ALL branches Passmedicine notes 2016 by Dr Sameh SA

Index 1) GIT 2) Cardiology 3) Chest 4) Nephrology 5) Rheumatology P ……………………………………………………………………………… P 109 …………………………………………………………… ……………… P 246 …………………………………………………… ……………………… P320 ………………………………………………………………………………… P397 Contact me at: samehezzat3@yahoo.com ‫السالم عليكم ورحمة هللا وبركاته‬ ‫هذه المذكرات قد قمت بجمعها من موقع باسميديسين اثناء مذاكرة الجزء االول من الزمالة واضفت اليها‬ ‫بعض المواضيع التي لم تكن موجودة في هذا الموقع ولكنها ذكرت في اون ايكسامينيشن اثناء مذاكرة‬ ‫الجزء الثاني واضفت اليها بعض الصور التوضيحية في بعض المواضيع وقمت بترتيبها حتي تاتي‬ ‫المواضيع بصورة متسلسلة وفي بعض االحيان استعنت بترتيب المواضيع من كتاب كومار‬ ‫هذا العمل هو خالص لوجه هللا و يحق الي شخص اضافة تعديالت عليه وللكن ال يحق الي شخص ان‬ ‫يضع اسمه عليه او يدعي ملكيته‪.‬‬ ‫ان كان هناك حقوق ملكية فهي تعود للموقعين الذين اخذنا منهم المعلومات ولم يكن قصدي اال ان تعم‬ ‫الفائدة علي الجميع ويستطيع اخواننا االطباء انهاء الزمالة بسهولة وفي وقت قصير وارجو ان كان هناك‬ ‫شبهه اني اعتديت علي ملكية هذه المواقع ارجو ان تدعو لي ان يسامحني هللا فلم يكن قصدي سوا نشر‬ ‫العلم دون اي مقابل مادي او معنوي وكذلك انا اعتقد ان العلماء االوائل لم نسمع ان احدا منهم منع نشر او‬ ‫نسخ كتبه‬ ‫وليغفر لنا هللا جميعا‬ ‫بالتوفيق لكم جميعا‬ ‫‪2‬‬ ‫‪Contact me at: samehezzat3@yahoo.com‬‬ GIT Contact me at: samehezzat3@yahoo.com Gastrointestinal physiology Acid secretion Principle mediators of acid secretion:    Gastrin Vagal stimulation Histamine Factors increasing acid secretion:     Gastrinoma Small bowel resection (removal of inhibition) Systemic mastocytosis (elevated histamine levels) Basophilia Factors decreasing acid secretion:   Drugs: H2-antagonists, PPIs Hormones: secretin, VIP, GIP, CCK Gastrointestinal enzymes:   Amylase is present in saliva and pancreatic secretions It breaks starch down into sugar The following brush border enzymes are involved in the breakdown of carbohydrates:    maltase: cleaves disaccharide maltose to glucose + glucose sucrase: cleaves sucrose to fructose and glucose lactase: cleaves disaccharide lactose to glucose + galactose Contact me at: samehezzat3@yahoo.com Gastrointestinal Hormones Below is a brief summary of the major hormones involved in food digestion: Gastrin Source Stimulus G cells in antrum of the stomach 1) luminal Actions 1) Increase HCL, pepsinogen and IF peptides/amino acids secretion, 2) Distension of 2) increases gastric motility, stomach, 3) stimulates parietal cell maturation 3) vagus nerves mediated by gastrinreleasing peptide Inhibited by:  low antral pH,  somatostatin CCK I cells in upper small intestine Secretin S cells in Somato statin 1) Increases secretion of enzyme-rich proteins and fluid from pancreas, 2) Triglycerides 2) contraction of gallbladder and relaxation of sphincter of Oddi, 3) decreases gastric emptying, 4) trophic effect on pancreatic acinar cells, 5) induces satiety 1) Acidic chyme, 2) fatty acids 1) Increases secretion of bicarbonate- Small intestine, pancreas Neural 1) Stimulates secretion by pancreas D cells in the pancreas & stomach Fat, bile salts and glucose in the intestinal lumen upper small intestine VIP 1) Partially digested rich fluid from pancreas and hepatic duct cells, 2) decreases gastric acid secretion, 3) trophic effect on pancreatic acinar cells and intestines, 2) inhibits acid secretion 1) Decreases acid and pepsin 2) 3) 4) 5) 6) secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, decreases insulin and glucagon secretion inhibits trophic effects of gastrin, stimulates gastric mucous production Contact me at: samehezzat3@yahoo.com