One stop doc gastrolentrology and renal medicine

ONE STOP DOC Gastroenterology and Renal Medicine One Stop Doc Titles in the series include: Cardiovascular System – Jonathan Aron Editorial Advisor – Jeremy Ward Cell and Molecular Biology – Desikan Rangarajan and David Shaw Editorial Advisor – Barbara Moreland Endocrine and Reproductive Systems – Caroline Jewels and Alexandra Tillett Editorial Advisor – Stuart Milligan Gastrointestinal System – Miruna Canagaratnam Editorial Advisor – Richard Naftalin Musculoskeletal System – Bassel Zebian and Wayne Lam Editorial Advisor – Alistair Hunter Nervous System – Elliott Smock Editorial Advisor – Clive Coen Nutrition and Metabolism – Miruna Canagaratnam and David Shaw Editorial Advisors – Barbara Moreland and Richard Naftalin Respiratory System – Jo Dartnell and Michelle Ramsay Editorial Advisor – John Rees Renal and Urinary System and Electrolyte Balance – Panos Stamoulos and Spyridon Bakalis Editorial Advisors – Alistair Hunter and Richard Naftalin Statistics and Epidemiology – Emily Ferenczi and Nina Muirhead Editorial Advisor – Lucy Carpenter Immunology – Stephen Boag and Amy Sadler Editorial Advisor – John Stewart Cardiology – Rishi Aggarwal, Emily Ferenczi and Nina Muirhead Editorial Advisor – Darrel Francis Volume Editor – Basant Puri ONE STOP DOC Gastroenterology and Renal Medicine Reena Popat MB BS BSc(Hons) Senior House Officer in Medicine, Hammersmith Hospital, London, UK Danielle Adebayo MB BS BSc(Hons) Senior House Officer in Medicine, Hammersmith Hospital, London, UK Contributing Author: Thomas Chapman MB BS BSc(Hons) Foundation Year 1, Guy’s and St Thomas’ NHS Trust, London, UK Editorial Advisor: Stephen Pereira BSc(Hons) PhD FRCP Senior Lecturer in Hepatology & Gastroenterology, The UCL Institute of Hepatology, London, UK Volume Editor: Basant Puri MA PhD MB BChir BSc(Hons) MathSci MRCPsych DipStat MMath Professor and Consultant in Imaging and Psychiatry and Head of the Lipid Neuroscience Group, Hammersmith Hospital, London, UK Series Editor: Elliott Smock MB BS BSc(Hons) Senior House Officer (FY2), University Hospital Lewisham, Lewisham, UK A MEMBER OF THE HODDER HEADLINE GROUP First published in Great Britain in 2007 by Hodder Arnold, an imprint of Hodder Education and a member of the Hodder Headline Group, an Hachette Livre UK Company, 338 Euston Road, London NW1 3BH http://www.hoddereducation.com © 2007 Edward Arnold (Publishers) Ltd All rights reserved Apart from any use permitted under UK copyright law, this publication may only be reproduced, stored or transmitted, in any form, or by any means with prior permission in writing of the publishers or in the case of reprographic production in accordance with the terms of licences issued by the Copyright Licensing Agency In the United Kingdom such licences are issued by the Copyright Licensing Agency: Saffron House, 6–10 Kirby Street, London EC1N 8TS Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made In particular, (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed Furthermore, dosage schedules are constantly being revised and new side-effects recognized For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book Hodder Headline’s policy is to use papers that are natural, renewable and recyclable products and made from wood grown in sustainable forests The logging and manufacturing processes are expected to conform to the environmental regulations of the country of origin British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN 978 0340 92556 10 Commissioning Editor: Sara Purdy Project Editor: Jane Tod Production Controller: Lindsay Smith Cover Design: Amina Dudhia Indexer: Indexing Specialists (UK) Ltd Typeset in 10/12pt Adobe Garamond/Akzidenz GroteskBE by Servis Filmsetting Ltd, Manchester Printed and bound in Spain What you think about this book? Or any other Hodder Arnold title? Please visit our website at www.hoddereducation.com CONTENTS PREFACE vi ABBREVIATIONS vii SECTION RENAL MEDICINE SECTION HEPATOBILIARY MEDICINE 43 SECTION UPPER GASTROINTESTINAL MEDICINE 81 SECTION LOWER GASTROINTESTINAL MEDICINE 117 APPENDIX 151 INDEX 153 PREFACE From the Series Editor, Elliott Smock Are you ready to face your looming exams? If you have done loads of work, then congratulations; we hope this opportunity to practise SAQs, EMQs, MCQs and Problem-based Questions on every part of the core curriculum will help you consolidate what you’ve learnt and improve your exam technique If you don’t feel ready, don’t panic – the One Stop Doc series has all the answers you need to catch up and pass There are only a limited number of questions an examiner can throw at a beleaguered student and this text can turn that to your advantage By getting straight into the heart of the core questions that come up year after year and by giving you the model answers you need this book will arm you with the knowledge to succeed in your exams Broken down into logical sections, you can learn all the important facts you need to pass without having to wade through tons of different textbooks when you simply don’t have the time All questions presented here are ‘core’; those of the highest importance have been highlighted to allow even shaper focus if time for revision is running out In addition, to allow you to organize your revision efficiently, questions have been grouped by topic, with answers supported by detailed integrated explanations On behalf of all the One Stop Doc authors I wish you the very best of luck in your exams and hope these books serve you well! From the Authors, Reena Popat and Danielle Adebayo This book is intended primarily for clinical medical students preparing for exams in renal medicine and gastroenterology, but will also be useful for junior doctors who are revising It is not meant to be a textbook of medicine, but highlights key areas often