Anatomy of the SI Duodenum Examine the first part of the duodenum that extends from the pyloric region

of the stomach. This part is suspended from the liver by the hepatoduodenal ligament and is intraperitoneal. The remainder of the duodenum is retroperitoneal. Peritoneal Relations It is retroperitoneal and fixed. Its anterior surface is covered with peritoneum, except in the median plane where it is crossed by superior mesenteric vessels and by the root of the mesentery.

Name and identify the four parts of the duodenum and state the artery that supplies each part. 1._Superior part, extends from the pyloric orifice of the stomach to the neck of the gallbladder, is just right of the body of vertebra L1 and passes anteriorly to the bile duct, gastroduodenal artery, portal vein and inferior vena cava -- supplied by branches derived from the celiac trunk (hepatic, right gastric supraduodenal, right gastoepiploic and superior panreatico-duodenal arteries) 2. Descending part, to the right of midline, its anterior surface is crossed by the transverse colon,

posterior to it is the right kidney and medial to it is the head of the pancreas contains major duodenal papilla which is the common entrance for bile and pancreatic ducts and minor duodenal papilla which is the entrance for the accessory pancreatic duct -- The upper part (supplied by branches derived from the celiac trunk (hepatic, right gastric supraduodenal, right gastoepiploic and superior panreatico-duodenal arteries)) 3. Horizontal part; begins at duodenal flexure where it is crossed by the superior mesenteric vessels and by the root of the mesentery -- Inferior pancreaticoduodenal branch of the superior mesenteric artery 4. Ascending part; passes upward or to let of aorta to approximately the upper border of vertebra L11 and terminates at the duodenojejunal flexure -- Inferior pancreaticoduodenal branch of the superior mesenteric artery

On the internal aspect of the duodenum find the minor and major duodenal papillae. What opens into the duodenum at each of these sites? Minor duodenal papilla Accessory pancreatic duct Major duodenal papilla Bile and pancreatic duct

Note the arrangement and distribution of the plicae circulares. What is their function? Unlike the folds in the stomach, they are permanent, and are not obliterated when the intestine is distended. The space between circular folds are smaller than the haustra of the colon, and, in contrast to haustra, circular folds reach around the whole circumference of the intestine. These differences can assist in distinguishing the small intestine from the colon on an abdominal x-ray.

Distribution They are not found at the commencement of the duodenum, but begin to appear about 2.5 or 5 cm. beyond the pylorus. In the lower part of the descending portion, below the point where the bile and pancreatic ducts enter the small intestine, they are very large and closely approximated. In the horizontal and ascending portions of the duodenum and upper half of the jejunum they are large and numerous, but from this point, down to the middle of the ileum, they diminish considerably in size. In the lower part of the ileum they almost entirely disappear; hence the comparative thinness of this portion of the intestine, as compared with the duodenum and jejunum. Function The circular folds slow the passage of the food along the intestines, and afford an increased surface for absorption. They are covered with small fingerlike projections called villi (singular, villus). Each villus, in turn, is covered with microvilli. The microvilli absorb fats and nutrients from the chyme.

Pancreas Is the pancreas an intraperitoneal or retroperitoneal organ? Retroperitoneal Examine the specimen to determine the relations of the pancreas. Anterior Stomach and duodenum Posterior Ucinate process, left kidney, Aorta and Vena Cava Identify the head, neck, body and tail of the pancreas. Note that the head of the pancreas lies in the curve of the duodenum and its tail extends towards the spleen.

Find the main and accessory pancreatic ducts. What part of the pancreas is drained by the duct system? The simple cuboidal epithelial cells lining the pancreatic ducts secrete bicarbonate (alkaline fluid) to help neutralize the acidic chyme arriving in the duodenum from the stomach. Most of the pancreatic juice travels through ducts that merge to form the main pancreatic duct, which drains into the major duodenal papilla in the duodenum. A smaller accessory pancreatic duct drains a small amount of pancreatic juice into a minor duodenal papilla in the duodenum .