Dysphagia The table below gives characteristic exam question features for conditions causing dysphagia:  Dysphagia may be associated with weight loss, anorexia or vomiting Oesophageal during eating cancer  Past history may include Barrett's oesophagus, GORD, excessive smoking or alcohol use Oesophagitis  May be history of heartburn  Odynophagia but no weight loss and systemically well Oesophageal  There may be a history of HIV or  other risk factors such as steroid inhaler use candidiasis Achalasia  Dysphagia of both liquids and solids from the start  Heartburn  Regurgitation of food - may lead to cough, aspiration pneumonia etc Pharyngeal pouch  More common in older men  Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles  Usually not seen but if large then a midline lump in the neck that gurgles on palpation  Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough  Halitosis may occasionally be seen Systemic sclerosis  Other features of CREST syndrome may be present, namely Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia  As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased  This contrasts to achalasia where the LES pressure is increased Myasthenia gravis  Other symptoms may include extraocular muscle weakness or ptosis  Dysphagia with liquids as well as solids Globus hystericus  May be history of anxiety  Symptoms are often intermittent and relieved by swallowing  Usually painless - the presence of pain should warrant further investigation for organic causes Pain on swallowing (odynophagia) is a typical of oesophageal candidiasis, a well documented complication of inhaled steroid therapy Contact me at: samehezzat3@yahoo.com Achalasia      Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) Due to degenerative loss of ganglia from Auerbach's plexus i.e LOS contracted, oesophagus above dilated Achalasia typically presents in middle-age, rare Equally common in men and women Clinical features: 1) dysphagia of BOTH liquids and solids, odynophagia 2) typically variation in severity of symptoms 3) heartburn 4) regurgitation of food - may lead to cough, aspiration pneumonia etc 5) malignant change in small number of patients Investigations: 1) manometry:  considered most important diagnostic test  excessive LOS tone which doesn't relax on swallowing 2) barium swallow shows grossly expanded oesophagus, fluid level, 'bird's beak' appearance 3) CXR: wide mediastinum, fluid level Treatment: 1) intra-sphincteric injection of botulinum toxin 2) Heller cardiomyotomy 3) balloon dilation 4) drug therapy has a role but is limited by side-effects This film demonstrates the classical 'bird's beak' appearance of the lower oesophagus that is seen in achalasia An air-fluid level is also seen due to a lack of peristalsis Mediastinal widening secondary to achalasia An airfluid level can sometimes be seen on CXR but it is not visible on this film Barium swallow - grossly dilated filled oesophagus with a tight stricture at the gastroesophageal junction resulting in a 'bird's beak' appearance Tertiary contractions give rise to a corkscrew appearance of the oesophagus Contact me at: samehezzat3@yahoo.com Oesophageal cancer    Until recent times oesophageal cancer was most commonly due to a squamous cell carcinoma but the incidence of adenocarcinoma is rising rapidly Adenocarcinoma is now the most common type of oesophageal cancer and is more likely to develop in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett's The majority of tumours are in the middle third of the oesophagus Risk factors: 1) smoking 2) alcohol 