focused on during the exams and in day-to-day clinical practice We have tried to distil the core topics in this specialty The questions at the beginning of each topic should help hone in the essential points We hope that this book also helps you work through clinical scenarios in a systematic manner, and to develop differential diagnoses and a competent management plan both as clinical students and junior doctors ABBREVIATIONS AAT ACE ACTH ADH AFB AFP Ag AJCC TNM ALF ALP ALT AMA ANA ANCA APACHE ARDS ARF ASO AST ATN ATP BDG BE BM BMG BP CEA CLF CMV CNS CO COPD CRF CRP Cr CRF CT CVA ␣1-antitrypsin angiotensin-converting enzyme adrenocorticotrophic hormone antidiuretic hormone acid-fast bacilli ␣-fetoprotein antigen American Joint Committee on Cancer, Tumor, Node and Metastases acute liver failure alkaline phosphatase alanine transaminase antimitochondrial antibody antinuclear antibody antineutrophil cytoplasmic antibody Acute Physiology And Chronic Health Evaluation acute respiratory distress syndrome acute renal failure antistreptolysin O aspartate transaminase acute tubular necrosis adenosine triphosphate bilirubin diglucuronide base excess blood sugar bilirubin monoglucuronide blood pressure carcinoembryonic antigen chronic liver failure cytomegalovirus central nervous system cardiac output chronic obstructive pulmonary disease chronic renal failure C-reactive protein creatinine chronic renal failure computed tomography cerebrovascular accident CVP DIC DMSA DNA dsDNA EBV ECF ECG ESR ESRF ERCP FAP FBC FIO2 FSGS GBM GCS GI GFR GGT GORD GP Hb HB HCC HDU 5-HIAA HIV HLA HMG CoA HNPCC HR HSP 5-HT HUS IBD IBS Ig central venous pressure disseminated intravascular coagulation dimercaptosuccinic acid deoxyribonucleic acid double-stranded deoxyribonucleic acid Epstein–Barr virus extracellular fluid electrocardiogram erythrocyte sedimentation rate end-stage renal failure endoscopic retrograde cholangiopancreatography familial adenomatous polyposis full blood count fraction of inspired oxygen focal segmental glomerulosclerosis glomerular basement membrane Glasgow coma scale gastrointestinal glomerular filtration rate ␥-glutamyl transferase gastro-oesophageal reflux disease general practitioner haemoglobin hepatitis B hepatocellular carcinoma high-dependency unit 5-hydroxy indole-acetic acid human immunodeficiency virus human leucocyte antigen 5-hydroxy-3-methylglutarylcoenzyme A hereditary non-polyposis colon cancer heart rate Henoch–Schönlein purpura 5-hydroxytryptamine haemolytic uraemic syndrome inflammatory bowel disease irritable bowel syndrome immunoglobulin viii ITU IV JVP KUB LDH LMP LOS MALT MC&S MEN MIBG MRA MRCP MRI MSU NG NSAID OGD PaCO2 PaO2 PAS PBC PET PPI PSC PTC ABBREVIATIONS intensive therapy unit intravenous jugular venous pressure kidneys, ureters and bladder lactate dehydrogenase last menstrual period lower oesophageal sphincter mucosa-associated lymphoid tissue microscopy, culture and sensitivity multiple endocrine neoplasia 131iodine-meta-iodobenzylguanidine magnetic resonance angiogram magnetic resonance cholangiopancreatography magnetic resonance imaging midstream urine nasogastric tube non-steroidal anti-inflammatory drug oesophago-gastroduodenoscopy partial pressure of arterial carbon dioxide partial pressure of arterial oxygen periodic acid–Schiff primary biliary cirrhosis positron emission tomography proton pump inhibitor primary sclerosing cholangitis percutaneous transhepatic cholangiography PVR RBC RF RNA RUQ sBP SCC SIADH SLE TB TBW TCC TENS TIPS TNM TPN TURP UDP UGT UTI VIP WCC WHO peripheral vascular resistance red blood cell renal failure ribonucleic acid right upper quadrant systolic blood pressure squamous cell carcinoma syndrome of inappropriate ADH secretion systemic lupus erythematosus tuberculosis total body water transitional cell carcinoma transcutaneous electrical nerve stimulation transjugular intrahepatic portosystemic shunt tumour, node, metastasis total parenteral nutrition trans-urethral resection of the prostate uridine diphosphate UDP glucuronyl transferase urinary tract infection vasoactive intestinal peptide white cell count World Health Organization SECTION RENAL MEDICINE • FLUID AND ELECTROLYTE BALANCE • SODIUM BALANCE • POTASSIUM BALANCE • ACID–BASE BALANCE 10 • ACUTE RENAL FAILURE 14 • CHRONIC RENAL FAILURE 18 • GLOMERULONEPHRITIS 22 • HAEMATURIA 26 • RENOVASCULAR DISEASE AND HYPERTENSION 30 • PROTEINURIA AND NEPHROTIC SYNDROME 32 • RENAL ONCOLOGY (I) 34 • RENAL ONCOLOGY (II) 36 • URINARY TRACT INFECTION (I) 38, 41 • URINARY TRACT INFECTION (II) 40, 42 Lower gastrointestinal medicine 145 EXPLANATION: ACUTE ABDOMEN (II) Acute appendicitis is the most common surgical emergency in the developed world, and it is characterized by inflammation of the vermiform appendix The majority of patients are between the age of 10 and 30 years The average lifetime incidence is per cent Appendicitis occurs when the lumen of the appendix is obstructed by a faecolith, foreign body, lymphoid follicle, caecal tumour or a carcinoid tumour Patients present with abdominal pain that classically starts as a central colicky umbilical pain, and then migrates to localize in the right iliac fossa Patients are often anorexic with nausea and occasional vomiting Patients with a pelvic appendix often have diarrhoea and urinary frequency Signs are: • Mild pyrexia, tachycardia • Fetor oris, facial flushing, tongue furring • Patient lies still • Right hip may be flexed due to psoas muscle irritation • Abdominal examination reveals: • tenderness over the right iliac fossa (McBurney’s point (38) – two-thirds of the way along a line drawn from the umbilicus to the anterior superior iliac spine) Ϯ guarding • the presence of percussion tenderness • Rovsing’s sign may be positive: pressure over the left iliac fossa on palpation produces pain in the