Where are the endocrine cells of the pancreas located? Scattered amongst the pancreatic acini are small clusters of cells called pancreatic islets (islets of Langerhans). They number in millions but forms only 1% of the pancreatic volume. 1. Alpha or A cells constitute about 17% of pancreatic islet cells and secrete glucagon 2. Beta or B cells constitute about 70% of pancreatic islet cells and secrete insulin 3. Delta or D cells constitute about 7% of pancreatic islet cells and secrete somatostatin (identical to the growth hormone inhibiting hormone secreted by the hypothalamus). 4. F cells constitute the remainder of pancreatic islet cells and secrete pancreatic polypeptide.

Which vessels provide the blood supply to the pancreas?

The arterial supply to the pancreas (Fig. 4.101) includes the: gastroduodenal artery from the common hepatic artery (a branch of the celiac trunk); anterior superior pancreaticoduodenal artery from the gastroduodenal artery; posterior superior pancreaticoduodenal artery from the gastroduodenal artery; dorsal pancreatic artery from the inferior pancreatic artery (a branch of the splenic artery); great pancreatic artery from the inferior pancreatic artery (a branch of the splenic artery); dorsal pancreatic and greater pancreatic arteries (branches of the splenic artery); anterior inferior pancreaticoduodenal artery from the inferior pancreaticoduodenal artery (a branch of the superior mesenteric artery); and posterior inferior pancreaticoduodenal artery from the inferior pancreaticoduodenal artery (a branch of the superior mesenteric artery).

How is the structure of the pancreas, modified for function? Pancreas is a flattened organ, Acinar cells, secrete mucin and digestive enzymes of the pancreatic juice. The simple cuboidal epithelial cells lining the ducts secrete bicarbonate to help neutralize the acidic chyme arriving in the duodenum from the stomach. Most pancreatic juice arrives from main pancreatic duct. Both hormonal and neural mechanisms control pancreatic juice secretions; enteroendocrine cells in intestinal glands release cholecystokinin to promote the secretion of pancreatic juices from acinar cells and secretin to stimulate the release of alkaline fluid from pancreatic duct cells Pancreatic juices secretion is also stimulated by parasympathetic (vagus) activity, while sympathetic activity inhibits pancreatic juice secretion The protein-digesting enzymes of the pancreas are produced in an inactive form just as pepsin is produced in the stomach as pepsinogen. Because they are inactive, the enzymes do not digest cells of the pancreas itself. Trypsin is secreted in an inactive form called trypsinogen. Pancreatic acinar cells also secrete a protein called trypsin inhibitor that combines with any trypsin formed accidentally in the pancreas or in pancreatic juice and blocks its enzymatic activity. When trypsinogen reaches the lumen of the small intestine, it encounters an activating brush-border enzyme called enterokinase, which splits off part of the trypsinogen molecule to form trypsin. In turn, trypsin acts on the inactive precursors (called chymotrypsinogen, procarboxypeptidase, and proelastase) to produce chymotrypsin, carboxypeptidase, and elastase, respectively.

Exocrine Secretions of the Pancreas Pancreatic juice is composed of two secretory products critical to proper digestion: digestive enzymes and bicarbonate. The enzymes are synthesized and secreted from the exocrine acinar cells, whereas bicarbonate is secreted from the epithelial cells lining small pancreatic ducts. Digestive Enzymes The pancreas secretes a magnificent battery of enzymes that collectively have the capacity to reduce virtually all digestible macromolecules into forms that are capable of, or nearly capable of being absorbed. Three major groups of enzymes are critical to efficient digestion: 1. Proteases Digestion of proteins is initiated by pepsin in the stomach, but the bulk of protein digestion is due to the pancreatic proteases. Several proteases are synthesized in the pancreas and secreted into the lumen of the small intestine. The two major pancreatic proteases are trypsin andchymotrypsin, which are synthesized and packaged into secretory vesicles as an the inactive proenzymes trypsinogen and chymotrypsinogen. As you might anticipate, proteases are rather dangerous enzymes to have in cells, and packaging of an inactive precursor is a way for the cells to safely handle these enzymes. The secretory vesicles also contain a trypsin inhibitor which serves as an additional safeguard should some of the trypsinogen be activated to trypsin; following exocytosis this inhibitor is diluted out and becomes ineffective - the pin is out of the grenade. Once trypsinogen and chymotrypsinogen are released into the lumen of the small intestine, they must be converted into their active forms in order to digest proteins. Trypsinogen is activated by the enzyme enterokinase, which is embedded in the intestinal mucosa. Once trypsin is formed it activates chymotrypsinogen, as well as additional molecules of trypsinogen. The net result is a rather explosive appearance of active protease once the pancreatic secretions reach the small intestine.