3) GORD 4) Barrett's oesophagus 5) achalasia 6) Plummer-Vinson syndrome 7) rare: coeliac disease, scleroderma Barium swallow - 5cm irregular narrowing of the mid-thoracic oesophagus with proximal shouldering Fluoroscopy - a region of fixed, irregular stricturing is seen in the distal oesophagus Contact me at: samehezzat3@yahoo.com Pharyngeal pouch     A pharyngeal pouch is a posteromedial diverticulum through Killian's dehiscence Killian's dehiscence is a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles It is more common in older patients and It is times more common in men Features: 1) Dysphagia 2) Regurgitation 3) Aspiration 4) Neck swelling which gurgles on palpation 5) Halitosis Still image taken from a barium swallow with fluoroscopy During swallowing an outpouching of the posterior hypopharyngeal wall is visualised at the level C5-C6, right above the upper oesophageal sphincter Contact me at: samehezzat3@yahoo.com The endoscopic appearances are of four linear oesophageal ulcers (A) with the remainder of the oesophageal mucosa erythematous and inflamed with islands of normal mucosa The endoscopic appearance demonstrates severe, diffuse oesophagitis in the mid to distal oesophagus Bisphosphonates are a well recognised cause of oesophagitis and potentially oesophageal structuring 10 Contact me at: samehezzat3@yahoo.com Epidermis:  The epidermis is the outermost layer of the skin and is composed of a stratified squamous epithelium with an underlying basal lamina  It may be divided in to five layers: Layer Description Stratum corneum Flat, dead, scale-like cells filled with keratin Continually shed Stratum lucidum Clear layer - present in thick skin only Stratum granulosum Cells form links with neighbours Stratum spinosum Squamous cells begin keratin synthesis Thickest layer of epidermis Stratum germinativum The basement membrane - single layer of columnar epithelial cells Gives rise to keratinocytes Contains melanocytes 401 Contact me at: samehezzat3@yahoo.com Clubbing The causes of clubbing may be divided into cardiac, respiratory and other Cardiac causes:    cyanotic congenital heart disease (Fallot's, TGA) bacterial endocarditis atrial myxoma Respiratory causes:      lung cancer pyogenic conditions: cystic fibrosis, bronchiectasis, abscess, empyema tuberculosis asbestosis, mesothelioma fibrosing alveolitis Other causes:     Crohn's, to a lesser extent UC cirrhosis, primary biliary cirrhosis Graves' disease (thyroid acropachy) rare: Whipple's disease Macroglossia Causes      hypothyroidism acromegaly amyloidosis Duchenne muscular dystrophy mucopolysaccharidosis (e.g Hurler syndrome) Patients with Down's syndrome are now thought to have apparent macroglossia due to a combination of mid-face hypoplasia and hypotonia 402 Contact me at: samehezzat3@yahoo.com Cocaine     Cocaine is an alkaloid derived from the coca plant It is widely used as a recreational stimulant The price of cocaine has fallen sharply in the past decade resulting in cocaine toxicity becoming a much more frequent clinical problem This increase has made cocaine a favourite topic of question writers Mechanism of action:  cocaine blocks the uptake of dopamine, noradrenaline and serotonin The use of cocaine is associated with a wide variety of adverse effects: Cardiovascular effects:      myocardial infarction both tachycardia and bradycardia may occur hypertension QRS widening and QT prolongation aortic dissection Neurological effects:     seizures mydriasis hypertonia hyperreflexia Psychiatric effects:    agitation psychosis hallucinations