right iliac fossa • Digital rectal examination may be painful with a low-lying appendix The natural course of appendicitis can be resolution, formation of an appendix mass (omentum and small bowel adhere to the appendix), an appendix abscess (in association with a mass there is swinging pyrexia), or appendix perforation Acute appendicitis is managed with open or laparoscopic appendicectomy with perioperative antibiotics An appendix mass is often initially managed conservatively with IV fluids and antibiotics, with a close monitoring of the mass size If symptoms resolve, elective appendicectomy is performed in a few months, otherwise an urgent appendicectomy is performed If there are signs of an abscess (swinging fever, tachycardia, increasing mass size) then the abscess should be drained via an incision lateral to McBurney’s point Following resolution an appendicectomy should be performed Continued on page 147 Answers 37 T F F F F 38 See explanation ONE STOP DOC 146 39 Regarding small-bowel obstruction a b c d e Adhesions are the most common cause Constipation is an early feature Small-bowel volvulus can lead to strangulation Abdominal X-rays show distended loops of bowel in the periphery Surgical intervention is the first line of management 40 Regarding large-bowel obstruction a b c d e Diverticulitis is the commonest cause Vomiting is an early feature Caecal perforation is a risk in the presence of a competent ileocaecal valve Ogilvie’s syndrome is a complication of electrolyte imbalance A flatus tube can help manage a caecal volvulus IV, intravenous; TB, tuberculosis Lower gastrointestinal medicine 147 EXPLANATION: ACUTE ABDOMEN (II) Cont’d from page 145 The causes of bowel obstruction can be mechanical or functional The functional causes (ileus or Ogilvie’s syndrome) are either in the post-operative period, due to metabolic causes such as diabetes mellitus, electrolyte disturbance and as a consequence of drugs (opiates, antidepressants), intra-abdominal sepsis and trauma Mechanical causes of obstruction can be classified as: Small bowel Large bowel Luminal Food bolus Foreign body Gallstone ileus Faecal impaction Intramural Strictures: Crohn’s disease Neoplasm Ischaemic Intussusception Infective causes: TB Carcinoma (commonest cause) Strictures: diverticulitis, ischaemic Hirschsprung’s disease Extramural Adhesions (commonest cause) Herniae Volvulus Gross lymphadenopathy Volvulus Diverticular abscess Gross lymphadenopathy Small-bowel obstruction presents with generalized colicky abdominal pain centred over the upper abdomen Vomiting usually follows the pain Bilous vomiting indicates a higher level of obstruction, and faeculant vomiting suggests lower levels of obstruction Progressive abdominal distension occurs, but constipation is a late feature The presence of scars suggests adhesions A distended tympanic abdomen may be noted, and in thin individuals visible peristalsis is present High-pitched tinkling bowel sounds are audible Hernia orifices should be checked for overlying skin changes, tenderness and irreducible masses In large-bowel obstruction, the patient often presents with generalized constant abdominal pain centred over the lower abdomen Vomiting occurs late, while absolute constipation is an early feature Abdominal distension is also noted Tenderness over the right iliac fossa (caecum) suggests impending perforation Caecal perforation is possible in the presence of a competent ileocaecal valve Abdominal X-ray plays an important role in diagnosis Small-bowel obstruction presents with central gas shadows and valvulae conniventes (visible lines going all the way across the small bowel), while X-rays of largebowel obstruction show a peripheral pattern of gas shadows, absence of gas in the rectum and haustral patterns Gastrograffin swallow or enema can help demarcate the level of obstruction Patients should be resuscitated and be placed nil by mouth IV fluids are administered A nasogastric tube should be inserted on free-flow drainage Any electrolyte abnormalities should be corrected The underlying cause should be treated, for example insertion of a flatus tube or a flexible sigmoidoscope may be therapeutic for a sigmoid volvulus Surgical indications are strangulation, peritonitis, closed loop obstruction (i.e the bowel is obstructed at two points) and when conservative measures fail Answers 39 T F T F F 40 F F T T F ONE STOP DOC 148 41 Regarding abdominal hernias a b c d e Strangulated hernias are a surgical emergency A Richter’s hernia presents with signs of obstruction Malnutrition is a risk factor for acquired abdominal hernias Chronic prostatic symptoms predispose to abdominal hernias Incarcerated hernias are often reducible 42 Regarding inguinal hernias a b c d e Direct hernias are usually congenital Direct hernias are more common than indirect hernias Indirect inguinal hernias are more likely to strangulate than direct hernias At surgery, indirect inguinal hernias are medial to the inferior epigastric vessels Direct inguinal hernias often descend into the scrotum 43 Consider femoral hernias a b c d e They are more common in males They account for 30 per cent of all abdominal hernias They have a high risk of strangulation The neck of the hernia lies below and medial to the pubic tubercle They can be managed conservatively 44 Draw the anatomy of the inguinal canal COPD, chronic obstructive pulmonary disease Lower gastrointestinal medicine 149 EXPLANATION: ACUTE ABDOMEN (III) A hernia is the abnormal protrusion of an organ or part of an organ through a defect in the wall of its containing cavity Abdominal hernias occur at sites of abdominal wall weakness The weakness can be: • Congenital: for example a patent processus vaginalis leading to an indirect inguinal hernia, or failure of closure of the umbilical orifice leading to an umbilical hernia • Acquired: primary (develop at natural weak points) or secondary (develop at sites of injury) Factors that predispose to acquired hernias include: • Increased abdominal pressure: heavy lifting, chronic cough (for example in COPD), straining to pass urine or defaecate, and abdominal distension (for example ascites) • Weakened abdominal wall: increased age, surgical incision, collagen disorders, malnutrition and paralysis of motor nerves Hernias are often described as: • Reducible: the contents of the hernia can be returned to its original cavity by gentle manipulation • Irreducible/incarcerated: the contents of the hernia cannot be returned to its original cavity, for example the abdominal cavity due to adhesions • Strangulated: the blood supply to the hernia contents is compromised and hence the lump is red, hot to touch and tender The patient may have signs of shock • Richter’s hernia: a knuckle of the bowel wall is caught in a hernia sac compromising its blood supply, but the continuity of the bowel lumen is maintained The two commonest types of hernias are inguinal and femoral hernia The inguinal canal is a 4-cm-long oblique passage that permits the passage of the spermatic cord or round ligament and the ilioinguinal nerve The key anatomy is summarized below (walls in bold) (44): Anterior superior iliac spine Deep inguinal ring (midpoint of inguinal ligament) Above: lowest fibres of internal oblique and transverses abdominis Posterior: Fascia transversalis along entire length, reinforced in medial third by conjoint tendon Below: Inguinal ligament Anterior: skin, superficial fascia, external oblique aponeurosis along entire length Internal oblique covers the lateral third Superficial ring (above and medial to pubic tubercle) Pubic tubercle Continued on page 150 Answers 41 42 43 44 TFTTF FFTFF FFTFF See explanation 150 ONE STOP DOC EXPLANATION: ACUTE ABDOMEN (III) Cont’d from page 149 Seventy per cent of inguinal hernias are indirect, while 30 per cent are direct There are two peaks in the incidence, at infancy and between the ages of 55 and 85 years They are more common in males and are more common on the right-hand side The differences between indirect and direct hernias are summarized below: Indirect inguinal hernia Direct inguinal hernia The sac passes via the deep ring and is lateral to the inferior epigastric vessels May be congenital Occurs at any age but especially in the young Control by pressure over internal ring Oblique protrusion on coughing Does not reach full size immediately on standing Descent into the scrotum is common Strangulation is common The sac passes via the posterior wall of the inguinal canal, medial to the inferior epigastric vessels Always acquired Usually occurs in the elderly No control by pressure over internal ring Straight protrusion on coughing Reaches full size immediately on standing Descent into the scrotum is rare Strangulation is uncommon The differential diagnoses are femoral hernia, skin lesions such as epidermoid cyst or fibroma, lymphadenopathy, femoral artery aneurysm, saphena varix, neuroma, ectopic testis and lipoma of the spermatic cord The precipitating factors, for example COPD or constipation, should be treated A truss is indicated for patients who are unfit for surgery Surgical management can be open or laparoscopic A herniotomy (excision of hernial sac) or herniorrhaphy (repair of posterior wall defect Ϯ insertion of non-absorbable mesh) is performed Femoral hernias account for 10 per cent of all hernias and are four times more common in females than males They are more common in the late middle age and the multiparous Bilateral hernias occur in 20 per cent of cases Femoral hernias have a high risk of strangulation, 30–80 per cent present in this manner The femoral hernias that strangulate are more likely to be the Richter’s type They appear below and lateral to the pubic tubercle, unlike inguinal hernias which are above and medial to the pubic tubercle Surgery is mandatory due to the high risk of strangulation COPD, chronic obstructive pulmonary disease APPENDIX FLUID AND SODIUM HOMEOSTASIS Reduced [Na+] Raised serum osmolality Anterior hypothalamus Hypovolaemia Juxtaglomerular cells ADH Renin Collecting duct water recovery Angiotensin I → II Aldosterone Collecting duct Na+ recovery HOMEOSTATIC MECHANISM CONTROLLING BLOOD PRESSURE Increased peripheral vascular resistance Reduced renal perfusion Renin Angiotensinogen ACE Angiotensin I Angiotensin II Aldosterone Vasoconstriction Na+/water retention ↑ peripheral vascular resistance ↑ cardiac output HYPERTENSION ACE, angiotensin-converting enzyme; ADH, antidiuretic hormone 152 APPENDIX BILIRUBIN METABOLISM Other haem sources, e.g myoglobin Haemoglobin Haem Biliverdin Uptake across sinusoidal Unconjugated bilirubin membrane, conjugated UDP glucuronyl in the endoplasmic transferase (UGT) reticulum Conjugated bilirubin Bile (80% BDG, 20% BMG) Terminal ileum and colon bacterial glucuronidase Urine Urobilinogen Stercobilinogen BDG, bilirubin diglucuronide; BMG, bilirubin monoglucuronide; UDP, uridine diphosphate INDEX AAT see α1-antitrypsin abdomen, acute 140–50 abdominal hernias 148, 149–50 abdominoperineal resection 129 abscesses anorectal 137 appendicitis 145 pericolic 119 pilonidal sinus 137 urinary tract infection 41 achalasia 85 acid-base balance 10–13, 15 acute abdomen 140–50 acute appendicitis 144, 145 acute cholecystitis 70, 71 acute liver failure (ALF) 48–51 acute pancreatitis 62, 63, 64–5, 73 Acute Physiology and Chronic Health Evaluation (APACHE) II score 63 acute pyelonephritis 41, 42 acute renal failure (ARF) 14–17 acute tubular necrosis (ATN) 14, 15 acute urethral syndrome 41 adenocarcinoma colorectal cancer 129 ductal 79 gall bladder 71, 77 gastric tumours 101 gastro-oesophageal reflux disease 95 oesophageal 99 renal 35 adenoma bile duct 75 