Trypsin and chymotrypsin digest proteins into peptides and peptides into smaller peptides, but

they cannot digest proteins and peptides to single amino acids. Some of the other proteases from the pancreas, for instance carboxypeptidase, have that ability, but the final digestion of peptides into amino acids is largely the effect of peptidases on the surface of small intestinal epithelial cells. More on this later. 2. Pancreatic Lipase A major component of dietary fat is triglyceride, or neutral lipid. A triglyceride molecule cannot be directly absorbed across the intestinal mucosa. Rather, it must first be digested into a 2monoglyceride and two free fatty acids. The enzyme that performs this hydrolysis is pancreatic lipase, which is delivered into the lumen of the gut as a constituent of pancreatic juice. Sufficient quantities of bile salts must also be present in the lumen of the intestine in order for lipase to efficiently digest dietary triglyceride and for the resulting fatty acids and monoglyceride to be absorbed. This means that normal digestion and absorption of dietary fat is critically dependent on secretions from both the pancreas and liver.

Pancreatic lipase has recently been in the limelight as a target for management of obesity. The drug orlistat (Xenical) is a pancreatic lipase inhibitor that interferes with digestion of triglyceride and thereby reduces absorption of dietary fat. Clinical trials support the contention that inhibiting lipase can lead to significant reductions in body weight in some patients. 3. Amylase The major dietary carbohydrate for many species is starch, a storage form of glucose in plants. Amylase (technically alpha-amylase) is the enzyme that hydrolyses starch to maltose (a glucoseglucose disaccharide), as well as the trisaccharide maltotriose and small branchpoints fragments called limit dextrins. The major source of amylase in all species is pancreatic secretions, although amylase is also present in saliva of some animals, including humans. Other Pancreatic Enzymes In addition to the proteases, lipase and amylase, the pancreas produces a host of other digestive enzymes, including ribonuclease, deoxyribonuclease, gelatinase and elastase. Bicarbonate and Water Epithelial cells in pancreatic ducts are the source of the bicarbonate and water secreted by the pancreas. Bicarbonate is a base and critical to neutralizing the acid coming into the small intestine from the stomach. The mechanism underlying bicarbonate secretion is essentially the same as for acid secretion and is dependent on the enzymecarbonic anhydrase. In pancreatic duct cells, the bicarbonate is secreted into the lumen of the duct and into pancreatic juice.

