these are very serious diseases that can be difficult to diagnose and treat.

WHEN SHOULD YOU SEE A RHEUMATOLOGIST?

If musculoskeletal pains are not severe or disabling and last just a few days, it makes sense to give the problem a reasonable chance to be resolved. But sometimes, pain in the joints, muscles or bones is severe or persists for more than a few days. At that point, you should see your physician.

Many types of rheumatic diseases are not easily identified in the early stages. Rheumatologists are specially trained to do the detective work necessary to discover the cause of swelling and pain. It’s important to determine a correct diagnosis early so that appropriate treatment can begin early. Some musculoskeletal disorders respond best to treatment in the early stages of the disease.

Because some rheumatic diseases are complex, one visit to a rheumatologist may not be enough to determine a diagnosis and course of treatment. These diseases often change or evolve over time. rheumatology work closely with patients to identify the problem and design an individualized treatment program.

HOW DOES THE RHEUMATOLOGIST WORK WITH OTHER HEALTH CARE PROFESSIONALS?

The role the rheumatologist plays in health care depends on several factors and needs. Typically the rheumatologist works with other physicians, sometimes acting as a consultant to advise another physician about a specific diagnosis and treatment plan. In other situations, the rheumatologist acts as a a manager, relying upon the help of many skilled professionals including nurses, physical and occupational therapists, psychologists and social workers. Team work is important, since musculoskeletal disorders are chronic. Health care professionals can help people with musculoskeletal diseases and their families cope with the changes the diseases cause in their lives.

IS SPECIALTY CARE MORE EXPENSIVE?

You may be surprised to learn that specialized care may save time and money and reduce the severity of disease. A rheumatologist is specially trained to spot clues in the medical history and physical examination. The proper tests done early may save money in the long run. Prompt diagnosis and specially tailored treatment often save money and buy time in treating the disease.

Article : http://www.rheumatology.org

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As a discipline that involves the study of many organs and physiological systems, urology can be broken down into subdisciplines. At larger centers and especially university hospitals, many urologists specialize within a particular subdiscipline of urology.

[edit]Endourology

Endourology is the branch of urology that deals with minimally invasive surgical procedures. As opposed to open surgery, endourology is performed using small cameras and instruments inserted into the urinary tract. Transurethral surgery has been the cornerstone of endourology. Most of the urinary tract can be reached via the urethra, enabling prostate surgery, surgery of tumors of the urothelium, stone surgery, and simple urethral and ureteral procedures.

[edit]Laparoscopy

Laparoscopy is a rapidly evolving branch of urology and has replaced some open surgical procedures. Robot-assisted surgery of the prostate, kidney, and ureter has been expanding this field. Today, many prostatectomies in the United States are carried out by robotic assistance. This has created controversy, however, as the machines are very expensive, require a dedicated surgical team and have high maintenance costs.

[edit]Urologic oncology

Urologic oncology concerns the surgical treatment of malignant genitourinary diseases such as cancer of the prostate, adrenal glands, bladder, kidneys, ureters, testicles, and penis. The medical treatment of advanced genitourinary cancer is managed by either a urologist or an oncologist depending on the cancer.

[edit]Neurourology

Neurourology concerns nervous system control of the genitourinary system, and of conditions causing abnormal urination. Neurological diseases and disorders such as a stroke, multiple sclerosis, Parkinson’s disease, and spinal cord injury can disrupt the lower urinary tract and result in conditions such as urinary incontinence, detrusor overactivity, urinary retention, and detrusor sphincter dyssynergia. Urodynamic studies play an important diagnostic role in neurourology. Therapy for nervous system disorders includes clean intermittent self-catheterization of the bladder, anticholinergic drugs, injection of Botulinum toxin into the bladder wall and advanced and less commonly used therapies such as sacral neuromodulation. Less marked neurological abnormalities can cause urological disorders as well—for example, abnormalities of the sensory nervous system are thought by many researchers to play a role in disorders of painful or frequent urination (e.g. painful bladder syndrome, formerly known as interstitial cystitis).

[edit]Pediatric urology

Pediatric urology concerns urologic disorders in children. Such disorders include cryptorchism (undescended testes), congenital abnormalities of the genitourinary tract, enuresis, underdeveloped genitalia (due to delayed growth or delayed puberty, often an endocrinological problem), and vesicoureteral reflux.

[edit]Andrology

Andrology focuses on the male reproductive system. It is mainly concerned with male infertility, erectile dysfunction and ejaculatory disorders. Since male sexuality is largely controlled by hormones, andrology overlaps with endocrinology. Surgery in this field includes fertilization procedures, vasectomy reversals, and the implantation of penile prostheses. Vasectomies may also be included here, although most urologists perform this procedure.