hepatic 75 metanephric 35 renal papillary 35 tubular adenoma 127 tubulovillous 127 villous 127 AFP see α-fetoprotein alcohol-induced pancreatitis 63, 67 ALF see acute liver failure α1-antitrypsin (AAT) 53 α-fetoprotein (AFP) 55, 75 α-gliadin 105 AMA see antimitochondrial antibodies aminosalicylates 113, 116 Amirand’s triangle 69 anaemia 85, 105 anal carcinoma 138, 139 anal disorders 130–9 anal fissures 135 anal fistulae 134, 135 angiodysplasia 91 anion gap 11 anorectal abscesses 137 antacids 95 antibiotics acute abdomen 143 appendicitis 145 Crohn’s disease 113 pilonidal sinus 137 tropical sprue 107 urinary tract infection 42 Whipple’s disease 107 anti-endomyseal antibodies 105 antigens 59, 105 anti-gliadin antibodies 105 antimitochondrial antibodies (AMA) 61 anti-reticulin antibodies 105 antispasmodics 119 anti-transglutaminase antibodies 105 α1-antitrypsin (AAT) 53 APACHE see Acute Physiology and Chronic Health Evaluation appendicectomy 145 appendicitis 144, 145 ARF see acute renal failure ascending cholangitis 73 ascites 55 asymptomatic bacteriuria 41 ATN see acute tubular necrosis autoimmune liver disease 53, 60–1 bacteria gallstones 69 overgrowth in small-bowel disorders 106, 107 urinary tract infection 39 bacteriuria 40, 41 Barrett’s oesophagus 94, 95, 99 Barron’s banding 133 base excess, acid-base values 11 B-cell lymphoma 109 benign tumours gastric 101 hepatobiliary oncology 75 kidney 35 oesophageal 99 bilateral hernias 150 bile duct adenoma 75 bile duct papilloma 75 bile salts 69 biliary colic 70, 71 bilirubin Child–Pugh criteria for cirrhosis 55 metabolism 44, 45, 152 bladder carcinoma 36, 37 bleeding, gastrointestinal 86–91 blind loop syndrome 107 blood analysis acute abdomen 143 acute pancreatitis 65 chronic pancreatitis 67 colorectal cancer 129 constipation 125 Crohn’s disease 113 diarrhoea 121 diverticular disease 119 dysphagia 83 haematuria 29 jaundice 47 malabsorption 103 oesophageal tumours 99 urinary tract infection 42 blood gas analysis 65 blood pressure gastrointestinal bleeding 89 homeostatic mechanisms 31, 151 hypertension 31, 151 blood products administration Boas’s sign 71 botulinium toxic injection 85 bowel obstructions 146, 147 154 INDEX Budd–Chiari syndrome 49, 53 bulk-forming laxatives 125 cadaveric kidney donors 21 caecal perforations 147 caeruloplasmin level 53 calcium bilirubinate 69 Campylobacter sp 123 cancer bladder 36, 37 colorectal 126–9 see also individual forms cannon ball metastases 35 carbuncles 41 carcinoid tumours of the small-bowel 108, 109 carcinoma anal 138, 139 bladder 36, 37 cholangiocarcinoma 78, 79 clear cell 35 gall bladder 71 gastric 100–1 hepatocellular 59, 75 oesophageal 99 renal cell 35 squamous cell 35, 99, 139 transitional cell 35, 37 see also adenocarcinoma central pontine myelinolysis Charcot’s triad 73 chemotherapy anal cancer 139 bladder cancer 37 colorectal cancer 129 gall bladder cancer 77 oesophageal cancer 99 pancreatic cancer 80 pelvic cancer 35 renal 35, 37 Child–Pugh criteria 54, 55 cholangiocarcinoma 78, 79 cholangitis ascending 73 gallstones 73 primary sclerosing 60, 61 cholecystectomy 71, 73 cholecystitis 70, 71 cholecystoduodenal fistula 73 cholestasis 53 cholesterol-rich gallstones 69 chromophil cell cancer 35 chronic liver failure (CLF) 52–5 chronic pancreatitis 66–7 chronic pyelonephritis 41 chronic renal failure (CRF) 18–21 Churg–Strauss syndrome 25 chylous fluid 55 cirrhosis 52–5 hepatitis 59 hepatocellular carcinoma 75 primary biliary 53, 60, 61 clear cell carcinoma 35 CLF see chronic liver failure Clostridium difficile 123 coeliac disease 104–5 colectomy 116 colitis ischaemic 91 ulcerative 61, 114–16 colloids colorectal cancer 126–9 complications of acute pancreatitis 65 conjugated hyperbilirubinaemia 45 constipation 124–5, 131, 147 constrictive pericarditis 53 copper metabolism 53 cortical necrosis 15 Courvoisier’s law 47, 79 crescentic glomerulonephritis 25 CRF see chronic renal failure Crigler–Najjar syndrome 45 Crohn’s disease 107, 110–13, 116 crystalloids Cullen’s sign 65 cystectomy 37 cystitis 41 dehydration 2, deoxyribonucleic acid (DNA) viruses 57 dermatitis herpetiformis 105 diabetes mellitus 67 diabetic nephropathy 19 dialysis 21, 51 diarrhoea 120–3 Crohn’s disease 111 small-bowel disorders 107 ulcerative colitis 115 diet anal fissures 135 colorectal cancer 127 gastric carcinoma 101 gluten-free 105 haemorrhoids 133 high-fibre 119, 123, 133 irritable bowel syndrome 123 low-fibre 119 supplements 61 ulcerative colitis 116 see also nutrition diffuse glomerular lesions 25 diffuse oesophageal spasm 85 dipstick test 29, 40, 42 direct inguinal hernias 150 diverticular disease 118–19, 143 DNA see deoxyribonucleic acid donors for renal transplantation 21 Dubin–Johnson syndrome 45 ductal adenocarcinoma 79 Dukes’ classification 129 duodenal nutrient absorption 103 duodenal ulcers 97 dysmotility diarrhoea 121 dysphagia 82–5, 95 dysplasia 31, 99 ECG see electrocardiogram elective appendicectomy 145 electrocardiograms (ECG) of hyperkalaemia/hypokalaemia electrolyte balance 2–3 emphysema 53 empyema 71 encephalopathy 49, 50, 51 endocrine causes of secondary hypertension 31 Index endocrine tumours 78, 79, 80 endoscopy 87, 89 end-stage renal failure (ESRF) 19, 25 epigastric pain 97 erythrocyte sedimentation rate (ESR) 115 Escherichia coli 123 ESR see erythrocyte sedimentation rate ESRF see end-stage renal failure essential hypertension 31 eutonic hyponatraemia excretion in hyperkalaemia extracellular fluid familial adenomatous polyposis (FAP) 127 fat malabsorption 103 female urinary tract infections 39 femoral hernias 148, 150 fibromuscular dysplasia 31 fissures, anal 135 fistulae anal 134, 135 diverticular disease 119 fluid administration balance 2–3 chylous 55 haemorrhagic 55 homeostatic mechanisms 151 hypotonic fluid loss rehydration 5, 121 straw-coloured 55 focal segmental