Endocrine vs. Exocrine The nervous and endocrine systems act together to coordinate functions of all body systems. Recall that the nervous system acts through nerve impulses (action potentials) conducted along axons of neurons. At synapses, nerve impulses trigger the release of mediator (messenger) molecules called neurotransmitters. The endocrine system also controls body activities by releasing mediators, called hormones, but the means of control of the two systems are very different. A hormone is a mediator molecule that is released in one part of the body but regulates the activity of cells in other parts of the body. Most hormones enter interstitial fluid and then the bloodstream. The circulating blood delivers hormones to cells throughout the body. Both neurotransmitters and hormones exert their effects by binding to receptors on or in their target cells. Several mediators act as both neurotransmitters and hormones. One familiar example is norepinephrine, which is released as a neurotransmitter by sympathetic postganglionic neurons and as a hormone by chromaffin cells of the adrenal medullae. Responses of the endocrine system often are slower than responses of the nervous system; although some hormones act within seconds; most take several minutes or more to cause a response. The effects of nervous system activation are generally briefer than those of the endocrine system. The nervous system acts on specific muscles and glands. The influence of the endocrine system is much broader; it helps regulate virtually all types of body cells. We will also have several opportunities to see how the nervous and endocrine systems function together as an interlocking super-system. For example, certain parts of the nervous system stimulate or inhibit the release of hormones by the endocrine system. Recall from Chapter 4 that the body contains two kinds of glands: exocrine glands and endocrine glands. Exocrine glands secrete their products into ducts that carry the secretions into body cavities, into the lumen of an organ, or to the outer surface of the body. Exocrine glands include sudoriferous (sweat), sebaceous (oil), mucous, and digestive glands. Endocrine glands secrete their products (hormones) into the interstitial fluid surrounding the secretory cells rather than into ducts. From the interstitial fluid, hormones diffuse into blood capillaries and blood carries them to target cells throughout the body. Because most hormones are required in very small amounts, circulating levels typically are low. The endocrine glands include the pituitary, thyroid, parathyroid, adrenal, and pineal glands. In addition, several organs and tissues are not exclusively classified as endocrine glands but contain cells that secrete hormones. These include the hypothalamus, thymus, pancreas, ovaries, testes, kidneys, stomach, liver, small intestine, skin, heart, adipose tissue, and placenta. Taken together, all endocrine glands and hormone-secreting cells constitute the endocrine system.

Exocrine glands secrete their products into ducts that empty onto the surface of a covering and lining epithelium such as the skin surface or the lumen of a hollow organ. The secretions of exocrine glands include mucus, sweat, oil, earwax, saliva, and digestive enzymes. Examples of exocrine glands include sudoriferous (sweat) glands, which produce sweat to help lower body temperature, and salivary glands, which secrete saliva. Saliva contains mucus and digestive enzymes among other substances. As you will learn later in the text, some glands of the body, such as the pancreas, ovaries, and testes, are mixed glands that contain both endocrine and exocrine tissue. Structural Classification of Exocrine Glands Exocrine glands are classified as unicellular or multicellular. As the name implies, unicellular glands are single-celled. Goblet cells are important unicellular exocrine glands that secrete mucus directly onto the apical surface of a lining epithelium. Most glands are multicellular glands, composed of many cells that form a distinctive microscopic structure or macroscopic organ. Examples include

sudoriferous, sebaceous (oil), and salivary glands. Multicellular glands are categorized according to two criteria: (1) whether their ducts are branched or unbranched and (2) the shape of the secretory portions of the gland If the duct of the gland does not branch, it is a simple gland. If the duct branches, it is a compound gland. Glands with tubular secretory parts are tubular glands; those with rounded secretory portions are acinar glands, also called alveolar glands. Tubuloacinar glands have both tubular and rounded secretory parts. Combinations of these features are the criteria for the following structural classification scheme for multicellular exocrine glands:

The neutrophil has a multilobed nucleus and a granulated cytoplasm that stains with both acid and basic dyes; it is often called a polymorphonuclear leukocyte (PMN) for its multilobed nucleus. NEUTROPHILS Neutrophils are produced by hematopoiesis in the bone marrow. They are released into the peripheral blood and circulate for 710 h before migrating into the tissues, where they have a life span of only a few days. In response to many types of infections, the bone marrow releases more than the usual number of neutrophils and these cells generally are the first to arrive at a site of inflammation. The resulting transient increase in the number of circulating neutrophils, called leukocytosis, is used medically as an indication of infection. Movement of circulating neutrophils into tissues, called extravasation, takes several steps: the cell first adheres to the vascular endothelium, then penetrates the gap between adjacent endothelial cells lining the vessel wall, and finally penetrates the vascular basement membrane, moving out into the tissue spaces. A number of substances generated in an inflammatory reaction serve as chemotactic factors that promote accumulation of neutrophils at an inflammatory site.Among these chemotactic factors are some of the complementcomponents, components of the blood-clotting system, and several cytokines secreted by activated TH cells and macrophages. Like macrophages, neutrophils are active phagocytic cells. Phagocytosis by neutrophils is similar to that described for macrophages, except that the lytic enzymes and bactericidal substances in neutrophils are contained within primary and secondary granules (see Figure 2-10a). The larger, denser primary granules are a type of lysosome containing peroxidase, lysozyme, and various hydrolytic enzymes. The smaller secondary granules contain collagenase, lactoferrin, and lysozyme. Both primary and secondary granules fuse with phagosomes, whose contents are then digested and eliminated much as they are in macrophages. Neutrophils also employ both oxygen-dependent and oxygen-independent pathways to generate antimicrobial substances. Neutrophils are in fact much more likely than macrophages to kill ingested microorganisms. Neutrophils exhibit a larger respiratory burst than macrophages and consequently are able to generate more reactive oxygen intermediates and reactive nitrogen intermediates (see Table 2-6). In addition, neutrophils express higher levels of defensins than macrophages do.

Gallstone formation is caused by malabsorption of bile acids, resulting in depletion of the bile salt pool and the secretion of lithogenic bile. Gallstone Pancreatitis Gallstones may cause acute pancreatitis as they pass through the ampulla of Vater. The occurrence of gallstone pancreatitis usually implies passage of a stone into the duodenum, and only about 20% of patients harbor a persistent stone in the ampulla or the common bile duct. Retained stones are more common in patients with jaundice, rising serum liver tests following hospitalization, severe pancreatitis, or superimposed ascending cholangitis. Urgent ERCP decreases the morbidity of gallstone pancreatitis in some subsets of patients. It remains unclear whether the benefit of ERCP is mainly attributable to treatment and prevention of ascending cholangitis or to relief of pancreatic duct obstruction. ERCP is warranted early in the course of gallstone pancreatitis if ascending cholangitis is also suspected, especially in a jaundiced patient. Urgent ERCP also appears to benefit patients predicted to have severe pancreatitis using a clinical index of severity such as the Glasgow or Ranson score. Maldigestion and Malabsorption Weight loss can be observed in up to 60% of patients after partial gastric resection. A significant component of this weight reduction is due to decreased oral intake. However, mild steatorrhea can also develop. Reasons for maldigestion/ malabsorption include decreased gastric acid production, rapid gastric emptying, decreased food dispersion in the stomach, reduced luminal bile concentration, reduced pancreatic secretory response to feeding, and rapid intestinal transit. Decreased serum vitamin B12 levels can be observed after partial gastrectomy. This is usually not due to deficiency of IF, since a minimal amount of parietal cells (source of IF) are removed during antrectomy. Reduced vitamin B12 may be due to competition for the vitamin by bacterial overgrowth or inability to split the vitamin from its protein-bound source due to hypochlorhydria. Iron-deficiency anemia may be a consequence of impaired absorption of dietary iron in patients with a Billroth II gastrojejunostomy. Absorption of iron salts is normal in these individuals; thus, a favorable response to oral iron supplementation can be anticipated. Folate deficiency with concomitant anemia can also develop in these patients. This deficiency may be secondary to decreased absorption or diminished oral intake. Malabsorption of vitamin D and calcium resulting in osteoporosis and osteomalacia is common after partial gastrectomy and gastrojejunostomy (Billroth II). Osteomalacia can occur as a late complication in up to 25% of post-partial gastrectomy patients. Bone fractures occur twice as commonly in men after gastric surgery as in a control population. It may take years before x-ray findings demonstrate diminished bone density. Elevated alkaline phosphatase, reduced serum calcium, bone pain, and pathologic fractures may be seen in patients with osteomalacia. The high incidence of these abnormalities in this subgroup of patients justifies treating them with vitamin D and calcium supplementation indefinitely. Therapy is especially important in females. Clinical Features of Chronic Pancreatitis Patients with chronic pancreatitis seek medical attention predominantly because of two symptoms: abdominal pain or maldigestion.The abdominal pain may be quite variable in location, severity, and frequency.The pain can be constant or intermittent with frequent pain-free intervals. Eating may exacerbate the pain, leading to a fear of eating with consequent weight loss. The spectrum of abdominal pain ranges from mild to quite severe with narcotic dependence as a frequent