[edit]Reconstructive urology

Reconstructive urology is a highly specialized field of urology that restores function to any of various structures of the genitourinary tract. Prostate procedures, full or partial hysterectomies, trauma (auto accidents, gunshot wounds, industrial accidents, straddle injuries, etc.), disease, obstructions, blockages (e.g., urethral strictures), and occasionally, childbirth, can necessitate require reconstructive surgery. The urinary bladder, ureters (the tubes that lead from the kidneys to the urinary bladder) and genitalia are other examples of reconstructive urology. Often, plastic surgeons assist in these procedures, although purely cosmetic procedures such as penis enlargement do not fall under the rubric of reconstructive urology.

[edit]Urogynecology

Urogynecology is a branch dealing with overactive bladder, pelvic organ prolapse, and urinary incontinence. Thorough knowledge of the female pelvic floor together with urodynamic skills are necessary to diagnose and treat these disorders. Depending on the cause of the individual problem, a medical or surgical treatment can be the solution.

Article Source:http://en.wikipedia.org/wiki/

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The urinary and reproductive tracts are closely linked, and disorders of one often affect the other, so a major part of the conditions managed in urology fall in the area of genitourinary disorders. Urology combines management of medical (i.e., non-surgical) problems such as urinary tract infections and benign prostatic hyperplasia, as well as surgical problems such as the surgical management of cancers, the correction of congenital abnormalities, and correcting stress incontinence. Urology is closely related to, and in some cases overlaps with, the medical fields of oncology, nephrology, gynecology, andrology, pediatric surgery, gastroenterology, andendocrinology.

Singapore Urology  Doctors and Clinics

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Other animals, such as insects, have respiratory systems with very simple anatomical features, and in amphibians even the skin plays a vital role in gas exchange. Plants also have respiratory systems but the directionality of gas exchange can be opposite to that in animals. The respiratory system in plants also includes anatomical features such as holes on the undersides of leaves known as stomata.

Singapore Respiratory  Doctors and Clinics

Article Source:http://en.wikipedia.org/wiki/Respiratory

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Psychiatric assessment typically starts with a mental status examination and the compilation of acase history. Psychological tests and physical examinations may be conducted, including on occasion the use of neuroimaging or other neurophysiological techniques. Mental disorders are diagnosed in accordance with criteria listed in diagnostic manuals such as the widely used Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, and the International Classification of Diseases (ICD), edited and used by the World Health Organization. The fifth edition of the DSM (DSM-5) is scheduled to be published in 2013, and its development is suspected to be of significant interest to many medical fields.^[3]

Psychiatric treatment applies a variety of modalities, including psychoactive medication, psychotherapy and a wide range of other techniques such as transcranial magnetic stimulation. Treatment may be delivered on an inpatient or outpatient basis, depending on the severity of functional impairment or on other aspects of the disorder in question. Research and treatment within psychiatry as a whole are conducted on an interdisciplinary basis, sourcing an array of sub-specialties and theoretical approaches.

Singapore Psychiatry  Doctors and Clinics

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British physicians traveled to India to see rhinoplasties being performed by native methods.^[6]Reports on Indian rhinoplasty performed by a Kumhar vaidya were published in the Gentleman’s Magazine by 1794.^[6] Joseph Constantine Carpue spent 20 years in India studying local plastic surgery methods.^[6] Carpue was able to perform the first major surgery in the Western world by 1815.^[7] Instruments described in the Sushruta Samhita were further modified in the Western world.^[7]

Aulus Cornelius Celsus, who lived in the first century AD, described plastic surgery of the face, using skin from other parts of the body

The ancient Egyptians and Romans also performed plastic cosmetic surgery. The Romans were able to perform simple techniques, such as repairing damaged ears from around the 1st century BC. For religious reasons, they did not dissect either human beings or animals, thus their knowledge was based in its entirety on the texts of their Greek predecessors. Notwithstanding, Aulus Cornelius Celsus left some surprisingly accurate anatomical descriptions,^[8] some of which — for instance, his studies on the genitalia and the skeleton — are of special interest to plastic surgery.^[9]

In 1465, Sabuncuoglu’s book, description, and classification of hypospadias was more informative and up to date. Localization of urethral meatus was described in detail. Sabuncuoglu also detailed the description and classification of ambiguous genitalia.^{[citation needed]} In mid-15th century Europe, Heinrich von Pfolspeundt described a process “to make a new nose for one who lacks it entirely, and the dogs have devoured it” by removing skin from the back of the arm and suturing it in place. However, because of the dangers associated with surgery in any form, especially that involving the head or face, it was not until the 19th and 20th centuries that such surgery became common.

Up until the techniques of anesthesia became established, surgeries involving healthy tissues involved great pain. Infection from surgery was reduced by the introduction of sterile techniques and disinfectants. The invention and use of antibiotics, beginning with sulfa drugs and penicillin, was another step in makingelective surgery possible.

In 1792, Chopart performed operative procedure on a lip using a flap from the neck. In 1814, Joseph Carpuesuccessfully performed operative procedure on a British military officer who had lost his nose to the toxic effects of mercury treatments. In 1818, German surgeon Carl Ferdinand von Graefe published his major work entitled Rhinoplastik. Von Graefe modified the Italian method using a free skin graft from the arm instead of the original delayed pedicle flap.