Others    hyperthermia metabolic acidosis rhabdomyolysis Management of cocaine toxicity:      in general benzodiazipines are generally first-line for most cocaine related problems chest pain: benzodiazipines + glyceryl trinitrate If myocardial infarction develops then primary percutaneous coronary intervention hypertension: benzodiazipines + sodium nitroprusside the use of beta-blockers in cocaine-induced cardiovascular problems is a controversial issue The American Heart Association issued a statement in 2008 warning against the use of beta-blockers (due to the risk of unopposed alpha-mediated coronary vasospasm) but many cardiologists since have questioned whether this is valid If a reasonable alternative is given in an exam it is probably wise to choose it 403 Contact me at: samehezzat3@yahoo.com Menstrual cycle  The menstrual cycle may be divided into the following phases: Days  Menstruation 1-4 Follicular phase (proliferative phase) 5-13 Ovulation 14 Luteal phase (secretory phase) 15-28 Further details are given in the table below Ovarian histology Follicular phase (proliferative phase) Luteal phase (secretory phase) A number of follicles develop Corpus luteum One follicle will become dominant around the mid-follicular phase Endometrial histology Proliferation of endometrium Endometrium changes to secretory lining under influence of progesterone Hormones A rise in FSH results in the development of follicles which in turn secrete oestradiol Progesterone secreted by corpus luteum rises through the luteal phase When the egg has matured, it secretes enough oestradiol to trigger the acute release of LH This in turn leads to ovulation If fertilisation does not occur the corpus luteum will degenerate and progesterone levels fall Oestradiol levels also rise again during the luteal phase Cervical mucus Following menstruation the mucus is Under the influence of thick and forms a plug across the external progesterone it becomes thick, os scant, and tacky Just prior to ovulation the mucus becomes clear, acellular, low viscosity It also becomes 'stretchy' - a quality termed spinnbarkeit Falls prior to ovulation due to the Basal body temperature influence of oestradiol Rises following ovulation in response to higher progesterone levels 404 Contact me at: samehezzat3@yahoo.com Achondroplasia    Achondroplasia is an autosomal dominant disorder associated with short stature It is caused by a mutation in the fibroblast growth factor receptor (FGFR-3) gene This results in abnormal cartilage giving rise to:      short limbs (rhizomelia) with shortened fingers (brachydactyly) large head with frontal bossing midface hypoplasia with a flattened nasal bridge 'trident' hands lumbar lordosis Osteogenesis imperfecta Osteogenesis imperfecta (more commonly known as brittle bone disease) is a group of disorders of collagen metabolism resulting in bone fragility and fractures The most common, and milder, form of osteogenesis imperfecta is type Overview:   autosomal dominant abnormality in type collagen due to decreased synthesis of pro-alpha or proalpha collagen polypeptides Features:      presents in childhood fractures following minor trauma blue sclera deafness secondary to otosclerosis dental imperfections are common Avascular necrosis    Avascular necrosis (AVN) may be defined as death of bone tissue secondary to loss of the blood supply This leads to bone destruction and loss of joint function It most commonly affects the epiphysis of long bones such as the femur Causes:     long-term steroid use chemotherapy alcohol excess trauma Features:   