glomerulosclerosis (FSGS) 23, 33 folate deficiency 103 folic acid 107 food regurgitation 85 FSGS see focal segmental glomerulosclerosis fulminant liver failure 49 gall bladder cancers 76, 77 gallstone ileus 73 gallstones 68–73 Gardner’s syndrome 127 gastrectomy 101 gastric acid secretion reduction 107 gastric tumours 100–1 gastric ulcers 97 gastrinoma 80 gastrograffin swallow 147 gastrointestinal bleeding 86–91 gastro-oesophageal reflux disease (GORD) 92–5, 99 gastro-oesophageal variceal bleeds 88, 89 GBM see glomerular basement membrane gender issues in urinary tract infection 39 genetics colorectal cancer 127 gastric carcinoma 101 GFR see glomerular filtration rate Gilbert’s syndrome 45 Glasgow Criteria 63 α-gliadin 105 glomerular basement membrane (GBM) 23, 25 glomerular disease 15 glomerular filtration rate (GFR) 15, 19 glomerulonephritis 19, 22–5 glucagonoma 80 gluten-free diet 105 glyceryl trinitrate 135 Goodsall’s rule 135 GORD see gastro-oesophageal reflux disease granulomatosis 25 Grawitz tumour 35 Grey–Turner sign 65 H2-receptor antagonists 95 haemangioma 75 haematemesis 87 haematochezia 87 haematogenous infections 41 haematoma 137 155 haematuria 26–9 haemochromatosis 52, 53 haemodialysis 21 haemofiltration 21 haemorrhagic fluid 55 haemorrhoidectomy 133 haemorrhoids 130–3 halitosis 85 Hartmann’s solution HCC see hepatocellular carcinoma Helicobacter pylori 96, 97 hemicolectomy 129 Henoch–Schönlein purpura 25 hepatic adenoma 75 hepatic failure 48–55 hepatic haemangioma 75 hepatic jaundice 45 hepatic venous outflow obstruction 53 hepatitis acute liver failure 49 autoimmune 53, 61 viral 49, 56–9 hepatobiliary medicine autoimmune liver disease 60–1 gallstones 68–73 jaundice 44–7 liver failure 48–55 oncology 74–80 pancreatitis 62–7 viral hepatitis 56–9 hepatocellular carcinoma (HCC) 59, 75 hepatocellular jaundice 45 hepatorenal syndrome 51 hepatotoxins 45 hereditary non-polyposis colon cancer (HNPCC) 127 hereditary syndromes in colorectal cancer 127 hernias 93, 148, 149–50 herniorrhaphy 150 herniotomy 150 herpes simplex 49 hiatus hernia 93 high-fibre diet 119, 123, 133 156 INDEX HLA see human leucocyte antigen HNPCC see hereditary non-polyposis colon cancer homeostatic mechanisms blood pressure 151 fluid and sodium 151 human leucocyte antigen (HLA) 61, 105 hydration status 2, hyperaesthesia 71 hyperbilirubinaemia 45 hypercoagulability 33 hyperkalaemia 8, 9, 17 hyperlipidaemia 33 hypernatraemia 4, hypernephroma 35 hypertension homeostatic mechanisms 31, 151 nephroangiosclerosis 19 portal 89 renovascular disease 30–1 hyperventilation 11 hypervolaemia hypotonic hyponatraemia hypoalbuminaemia 33 hypoglycaemia 51 hypokalaemia 8, hypomagnesaemia hyponatraemia 6–7 hypotension 15 hypotonic fluid loss hypotonic hyponatraemia hypovolaemia 7, 15, 87 hypovolaemia hypotonic hyponatraemia IBD see inflammatory bowel disease IBS see irritable bowel syndrome IgA see immunoglobulin A ileoanal pouch construction 116 ileostomy 116 ileum in nutrient absorption 103 ileus 73, 147 imaging acute abdomen 143 acute liver failure 51 acute pancreatitis 65 anal fistula 135 chronic pancreatitis 67 colorectal cancer 129 Crohn’s disease 113 diverticular disease 119 dysphagia 83 gastrointestinal bleeding 91 haematuria 29 hepatocellular carcinoma 75 jaundice 47 oesophageal tumours 99 pancreatic tumours 79 urinary tract infection 42 immunoglobulin A (IgA) 25, 105 immunosuppressive agents 113 incarcerated hernias 149 indirect inguinal hernias 149, 150 infective diarrhoea 122, 123 infiltrative disorders 45 inflammatory bowel disease (IBD) 110–16, 127 inflammatory diarrhoea 121 infliximab 113 inguinal hernias 148, 149–50 injection sclerotherapy 133, 137 insulinoma 80 intake in hyperkalaemia/ hypokalaemia interferon-α 57 intersphincteric abscesses 137 interstitial fluid interstitial necrosis 15 intestinal motility impairment 107 intracellular fluids intravascular fluid iron deficiency anaemia 85 malabsorption 103 irreducible hernias 149 irritable bowel syndrome (IBS) 123 ischaemia 45, 143 ischaemic colitis 91 ischiorectal abscesses 137 Ivor–Lewis operation 99 jaundice 44–7, 61, 73 jejunal diverticulosis 107 jejunum in nutrient absorption 103 kidney donors 21 kidney tumours 35 King’s College Hospital criteria for liver transplantation 51 lamivudine 57 large-bowel obstruction 146, 147 laxatives 125, 133, 135 lecithin 69 lifestyle modifications constipation 125 gastro-oesophageal reflux disease 95 peptic ulcer disease 97 lithogenesis 69 live related/live-non-related kidney donors 21 liver failure 48–55 liver transplantation 51, 61 local complications of acute pancreatitis 65 LOS see lower oesophageal sphincter lower oesophageal sphincter (LOS) 93 low-fibre diets 119 lymphoma of small bowel 108, 109 McBurney’s point 145 malabsorption chronic pancreatitis 67 coeliac disease 105 small-bowel disorders 102–3 malignant tumours hepatobiliary oncology 75–80 kidney 35 oesophageal 99 see also individual types Mallory–Weiss tears 89 MALT see mucosa-associated lymphoid tissue Meckel’s diverticulum 91, 97 Index Mediterranean lymphoma 109 melaena 87 membranoproliferative glomerulonephritis 25 membranous nephropathy 25, 33 MEN see multiple endocrine neoplasia mesangiocapillary glomerulonephritis 25, 33 mesenteric adenitis 143 metabolic acidosis 10, 11 metabolic alkalosis 11, 13 metabolism acid-base balance 11 bilirubin 45 chronic liver failure 53 copper 53 jaundice 45 metanephric adenoma 35 metastases 35, 80 microscopic polyarteritis 25 minimal change disease 23, 33 Mirizzi’s syndrome 71 mixed gallstones 69 Modified Glasgow Criteria 63 mucocele 71 mucosa-associated lymphoid tissue (MALT) lymphoma 109 multiple endocrine neoplasia (MEN) 78, 79, 80 Murphy’s sign 71 nephrectomy 35 nephritic syndrome 22, 23 nephroangiosclerosis 19 nephroblastoma 34, 35 nephropathy diabetic 19 immunoglobulin A 25 membranous 25, 33 minimal