consequence. Maldigestion is manifested as chronic diarrhea, steatorrhea, weight loss, and fatigue. Patients with abdominal pain may or may not progress to maldigestion, and ~20% of patients will present with symptoms of maldigestion without a history of abdominal pain. Patients with chronic pancreatitis have significant morbidity and mortality and utilize appreciable amounts of societal resources. Despite the steatorrhea, clinically apparent deficiencies of fat-soluble vitamins are surprisingly uncommon. Physical findings in these patients are usually unimpressive so that there is a disparity between the severity of abdominal pain and the physical signs, which usually consist of some mild tenderness and mild temperature elevation.

MOUTH ULCERS- A Patient's Guide Dr Martin Tooke -Family Doctor What is a mouth ulcer? A mouth ulcer is a breach or break in the mucous membrane which lines the inside of the mouth. It usually looks like a depression in the mucous membrane and usually has a yellow or white colour. The size may vary from a millimetre or less in diameter to several centimetres. It is often painful. What are the most common types of mouth ulcers? There are many different types of mouth ulcers. The two most common types are 1) ulcers caused by minor injuries and 2) aphthous ulcers. 1)Ulcers caused by minor injuries: If a person has a sharp edge on a tooth (for example, because the tooth is chipped), or poorly fitting dentures, the mucosal lining of the mouth may be injured and this may result in an ulcer. These ulcers usually heal rapidly if the source of the injury is removed (for example, if poorly fitting dentures are removed or replaced). 2)Aphthous ulcers: Most people probably get aphthous mouth ulcers at some time in their life. Usually the first attack occurs in adolescence or young adulthood. These ulcers are usually small (less than 5 mm in diameter) and painful. There may be just one or two at a time, or there may be very numerous ulcers in the mouth. People with this condition usually feel fairly well apart from the pain in their mouth. The ulcers usually heal in 1 to 2 weeks but they tend to recur at intervals over the course of many years. In some cases recurrences can be so frequent that mouth ulcers may be constantly present for prolonged periods. Occasionally, aphthous ulcers can be much larger (more than a centimetre in diameter), and then

they can take months to heal. These large ulcers are called 'major aphthous ulcers'. People may feel pain or tingling in the mouth for a day or two before aphthous ulcers break out. It's best to start treatment at this time if possible. The exact cause of aphthous ulcers is unknown but it is thought that they may result from the body's own immune system attacking the mucosal lining of the mouth. They may occur after minor injury to the inside of the mouth. Aphthous ulcers are more likely to occur at times of stress. They may occasionally occur after eating certain foods. They may be more common when certain hormones circulate; they tend to be more common round about the time of a menstrual period but less common during pregnancy. Sometimes aphthous ulcers can be caused by deficiency in vitamin B12, folic acid or iron. In rare instances, aphthous ulcers may be caused by coeliac disease (coeliac disease is a condition caused by an inability to tolerate gluten in the diet). A blood test can be used to test for coeliac disease.