The first American plastic surgeon was John Peter Mettauer, who, in 1827, performed the first cleft palate operation with instruments that he designed himself. In 1845, Johann Friedrich Dieffenbach wrote a comprehensive text on rhinoplasty, entitled Operative Chirurgie, and introduced the concept of reoperation to improve the cosmetic appearance of the reconstructed nose.

In 1891, American otorhinolaryngologist John Roe presented an example of his work, a young woman on whom he reduced a dorsal nasal hump for cosmetic indications. In 1892, Robert Weir experimented unsuccessfully with xenografts (duck sternum) in the reconstruction of sunken noses. In 1896, James Israel, a urological surgeon from Germany, and in 1889 George Monks of the United States each described the successful use of heterogeneous free-bone grafting to reconstruct saddle nose defects. In 1898, Jacques Joseph, the German orthopaedic-trained surgeon, published his first account of reduction rhinoplasty. In 1928, Jacques Joseph published Nasenplastik und Sonstige Gesichtsplastik.

Singapore Plastic Surgery Doctors and Clinics

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There may be other differences in spelling: in the USA, a pediatrician (US spelling) is often a primary care physician who specializes in children, whereas in the Commonwealth a paediatrician (British spelling) generally is a medical specialist not in primary general practice. For further detail, see discussion on the broad and narrow meanings.

Singapore Paediatrics  Doctors and Clinics

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The full name of the specialty is otorhinolaryngology^[1]; The full term otorhinolaryngology (neoclassical Greek and modern Greek: ὠτο(ρ)ρινολαρυγγολογία), also includes ῥινο- – rhino-(root of ῥίς) “nose”. The term comes from the Classical Greek roots ὠτ- – ot- (root of οὖς) “ear”, λαρυγγ- – laryng- (root of λάρυγξ) “larynx/throat”, and the root -logy “study”, and it literally means “the study of ear and throat”.

Some people refer to it as head and neck surgery. Practitioners are calledotolaryngologists–head and neck surgeons, or sometimes otorhinolaryngologists(ORL).

Singapore Otolaryngology Doctors and Clinics

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Nicholas Andry coined the word “orthopaedics”, derived from Greek words for orthos (“correct”, “straight”) and paideion (“child”), when he published Orthopaedia: or the Art of Correcting and Preventing Deformities in Children in 1741. Correction of spinal and bony deformities became the cornerstone of orthopaedic practice. Today, over 6 months of training is dedicated to the treatment of the pediatric population.

In the United States orthopedics is standard, although the majority of college, university and residency programs, and even the American Academy of Orthopaedic Surgeons, still use Andry’s spelling. Elsewhere, usage is not uniform; in Canada, both spellings are acceptable; orthopaedicsusually prevails in the rest of the Commonwealth, especially in Britain.

Singapore Orthopedic surgery Doctors and Clinics

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The word ophthalmology comes from the Greek roots ophthalmos meaning eye and logosmeaning word, thought, or discourse; ophthalmology literally means “the science of eyes”. “Opthomology” is a common mis-hearing or mis-remembering of the term. As a discipline, it applies to animal eyes also, since the differences from human practice are surprisingly minor and are related mainly to differences in anatomy or prevalence, not differences in disease processes. However, veterinary medicine is regulated separately in many countries and states/provinces resulting in few ophthalmologists treating both humans and animals.

Singapore Opthalomology  Doctors and Clinics

Article Source:http://en.wikipedia.org/wiki/Ophthalmology

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Oncology is concerned with:

• The diagnosis of any cancer in a person
• Therapy (e.g., surgery, chemotherapy, radiotherapy and other modalities)
• Follow-up of cancer patients after successful treatment
• Palliative care of patients with terminal malignancies
• Ethical questions surrounding cancer care
• Screening efforts:
  • of populations, or
  • of the relatives of patients (in types of cancer that are thought to have a hereditary basis, such as breast cancer)

Singapore Oncology  Doctors and Clinics

Article Source:http://en.wikipedia.org/wiki/Oncology

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Singapore Obstetrics  Doctors and Clinics

Article Source:http://en.wikipedia.org/wiki/Obstetrics

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Neurology is the medical application of neuroscience which is the scientific study of the nervous system.

Singapore Neurology  Doctors and Clinics

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Scope of the specialty

Nephrology concerns the diagnosis and treatment of kidney diseases, including electrolyte disturbances and hypertension, and the care of those requiring renal replacement therapy, including dialysis and renal transplant patients. Many diseases affecting the kidney are systemic disorders not limited to the organ itself, and may require special treatment. Examples include acquired conditions such as systemic vasculitides (e.g. ANCA vasculitis) and autoimmune diseases (e.g., lupus), as well as congenital or genetic conditions such as polycystic kidney disease.

Patients are referred to nephrology specialists for various reasons, such as acute renal failure, chronic kidney disease, hematuria, proteinuria,kidney stones, hypertension, and disorders of acid/base or electrolytes.

Singapore Nephrology Doctors and Clinics

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