change 33 nephrotic syndrome 23, 32–3 nephrotoxins 15 nephro-uretectomy 35 normovolaemia hypotonic hyponatraemia nutrient absorption in small boweldisorders 102, 103 nutrition Child–Pugh criteria for cirrhosis 55 Crohn’s disease 113 primary biliary cirrhosis 61 see also diet obstructions acute abdomen 143 colorectal cancer 129 diverticular disease 119 hepatic venous outflow 53 jaundice 47, 73 large-bowel 146, 147 small-bowel 146, 147 obstructive jaundice 47, 73 odynophagia 83 oesophageal spasm 85 oesophageal sphincter 93 oesophageal tumours 98–9 oesophagitis 95 oesophagogastrectomy 101 Ogilvie’s syndrome 147 oliguria 15 oncocytoma 35 oncology hepatobiliary 74–80 renal 34–7 opioid analgesia 143 oral rehydration 121 Osler–Rendu–Weber syndrome 75 osmolality 3, 5, 7, 15 osmotic diarrhoea 120, 121 osmotic laxatives 125 overdose of paracetemol 49, 51 Paco2 see partial pressure of arterial carbon dioxide pain management in chronic pancreatitis 67 palliative care cholangiocarcinoma 79 colorectal cancer 129 gall bladder cancers 77 157 gastric carcinoma 101 oesophageal tumours 99 pancreatic tumours 80 radiotherapy in renal oncology 35 panacinar emphysema 53 pancreatic tumours 78, 79–80 pancreatitis 62–7, 73 Pao2 see partial pressure of arterial oxygen papillary adenoma 35 papilloma 75 paracetemol overdose/ poisoning 49, 51 para-oesophageal hiatus hernia 93 partial pressure of arterial carbon dioxide (Paco2) 11 partial pressure of arterial oxygen (Pao2) 11 PBC see primary biliary cirrhosis pelvic tumours 35 peptic ulcers 89, 96–7 perforations acute abdomen 143 caecal 147 colorectal cancer 129 diverticular 119 gall bladder 71 perianal abscesses 137 perianal disorders 130–9 perianal haematoma 137 pericolic abscesses 119 perinephric abscesses 41 peripheral vascular resistance (PVR) 31 peritoneal dialysis 21 pH, acid-base balance 11 pigment gallstones 69 piles 130–3 pilonidal sinus 137 plasma acid-base balance 10–13 osmolality 3, 5, 15 potassium 8–9 sodium 4–7 Plummer–Vinson syndrome 85 pneumatic balloon dilatation 85 158 INDEX polyarteritis 25 polyps 127 portal hypertension 59, 89 post-hepatic jaundice 47 post-renal causes of acute renal failure 17 post-streptococcal glomerulonephritis 24, 25 potassium administration potassium balance 8–9 PPI see proton pump inhibitors pre-hepatic jaundice 45 pre-renal causes of acute renal failure 15 primary biliary cirrhosis (PBC) 53, 60, 61 primary glomerulonephritis 33 primary hypertension 31 primary malignant tumours 75 primary sclerosing cholangitis (PSC) 60, 61 prolapse, rectal 137 protein deficiencies 103 proteinuria 32–3 prothrombin time 51 proton pump inhibitors (PPI) 67, 95 pruritis 47, 61 pruritis ani 131 PSC see primary sclerosing cholangitis pseudohyperkalaemia psychotherapy for irritable bowel syndrome 123 pulmonary oedema 17 pure water depletion purpura 25 PVR see peripheral vascular resistance pyelonephritis 41, 42 pyonephrosis 41 pyuria 41 radiotherapy anal carcinoma 139 colorectal cancer 129 gall bladder cancers 77 oesophageal tumours 99 pancreatic tumours 80 renal oncology 35, 37 Ranson’s criteria 63 rapidly progressive (crescentic) glomerulonephritis 25 rectal bleeding 115 rectal prolapse 137 reducible hernias 149 reflux disease 92–5, 99 regurgitation in gastro-oesophageal reflux disease 95 rehydration 5, 121 reinfection in urinary tract infection 42 relapse in urinary tract infection 42 renal artery stenosis 30, 31 renal cell carcinoma 35 renal medicine acid-base balance 10–13 acute renal failure 14–17 chronic renal failure 18–21 electrolyte balance 2–3 fluid balance 2–3 glomerulonephritis 22–5 haematuria 26–9 hypertension 30–1 nephrotic syndrome 32–3 oncology 34–7 potassium balance 8–9 proteinuria 32–3 renal failure 14–21, 51 renovascular disease 30–1 secondary hypertension 31 sodium balance 4–7 urinary tract infection 38–42 renal oncocytoma 35 renal papillary adenoma 35 renal replacement 21 renin-angiotensin mechanism 31, 151 renovascular disease 15, 30–1 replacement oral rehydration 121 respiratory acidosis 11, 12, 13 respiratory alkalosis 11, 13 resuscitation 91, 143 ribonucleic acid (RNA) viruses 57 Richter’s hernia 149 RNA see ribonucleic acid Robson criteria 35 Rockall score 89 rolling hiatus hernia 93 Rome III criteria 123 Rovsing’s sign 145 Salmonella sp 123 SCC see squamous cell carcinoma Schatzki ring 85 sclerotherapy 133, 137 secondary glomerulonephritis 33 secondary hypertension 31 secretory diarrhoea 121 serological tests for hepatitis B 59 Shigella sp 123 sigmoid colon 119 skin tags 133, 135 sliding hiatus hernia 93 small-bowel disorders 102–9 obstruction 146, 147 tumours 108–9 small-vessel disease 15 sodium acute renal failure 15 balance 4–7 homeostatic mechanisms 151 urine osmolality 5, sodium bicarbonate 11 somatostatinoma 80 spasms 85, 135 sphincter lower oesophageal 93 spasms 135 sprue-associated lymphoma 109 squamous cell carcinoma (SCC) anal 139 oesophageal 99 pelvic 35 steatorrhoea 67, 107 stenosis, renal artery 30, 31 sterile pyuria 41 stimulant laxatives 125 Index stomach tumours 100–1 strangulated hernias 149 straw-coloured fluid 55 streptococcal infection 24, 25 strictures 95 subacute liver failure 49 supralevator abscesses 137 surgery abdominal hernias 150 acute abdomen 143 anal carcinoma 139 anal fissures 135 anal fistulae 135 anorectal abscesses 137 bowel obstruction 147 chronic pancreatitis 67 colorectal cancer 129 Crohn’s disease 113 diverticular disease 119 gall bladder cancers 77 gastric carcinoma 101 gastro-oesophageal reflux disease 95 hepatocellular carcinoma 75 oesophageal tumours 99 pancreatic tumours 80 peptic ulcer disease 97 renal oncology 35, 37 small-bowel tumours 109 ulcerative colitis 116 systemic complications of acute pancreatitis 65 systemic hypotension 15 TB see tuberculosis TCC see transitional cell carcinoma T-cell lymphoma 109 telipressin 89 terminal ileum 