initially asymptomatic pain in the affected joint Investigation:   plain x-ray findings may be normal initially MRI is the investigation of choice It is more sensitive than radionuclide bone scanning 405 Contact me at: samehezzat3@yahoo.com Lower back pain   Lower back pain (LBP) is one of the most common presentations seen in practice Whilst the majority of presentations will be of a non-specific muscular nature it is worth keeping in mind possible causes which may need specific treatment Red flags for lower back pain:  age < 20 years or > 50 years  history of previous malignancy  night pain  history of trauma  systemically unwell e.g weight loss, fever The table below indicates some specific causes of LBP: Facet joint Spinal stenosis     May be acute or chronic Pain worse in the morning and on standing On examination there may be pain over the facets The pain is typically worse on extension of the back  Usually gradual onset  Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking  Resolves when sits down  Pain may be described as 'aching', 'crawling'  Relieved by sitting down, leaning forwards and crouching down  Clinical examination is often normal  Requires MRI to confirm diagnosis Ankylosing  Typically a young man who presents with lower back pain and stiffness spondylitis  Stiffness is usually worse in morning and improves with activity Peripheral arthritis (25%, more common if female) Peripheral  Pain on walking, relieved by rest  Absent or weak foot pulses and other signs of limb ischaemia arterial  Past history may include smoking and other vascular diseases disease ‫؟‬٢ُ ‫ق ؽجّي‬٤ً : ‫ٍ هللا‬ٍٞ‫ٍأُذ ػبئْخ ٓو ًح ه‬ َ‫ ًؼولح اُؾج‬: ٍ‫هب‬ ‫ق اُؼولح ؟‬٤ً ، ‫ ٓو ًح ثؼل ٓوح‬ُٚ‫كٌبٗذ رَأ‬ ‫ب‬ُٜ‫ ؽب‬٠ِ‫ ػ‬: ‫ت‬٤‫غ‬٤‫ك‬ 406 Contact me at: samehezzat3@yahoo.com Prolapsed disc  A prolapsed lumbar disc usually produces clear dermatomal leg pain associated with neurological deficits Features:   leg pain usually worse than back pain often worse when sitting The table below demonstrates the expected features according to the level of compression: Site of compression Features L3 nerve root compression Sensory loss over anterior thigh Weak quadriceps Reduced knee reflex Positive femoral stretch test L4 nerve root compression Sensory loss anterior aspect of knee Weak quadriceps Reduced knee reflex Positive femoral stretch test L5 nerve root compression Sensory loss dorsum of foot Weakness in foot and big toe dorsiflexion Reflexes intact Positive sciatic nerve stretch test S1 nerve root compression Sensory loss posterolateral aspect of leg and lateral aspect of foot Weakness in plantar flexion of foot Reduced ankle reflex Positive sciatic nerve stretch test Management:   similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises if symptoms persist then referral for consideration of MRI is appropriate 407 Contact me at: samehezzat3@yahoo.com Paget's disease of the bone Paget's disease is a disease of increased but uncontrolled bone turnover It is thought to be primarily a disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic activity Paget's disease is common (UK prevalence 5%) but symptomatic in only in 20 patients Predisposing factors     increasing age male sex northern latitude family history Clinical features - only 5% of patients are symptomatic     bone pain (e.g pelvis, lumbar spine, femur) classical, untreated features: bowing of tibia, bossing of skull raised alkaline phosphatase (ALP) - calcium* and phosphate are typically normal skull x-ray: thickened vault, osteoporosis circumscripta © Image used