Viral infections causing mouth ulcers: Several different types of viral infections can result in ulcers forming in the mouth and throat. The herpes simplex virus can cause an illness known as primary herpetic gingivostomatitis. This illness is most common in children. Numerous small painful ulcers occur on the lips, in the mouth and in the throat. There is usually a fever and the glands in the neck are enlarged. The child is usually miserable and may have difficulty eating and drinking because of the pain. Another viral infection called hand, foot and mouth disease is most common in preschool children. Small ulcers occur in the mouth and little blisters also occur on the hands and feet of the child. Healthy people with normal immunity recover rapidly from most viral infections in the mouth and throat; people suffering from the viral illnesses described above usually recover completely after a week or two. Mouth cancer: Most mouth ulcers are caused by relatively harmless conditions. However, an ulcer in the mouth may sometimes be the first sign of a mouth cancer. Any sore or ulcer in the mouth which is unexplained and not healing should be checked carefully by a general practitioner or specialist in case it might be a cancer. This is particularly important for older people and smokers, because mouth cancer is more common in these groups. What are the other causes of mouth ulcers? There are a great many other conditions which can cause mouth ulcers. These can include infections; abnormalities of the blood; adverse reactions to medications; and skin conditions in which rashes or ulcers may occur on other parts of the body too, not only in the mouth. People who suffer from

intestinal conditions such as ulcerative colitis or Crohn's disease may also get mouth ulcers. Ulcers can sometimes occur after radiotherapy to the head and neck region. How are mouth ulcers treated? Treatment of mouth ulcers may include soothing mouthwashes (such as salt and warm water or compound thymol glycerin mouthwash) or antiseptic mouthwashes such as chlorhexidine mouthwash or povidone iodine mouthwash. Pain can be relieved by using local anaesthetics such as benzydamine hydrochloride, choline salicylate gel or lignocaine. Local anaesthetics like this cause temporary numbness at the site where they are applied. These local anaesthetics may be used in the form of a mouthwash, a spray, a jelly or an ointment. (Local anaesthetics need to be used with care: if the back of the tongue or the throat is made numb this can result in choking when swallowing food or drink. Local anaesthetics are also not suitable for young children with mouth ulcers). Carmellose gelatin paste may be applied to mouth ulcers; it forms a protective layer over the ulcer. Paracetamol is useful to relieve pain, especially for young children with viral infections causing mouth ulcers. Such young children need to be encouraged to drink to avoid dehydration. Carbenoxolone gel or mouthwash can be used. Many of the remedies above may be bought from a pharmacy without a prescription. Treatment of aphthous ulcers may, on medical advice, include corticosteroids applied as a paste or used as a mouthwash. Occasionally it may be necessary to take corticosteroid tablets (so that they are absorbed into the bloodstream) to treat some severe types of mouth ulcer. For large aphthous ulcers, corticosteroids may sometimes be injected beneath the ulcer. Before using corticosteroids of any type it is important to be sure that the ulcers are not caused by a viral infection. Aciclovir, a type of antiviral medication may sometimes be helpful for mouth ulcers caused by the herpes simplex virus. Aciclovir cream may be used for treatment of cold sores. It should be applied as early as possible, preferably when the tingling sensation is present but the cold sore has not yet appeared. A mouthwash containing tetracycline (a type of antibiotic) is sometimes used for treatment of mouth ulcers. A medication called cimetidine, originally used to treat stomach ulcers, has also been used in the treatment of aphthous mouth ulcers. Summary Most mouth ulcers are not due to serious illness. Occasionally they can be associated with poor immunity or other medical conditions. Ulcers that so not heal should always be checked by a doctor.

Acute cholecystitis Email this page to a friendShare on facebookShare on twitterBookmark & SharePrinter-friendly version Acute cholecystitis is a sudden inflammation of the gallbladder that causes severe abdominal pain. See also: Chronic cholecystitis Causes In 90% of cases, acute cholecystitis is caused by gallstones in the gallbladder. Other causes include severe illness and (rarely) tumors of the gallbladder. Acute cholecystitis occurs when bile becomes trapped in the gallbladder. The buildup of bile causes irritation and pressure in the gallbladder. This can lead to infection and a hole (perforation) in the organ. Gallstones occur more often in women than men. Gallstones become more common with age in both sexes. Native Americans and Hispanics have a higher rate of gallstones than most other people. Symptoms The main symptom is pain in the upper right side or upper middle of the abdomen. The pain may:

Be sharp, cramping, or dull Be steady Spread to the back or below the right shoulder blade

Other symptoms that may occur include:

Clay-colored stools Fever Nausea and vomiting Yellowing of skin and whites of the eyes (jaundice)

Exams and Tests A physical exam will show that your abdomen is tender to the touch. Your doctor may order the following blood tests:

Amylase and lipase Bilirubin Complete blood count (CBC) -- may show a higher than normal white blood cell count Liver function tests

Imaging tests that can show gallstones or inflammation include:

Abdominal ultrasound

Abdominal CT scan Abdominal x-ray Oral cholecystogram Gallbladder radionuclide scan

Treatment Seek immediate medical attention for severe abdominal pain. In the emergency room, patients with acute cholecystitis are given fluids through a vein and antibiotics to fight infection. Although cholecystitis may clear up on its own, surgery to remove the gallbladder (cholecystectomy) is usually needed when gallstones are present. Surgery may be done as soon as possible; however, some patients will not need surgery right away. Nonsurgical treatment includes:

Antibiotics to fight infection Low-fat diet (when food can be tolerated)

Pain medicines

You may need emergency surgery if you have gangrene (tissue death), perforation, pancreatitis, or inflammation of the common bile duct. In very ill patients, a tube may be placed through the skin to drain the gallbladder until the patient gets better and can have surgery. See also: Gallstones - discharge Outlook (Prognosis) Patients who have surgery to remove the gallbladder usually do very well. Possible Complications

Empyema (pus in the gallbladder) Gangrene (tissue death) of the gallbladder Injury to the bile ducts draining the liver (an occasional complication of cholecystectomy) Pancreatitis Peritonitis (inflammation of the lining of the abdomen)

When to Contact a Medical Professional Call your health care provider if:

Severe abdominal pain does not go away Symptoms of cholecystitis return

Prevention Removing the gallbladder and gallstones will prevent further attacks.

Conservative treatment treatment designed to avoid radical medical therapeutic measures or operative procedures.

Dental Technician Although their role is rarely recognised by patients, dental technicians are an essential part of the dental team. There are just over 7,000 dental technicians registered in the UK today (September 2008). Dental technicians are responsible for making a wide range of dental appliances including crowns, bridges, orthodontic appliances and dentures, working to the prescription of the dentist for each patient. Without the help of a dental technician, dentists would be unable to offer the full range of services to their patients. A high degree of technical skill and a high level of manual dexterity are

essential - along with some artistic flair. There are four specialist areas:

Prosthodontic technicians design and make dentures, which can either be made of acrylic or chrome cobalt Conservation technicians specialise in crown and bridge work. A wide range of materials can be used, including metal alloys and gold or porcelain Orthodontic technicians make braces to correct tooth positions Maxillo-facial technicians (sometimes also known as maxillofacial prosthetists) work in hospital oral surgery, ophthalmic, cancer and burns units, helping to reconstruct the faces of patients damaged by accident or disease.

A dental technician can either choose to work as a generalist producing a wide variety of technical items or specialise in one of the above areas. Workplace The majority of dental technicians are employed in commercial dental laboratories but they can also work within general dental practices, hospitals, the SPCDS and the armed forces. Commercial dental laboratories range from single-handed businesses to large multi-site laboratories offering a comprehensive service. Technicians usually carry out work for local dentists although some laboratories offer a postal service, dealing with dentists from a wide area. A technician working in a dental hospital may be attached to the maxillofacial department and be involved with making larger prostheses including eyes, nose and ears. It is also possible for technicians to be involved in research or teach undergraduate dental students some of the technical aspects of dentistry. Career development Additional qualifications allow a technician to become an instructor technician. Or there is the option of becoming a laboratory owner or a senior technician with responsibility for quality control or management within a larger laboratory. Another possibility is within sales for a laboratory or trade company.