103 thin basement membrane disease 23 thromboprophylaxis 116 TNM see tumour, node, metastasis total body water transitional cell carcinoma (TCC) 35, 37 transplantation 21, 51, 61 trans-urethral resection 37 Tropheryma whipplei 107 tropical sprue 107 tuberculosis (TB) 41, 42 tubular adenoma 127 tubulovillous adenoma 127 tumour, node, metastasis (TNM) classification 129 tumours bladder 36, 37 hepatobiliary oncology 74–80 oesophageal 98–9 renal 35 small-bowel 108–9 stomach 100–1 see also individual types ulcerative colitis 61, 114–16 ulcers, peptic 96–7 umbilical hernias 149 unconjugated hyperbilirubinaemia 45 159 urethral syndrome 41 urinary tract infection (UTI) 38–42 urine -borne infections 41 dipstick test 29, 40, 42 haematuria 27 osmolality 5, 7, 15 output 143 sampling in urinary tract infection 42 UTI see urinary tract infection Vibrio cholerae 123 villous adenoma 127 vipoma 80 viral hepatitis 49, 56–9 vitamins B12 103, 107 C 103 deficiencies 102, 103 supplements 61 von Hippel–Lindau disease 75 water brash 95 Wegener’s granulomatosis 25 Whipple’s disease 107 Whipple’s resection 80 Wilms’ tumours 35 Wilson’s disease 49, 53 X-rays in bowel obstruction 147 [...]... erythematosus (SLE) and post-infectious glomerulonephritis • Myeloma screen: urinary Bence Jones protein, protein electrophoresis, immunoglobulin levels • Renal ultrasound: to exclude stones, hydronephrosis and tumours Small kidneys suggest CRF • Kidneys, ureters and bladder (KUB) X-ray: 80 per cent of renal stones are radio-opaque • Radionuclide renal scan: exclude obstruction, scarring • Renal biopsy Prevention... syndrome and laxatives • Increased renal loss: diuretics, hyperaldosteronism, renal artery stenosis and osmotic diuresis • Tissue redistribution: insulin therapy, alkalosis and catecholamines • Reduced intake (rare) Hypokalaemia can be associated with hypomagnesaemia, therefore magnesium deficiency must be sought and corrected first Answers 8 9 10 11 FTFFT TTTTT See explanation FTFTT ONE STOP DOC 10... CRF, chronic renal failure; ESRF, end-stage renal failure; GFR, glomerular filtration rate; GI, gastrointestinal Renal medicine 19 EXPLANATION: CHRONIC RENAL FAILURE Chronic renal failure is defined as irreversible chronic renal damage resulting in more than 50 per cent loss of renal function It can be divided into three main categories: mild (GFR 30–70 mL/min), moderate (GFR 10–30 mL/min) and end-stage... end-stage renal failure; GBM, glomerular basement membrane; Ig, immunoglobulin; SLE, systemic lupus erythematosus Renal medicine 25 EXPLANATION: GLOMERULONEPHRITIS Cont’d from page 23 DIFFUSE GLOMERULAR LESIONS • IgA nephropathy is the commonest type of glomerulonephritis and usually occurs in children and young men with intercurrent infections On microscopy there is diffuse mesangial cell proliferation and. .. sensitive measure of ARF PRE -RENAL CAUSES • Hypovolaemia: haemorrhage, GI loss, third space loss (pancreatitis), renal loss (diabetes insipidus), skin and mucous membrane losses (burns) • Systemic hypotension: cardiogenic shock, sepsis and liver failure • Renovascular disease: renal artery stenosis RENAL CAUSES • Acute tubular necrosis (ATN): caused by pre -renal causes and nephrotoxins which include... the scrotum, and haematuria ANA, antinuclear antibody; ANCA, antineutrophil cytoplasmic antibody; ARF, acute renal failure; ATN, acute tubular necrosis; CRF, chronic renal failure; dsDNA, double-stranded deoxyribonucleic acid; KUB, kidneys, ureters and bladder; MRA, magnetic resonance angiogram; RBC, red blood cell; SLE, systemic lupus erythematosus Renal medicine 17 EXPLANATION: ACUTE RENAL FAILURE... casts are present in glomerulonephritis, vasculitis or malignant hypertension White cell casts can be noted in pyelonephritis Epithelial cell casts are present in ATN or glomerulonephritis • Arterial blood gas • Full blood count: anaemia is more indicative of chronic renal failure (CRF) • Renal profile • Liver profile and hepatitis screen • Bone profile: hypocalcaemia and hyperphosphataemia is more... disease: vasculitides and malignant hypertension Glomerular disease Continued on page 17 Answers 16 17 18 19 TTFTT FTFTF TTFTF See explanation ONE STOP DOC 16 20 Theme – Renal failure investigations For the following scenarios choose the most appropriate diagnostic investigation Each option may be used once only Options A B C D E Renal ultrasound Hysterosalpingogram KUB X-ray MRA Renal venogram F G H... glomerular filtration rate; GI, gastrointestinal; NSAID, non-steroidal anti-inflammatory drug Renal medicine 15 EXPLANATION: ACUTE RENAL FAILURE Acute renal failure (ARF) is defined as a rapid decline in renal function over hours to days that leads to retention of nitrogenous waste products (urea and Cr) and impairment of the acid–base balance It is usually characterized by oliguria (Ͻ400 mL/day),... Membranoproliferative glomerulonephritis responds well to treatment 75 per cent of cases of membranous nephropathy are idiopathic ESRF, end-stage renal failure; FSGS, focal segmental glomerulosclerosis; GBM, glomerular basement membrane; HIV, human immunodeficiency virus; Ig, immunoglobulin Renal medicine 23 EXPLANATION: GLOMERULONEPHRITIS Glomerulonephritis encompasses renal diseases with an underlying .. .ONE STOP DOC Gastroenterology and Renal Medicine One Stop Doc Titles in the series include: Cardiovascular System – Jonathan Aron Editorial Advisor – Jeremy Ward Cell and Molecular... Ferenczi and Nina Muirhead Editorial Advisor – Darrel Francis Volume Editor – Basant Puri ONE STOP DOC Gastroenterology and Renal Medicine Reena Popat MB BS BSc(Hons) Senior House Officer in Medicine, ... Barbara Moreland and Richard Naftalin Respiratory System – Jo Dartnell and Michelle Ramsay Editorial Advisor – John Rees Renal and Urinary System and Electrolyte Balance – Panos Stamoulos and Spyridon