on license from Radiopaedia The radiograph demonstrates marked thickening of the calvarium There are also illdefined sclerotic and lucent areas throughout These features are consistent with Paget's disease 408 Contact me at: samehezzat3@yahoo.com © Image used on license from Radiopaedia Pelvic x-ray from an elderly man with Paget's disease There is a smooth cortical expansion of the left hemipelvic bones with diffuse increased bone density and coarsening of trabeculae Indications for treatment include bone pain, skull or long bone deformity, fracture, periarticular Paget's   bisphosphonate (either oral risedronate or IV zoledronate) calcitonin is less commonly used now Complications      deafness (cranial nerve entrapment) bone sarcoma (1% if affected for > 10 years) fractures skull thickening high-output cardiac failure *usually normal in this condition but hypercalcaemia may occur with prolonged immobilisation 409 Contact me at: samehezzat3@yahoo.com Splenectomy Following a splenectomy patients are particularly at risk from pneumococcus, Haemophilus, meningococcus and Capnocytophaga canimorsus* infections Vaccination:     if elective, should be done weeks prior to operation Hib, meningitis A & C annual influenza vaccination pneumococcal vaccine every years Antibiotic prophylaxis:   penicillin V: unfortunately clear guidelines not exist of how long antibiotic prophylaxis should be continued It is generally accepted though that penicillin should be continued for at least years and at least until the patient is 16 years of age, although the majority of patients are usually put on antibiotic prophylaxis for life *usually from dog bites Valsalva manoeuvre The Valsalva manoeuvre describes a forced expiration against a closed glottis This leads to increased intrathoracic pressure which in turn has a number of effects on the cardiovascular system Uses:   to terminate an episode of supraventricular tachycardia normalizing middle-ear pressures Stages of the Valsalva manoeuvre 1) 2) 3) 4) 5) Increased intrathoracic pressure Resultant increase in venous and right atrial pressure reduces venous return The reduced preload leads to a fall in the cardiac output (Frank-Starling mechanism) When the pressure is released there is a further slight fall in cardiac output due to increased aortic volume Return of normal cardiac output 410 Contact me at: samehezzat3@yahoo.com Vitamin B12 deficiency Vitamin B12 is mainly used in the body for red blood cell development and also maintenance of the nervous system It is absorbed after binding to intrinsic factor (secreted from parietal cells in the stomach) and is actively absorbed in the terminal ileum A small amount of vitamin B12 is passively absorbed without being bound to intrinsic factor Causes of vitamin B12 deficiency:      pernicious anaemia post gastrectomy poor diet disorders of terminal ileum (site of absorption): Crohn's, blind-loop etc metformin (rare) Features of vitamin B12 deficiency:     macrocytic anaemia sore tongue and mouth neurological symptoms: e.g Ataxia neuropsychiatric symptoms: e.g Mood disturbances Management:   if no neurological involvement mg of IM hydroxocobalamin times each week for weeks, then once every months if a patient is also deficient in folic acid then it is important to treat the B12 deficiency first to avoid precipitating subacute combined degeneration of the cord Vitamin C (ascorbic acid) Vitamin C is a water soluble vitamin Functions:  antioxidant  collagen synthesis: acts as a cofactor for enzymes that are required for the hydroxylation proline and lysine in the synthesis of collagen  facilitates iron absorption  cofactor for norepinephrine synthesis Vitamin C deficiency (scurvy) leads to defective synthesis of collagen resulting in capillary fragility (bleeding tendency) and poor wound healing Features vitamin C deficiency:     gingivitis, loose teeth poor wound healing bleeding from gums, haematuria, epistaxis general malaise 411 Contact me at: samehezzat3@yahoo.com Vitamin D Vitamin D is a fat soluble vitamin that plays a key role in calcium and phosphate metabolism Sources:   vitamin D2 (ergocalciferol): plants vitamin D3 (cholecalciferol): dairy products, can be synthesised by the skin from sunlight Functions:     increases plasma calcium and plasma phosphate increases renal tubular reabsorption and gut absorption of calcium increases renal phosphate reabsorption increases osteoclastic activity Consequences of vitamin D deficiency:   rickets: seen in children osteomalacia: seen in adults Zinc deficiency Features:         perioral dermatitis: red, crusted lesions acrodermatitis alopecia short stature hypogonadism hepatosplenomegaly geophagia (ingesting clay/soil) cognitive impairment Pellagra Pellagra is a caused by nicotinic acid (niacin) deficiency The classical features are the D's - dermatitis, diarrhoea and dementia Pellagra may occur as a consequence of isoniazid therapy (isoniazid inhibits the conversion of tryptophan to niacin) and it is more common in alcoholics Features:     dermatitis (brown scaly rash on sun-exposed sites - termed Casal's necklace if around neck) diarrhoea dementia, depression death if not treated 412 Contact me at: samehezzat3@yahoo.com Folate metabolism:   Liver is the best source of folic acid Folic acid is also present in green vegetables and nuts Drugs which interfere with metabolism    trimethoprim methotrexate pyrimethamine Drugs which can reduce absorption:  phenytoin Vitamin deficiency The table below summarises vitamin deficiency states Vitamin Chemical name Deficiency state A Retinoids Night-blindness (nyctalopia) B1 Thiamine Beriberi  polyneuropathy, Wernicke-Korsakoff syndrome  heart failure B3 Niacin Pellagra  dermatitis  diarrhoea  dementia B6 Pyridoxine Anaemia, irritability, seizures B7 Biotin Dermatitis, seborrhea B9 Folic acid Megaloblastic anaemia, deficiency during pregnancy - neural tube defects B12 Cyanocobalamin Megaloblastic anaemia, peripheral neuropathy C Ascorbic acid Scurvy  gingivitis  bleeding D Ergocalciferol, cholecalciferol Rickets, osteomalacia E Tocopherol, tocotrienol Mild haemolytic anaemia in newborn infants, ataxia, peripheral neuropathy K Naphthoquinone Haemorrhagic disease of the newborn, bleeding diathesis 413 Contact me at: samehezzat3@yahoo.com Cystic fibrosis      Cystic fibrosis (CF) is an autosomal recessive disorder Causes increased viscosity of secretions (e.g lungs and pancreas) It is due to a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which codes a cAMP-regulated chloride channel In the UK 80% of CF cases are due to delta F508 on the long arm of chromosome Cystic fibrosis affects per 2500 births, and the carrier rate is c in 25 Organisms which may colonise CF patients:     Staphylococcus aureus Pseudomonas aeruginosa Burkholderia cepacia* Aspergillus *previously known as Pseudomonas cepacia ً‫تم بفضل هللا الجزء الثالث واالخٌر اسأل هللا ان ٌوفقكم جمٌعا وٌنفع بكم جمٌع المرض‬ 414 Contact me at: samehezzat3@yahoo.com ‫هجَ ‪ٝ‬كبر‪ٚ‬؛ هَْ اَُلبػ أُـ‪ ٢ُٞ‬عٌ٘‪٤‬ي فبٕ ٌِٓٔز‪ ٚ‬اُ‪ٞ‬اٍؼخ ث‪ ٖ٤‬أ‪ٝ‬الك‪ ٙ‬األهثؼخ‪ ،‬كٌبٕ ٖٗ‪٤‬ت اث٘‪ٚ‬‬ ‫األًجو “ع‪ٞ‬ع‪ ”٢‬ثالك ه‪٤ٍٝ‬ب ‪ٝ‬ثِـبه‪٣‬ب ‪ٝ‬اُو‪ٞ‬هبى‪ٝٝ ،‬هس ثوًخ فبٕ ػوُ أث‪ ٚ٤‬ػبّ ‪ٛ 652‬غو‪٣‬ب‪ ،‬أ‪ ١‬هجَ ٍو‪ٛٞ‬‬ ‫ثـلاك ثأهثغ ٍ٘‪ٞ‬اد‪.‬‬ ‫هئ‪َ٤‬ب ُِوج‪ِ٤‬خ اُن‪ٛ‬ج‪٤‬خ ك‪٢‬‬ ‫ً‬ ‫‪ًٝ‬بٕ ثوًخ فبٕ (‪ )ّ 1267 -1256‬أ‪ ٖٓ ٍٝ‬أٍِْ ٖٓ أٓواء أُـ‪ًٝ :ٍٞ‬بٕ‬ ‫ه‪٤ٍٝ‬ب ث‪ٍ٘ ٖ٤‬ز‪ّ 1267ٝ 1256 ٢‬‬ ‫‪ًٝ‬بٕ ٍجت ئٍالٓ‪ ٞٛ ٚ‬إٔ اُْ‪٤‬ـ ٗغْ اُل‪ٓ ٖ٣‬قزبه اُيا‪ٛ‬ل‪ٙٝ ١‬غ ُجوًخ فبٕ ك‪ٍ٘ ٢‬خ ‪ٛ1260‬ـ هٍبُخ‬ ‫رإ‪٣‬ل ثبُجوا‪ ٖ٤ٛ‬هٍبُخ اُ٘ج‪ ٢‬اُل‪٤٘٣‬خ‪ٝ ،‬رلؽ٘ ٓب مًو‪ ٙ‬أٌُ٘و‪ُٜ ٕٝ‬ن‪ ٙ‬اُوٍبُخ‪ٝ ،‬رٔ ُّ‬ ‫لٗب ث‪ٕٞ‬ق ُِٔ٘ب‪ٟ‬واد‬ ‫اُز‪ ٢‬هبٓذ ث‪ ٖ٤‬أَُ‪٤‬ؾ‪ٝ ٖ٤٤‬أَُِٔ‪.ٖ٤‬‬ ‫‪ٝ‬هل ه‪ َ٤‬ك‪ٍ ٢‬جت ئٍالٓ‪ ٚ‬ئٗ‪ ٚ‬راله‪ًٓٞ٣ ٠‬ب ٓغ ػ‪٤‬و ُِزغبه آر‪٤‬خ ٖٓ ثقبه‪ُٔٝ ،١‬ب فال ثزبعو‪ٍ ْٜ٘ٓ ٖ٣‬أُ‪ٜٔ‬ب‬ ‫ػٖ ػوبئل اإلٍالّ‪ ،‬كْوؽب‪ٛ‬ب ّوؽًب ٓو٘ ً‬ ‫ؼب اٗز‪ ٠ٜ‬ث‪ ٚ‬ئُ‪ ٠‬اػز٘بم ‪ٛ‬نا اُل‪ٝ ٖ٣‬اإلفالٓ ُ‪ٝ ٚ‬هل ًبّق‬ ‫إٔـو ئف‪ٞ‬ر‪ ٚ‬أ‪ ٍٝ‬األٓو ػٖ رـ‪٤٤‬و‪ُ ٙ‬ل‪ٝ ،ٚ٘٣‬اػز٘به‪ ٚ‬اإلٍالّ‪ٝ ،‬ؽجت ئُ‪ ٚ٤‬إٔ ‪٣‬ؾن‪ ٝ‬ؽن‪ ،ٙٝ‬صْ أػِٖ ثؼل مُي‬ ‫اػز٘به‪ُٜ ٚ‬نا اُل‪."…ٖ٣‬‬ ‫ًبٕ ئٍالٓ‪ٕ ٚ‬لٓخ ًج‪٤‬وح ثبَُ٘جخ ُجبه‪ ٢‬أكواك اُج‪٤‬ذ أُـ‪ ٢ُٞ‬اُؾبًْ‪ٝ ،‬أ‪ٚ٣‬ب ُٔإهف‪ ٢‬اُـوة ك‪ٔ٤‬ب ثؼل‪،‬‬ ‫ك‪ ٢ٜ‬أُوح األ‪ ٢ُٝ‬ك‪ ٢‬اُزبه‪٣‬ـ اُز‪٣ ٢‬لفَ ك‪ٜ٤‬ب أُ٘زٖو‪ ٖ٣‬ك‪ ٖ٣‬أُـِ‪ٞ‬ث‪.ٖ٤‬‬ ‫‪ٝ‬ؽ‪ٔ٘٤‬ب أٍِْ ثوًخ فبٕ أهبّ ٓ٘به اُل‪ٝ ،ٖ٣‬أ‪ٜٟ‬و ّوائغ اإلٍالّ‪ٝ ،‬أًوّ اُلو‪ٜ‬بء‪ٝ ،‬اُؼِٔبء ‪ٝ‬أكٗب‪ِْٜٕٝٝ ْٛ‬‬ ‫‪ٝ‬ارقن أَُبعل ‪ٝ‬أُلاهً ث٘‪ٞ‬اؽ‪ٌِٔٓ ٢‬ز‪ٝ ٚ‬أفن اإلٍالّ عَ ػْ‪٤‬ور‪ ٚ‬‬ ‫ؽب‪ ٍٝ‬ثوًخ فبٕ ‪ٝ‬هق اُيؽق أُـ‪ ٢ُٞ‬ػِ‪ ٠‬ثـلاك‪ ،‬كلفَ ك‪ ٢‬ؽو‪ٝ‬ة ٓغ ‪ٞٛ‬الً‪ ٞ‬اُن‪ٗ ١‬وْ ػِ‪ ٚ٤‬ئٍالٓ‪ٚ‬‬ ‫‪ٔٛٝ‬غ ك‪ ٢‬االٍز‪٤‬الء ػِ‪ ٠‬أها‪ٌِٔٓ ٢ٙ‬ز‪ ،ٚ‬كَبه ثوًخ ُِوبئ‪ُٝ ،ٚ‬و‪ٞٛ ٢‬الً‪ٛ ٞ‬ي‪ٔ٣‬خ ‪ِٛ‬ي ك‪ٜ٤‬ب أؿِت‬ ‫ع‪ٛ ٖٓٝ ْٚ٤‬ن‪ ٙ‬اَُ٘خ – ‪ٛ 653‬غو‪٣‬ب – ْٗأد اُؾوة ث‪ ٖ٤‬اُ‪ٞ‬بئلز‪ٓ ٖ٤‬ـ‪ ٍٞ‬اُوج‪ِ٤‬خ اُن‪ٛ‬ج‪٤‬خ ثو‪٤‬بكح ثوًخ‬ ‫فبٕ ‪ٓٝ‬ـ‪ ٍٞ‬كبهً ثو‪٤‬بكح ‪ٞٛ‬الً‪ٝ ٞ‬أث٘بئ‪ ٖٓ ٚ‬ثؼل‪ٙ‬‬ ‫‪ٝ‬ثؼل ٍو‪ ٛٞ‬ثـلاك‪ ،‬اٍزـَ ثوًخ فبٕ ‪ٝ‬كبح فبٕ أُـ‪ ٍٞ‬األًجو‪ٝ ،‬أّؼَ ٗبه ؽوة أ‪٤ِٛ‬خ ث‪ ٖ٤‬أكواك اُج‪٤‬ذ‬ ‫أُـ‪ ٢ُٞ‬ك‪ٗ ٢‬ياػ‪ ْٜ‬ػِ‪ٖ٘ٓ ٠‬ت اُقبٕ‪ٝ ،‬هل رَجت ‪ٛ‬نا اُٖواع ك‪ ٢‬ػ‪ٞ‬كح ‪ٞٛ‬الً‪ ٖٓ ٞ‬اُْبّ َٓوػب‪،‬‬ ‫ٖٓ‪ٞ‬ؾجب ٓؼ‪ ٚ‬أؿِت ع‪ ْٚ٤‬اُغواه‪ ‬ربهًب ثؼ‪ٓ ٚٚ‬غ هبئل‪ً“ ٙ‬زجـب” اُن‪ ١‬اله‪ ٢‬اُ‪ٜ‬ي‪ٔ٣‬خ ػِ‪ ٠‬أ‪٣‬ل‪١‬‬ ‫أَُِٔ‪ ٖ٤‬ك‪ٓ ٢‬ؼوًخ ػ‪ ٖ٤‬عبُ‪ٞ‬د اُقبُلح ‪ٛ 658‬غو‪٣‬ب‪ٝ ،‬اُز‪ ٢‬أٗوند اُؼبُْ ٖٓ اُيؽق أُـ‪ ٢ُٞ‬أُلٓو‪.‬‬ ‫‪ٝ‬اٍزٔو ثوًخ فبٕ ك‪ ٢‬ؽو‪ٝ‬ث‪ٓ ٚ‬غ ‪ٞٛ‬الً‪ٝ ٞ‬أث٘بئ‪ٝ ،ٚ‬ػَٔ ك‪ٗ ٢‬لٌ اُ‪ٞ‬هذ ػِ‪ٓ ٠‬ل اُؼالهبد اُلثِ‪ٓٞ‬بٍ‪٤‬خ‬ ‫أَُِ‪٤‬خ ٓغ أُٔبُ‪٤‬ي ك‪ٖٓ ٢‬و‪ٝ ،‬ى‪ٝ‬ط اث٘ز‪ ٖٓ ٚ‬اَُِ‪ٞ‬بٕ اُظب‪ٛ‬و ث‪٤‬جوً‪ٝ ،‬أٗغجذ ؿالٓب أ‪ِٛ‬ن ػِ‪ ٚ٤‬أث‪ٚ٤‬‬ ‫اٍْ عل‪ ٙ‬ثوًخ فبٕ‪.‬‬ ‫‪ٝ‬ر‪ٞٞ‬هد اُؼالهبد ث‪ ٖ٤‬اُغبٗج‪ ،ٖ٤‬كأٓو ث‪٤‬جوً ثبُلػبء ُِقبٕ اُززو‪ ٟ‬ػِ‪٘ٓ ٠‬بثو اُوب‪ٛ‬وح ‪ٝ‬اُولً ‪ٝ‬اُؾوٓ‪ٖ٤‬‬ ‫اُْو‪٣‬ل‪ ٖ٤‬ثٌٔخ أٌُوٓخ ‪ٝ‬أُل‪٘٣‬خ أُ٘‪ٞ‬هح‪.‬‬ ‫اٍزٔو ثوًخ فبٕ ك‪ ٢‬فلٓخ اإلٍالّ ؽز‪ٝ ٠‬كبر‪) ٚ‬هؽٔ‪ ٚ‬هللا( ك‪ ٢‬ػبّ ‪ٛ 665‬غو‪٣‬ب‪ ،‬ثؼلٓب أ‪ٔٛ‬ئٖ ػِ‪٠‬‬ ‫اٍزوواه اإلٍالّ ثل‪ُٝ‬ز‪ٝ ٚ‬آزل ٍِ‪ٞ‬بٕ هج‪ِ٤‬ز‪“ ٚ‬اُوج‪ِ٤‬خ اُن‪ٛ‬ج‪٤‬خ” ٖٓ روًَزبٕ ‪ٝ‬ؽز‪ ٠‬ه‪٤ٍٝ‬ب ‪٤ٍٝ‬جو‪٣‬ب ‪،‬‬ ‫‪ٝ‬هل ؽٌٔ‪ٞ‬ا ٓ‪ٗ ٌٍٞٞ‬لَ‪ٜ‬ب ‪ٖ٘٣ ٌٖ٣ ُْٝ ،‬ت أٓ‪٤‬و‪ٛ‬ب ئال ثؼل ٓ‪ٞ‬اكوز‪٣ٝ ، ْٜ‬إك‪ ١‬اُغي‪٣‬خ َُال‪ ٖ٤ٛ‬أُـ‪ٍٞ‬‬ ‫أَُِٔ‪.ٖ٤‬‬ ‫‪415‬‬ ‫‪Contact me at: samehezzat3@yahoo.com‬‬ ... should be employed 13 Contact me at: samehezzat3@yahoo.com Drugs causing dyspepsia: Causes  NSAIDs  bisphosphonates  steroids The following drugs may cause reflux By reducing lower oesophageal sphincter... Small intestine, pancreas Neural 1) Stimulates secretion by pancreas D cells in the pancreas & stomach Fat, bile salts and glucose in the intestinal lumen upper small intestine VIP 1) Partially... treatment: endoscopically (for example, EMR Endoscopic mucosal resection) or even surgically (e.g oesophagectomy), photodynamic therapy, ablative therapy 20 Contact me at: samehezzat3@yahoo.com