Cholelithiasis is the medical term for gallstone disease.

Gallstones are concretions that form in the biliary tract, usually in the gallbladder (see the image below).Gallstones develop insidiously, and they may remain asymptomatic for decades. Migration of a a gallstone into the opening of the cystic duct may block the outflow of bile during gallbladder contraction. The resulting increase in gallbladder wall tension produces a characteristic type of pain (biliary colic). Cystic duct obstruction, if it persists for more than a few hours, may lead to acute gallbladder inflammation (acute cholecystitis). Choledocholithiasis refers to the presence of one or more gallstones in the common bile duct. Usually, this occurs when a gallstone passes from the gallbladder into the common bile duct A gallstone in the common bile duct may impact distally in the ampulla of Vater, the point where the common bile duct and pancreatic duct join before opening into the duodenum. Obstruction of bile flow by a stone at this critical point may lead to abdominal pain and jaundice. Stagnant bile above an obstructing bile duct stone often becomes infected, and bacteria can spread rapidly back up the ductal system into the liver to produce a life-threatening infection called ascending cholangitis. Obstruction of the pancreatic duct by a gallstone in the ampulla of Vater also can trigger activation of pancreatic digestive enzymes within the pancreas itself, leading to acute pancreatitis.[1, 2] Chronically, gallstones in the gallbladder may cause progressive fibrosis and loss of function of the gallbladder, a condition known as chronic cholecystitis. Chronic cholecystitis predisposes to gallbladder cancer. Ultrasonography is the initial diagnostic procedure of choice in most cases of suspected gallbladder or biliary tract disease (see Workup). The treatment of gallstones depends upon the stage of disease. Asymptomatic gallstones may be managed expectantly. Once gallstones become symptomatic, definitive surgical intervention with excision of the gallbladder (cholecystectomy) is usually indicated. Cholecystectomy is among the most frequently performed abdominal surgical procedures (see Treatment). Complications of gallstone disease may require specialized management to relieve obstruction and infection. Pathophysiology Gallstone formation occurs because certain substances in bile are present in concentrations that approach the limits of their solubility. When bile is concentrated in the gallbladder, it can become supersaturated with these substances, which then precipitate from solution as microscopic crystals. The crystals are trapped in gallbladder mucus, producing gallbladder sludge. Over time, the crystals grow, aggregate, and fuse to form macroscopic stones. Occlusion of the ducts by sludge and/or stones produces the complications of gallstone disease. The 2 main substances involved in gallstone formation are cholesterol and calcium bilirubinate. Cholesterol gallstones More than 80% of gallstones in the United States contain cholesterol as their major component. Liver cells secrete cholesterol into bile along with phospholipid (lecithin) in the form of small spherical membranous bubbles, termed unilamellar vesicles. Liver cells also secrete bile salts, which are powerful detergents required for digestion and absorption of dietary fats. Bile salts in bile dissolve the unilamellar vesicles to form soluble aggregates called mixed micelles. This happens mainly in the gallbladder, where bile is concentrated by reabsorption of electrolytes and water. Compared with vesicles (which can hold up to 1 molecule of cholesterol for every molecule of lecithin), mixed micelles have a lower carrying capacity for cholesterol (about 1 molecule of cholesterol for every 3 molecules of lecithin). If bile contains a relatively high proportion of cholesterol to begin with, then as

bile is concentrated, progressive dissolution of vesicles may lead to a state in which the cholesterol-carrying capacity of the micelles and residual vesicles is exceeded. At this point, bile is supersaturated with cholesterol, and cholesterol monohydrate crystals may form. Thus, the main factors that determine whether cholesterol gallstones will form are (1) the amount of cholesterol secreted by liver cells, relative to lecithin and bile salts, and (2) the degree of concentration and extent of stasis of bile in the gallbladder. Calcium, bilirubin, and pigment gallstones Bilirubin, a yellow pigment derived from the breakdown of heme, is actively secreted into bile by liver cells. Most of the bilirubin in bile is in the form of glucuronide conjugates, which are quite water soluble and stable, but a small proportion consists of unconjugated bilirubin. Unconjugated bilirubin, like fatty acids, phosphate, carbonate, and other anions, tends to form insoluble precipitates with calcium. Calcium enters bile passively along with other electrolytes. In situations of high heme turnover, such as chronic hemolysis or cirrhosis, unconjugated bilirubin may be present in bile at higher than normal concentrations. Calcium bilirubinate may then crystallize from solution and eventually form stones. Over time, various oxidations cause the bilirubin precipitates to take on a jet-black color, and stones formed in this manner are termed black pigment gallstones. Black pigment stones represent 10-20% of gallstones in the United States. Bile is normally sterile, but in some unusual circumstances (eg, above a biliary stricture), it may become colonized with bacteria. The bacteria hydrolyze conjugated bilirubin, and the resulting increase in unconjugated bilirubin may lead to precipitation of calcium bilirubinate crystals. Bacteria also hydrolyze lecithin to release fatty acids, which also may bind calcium and precipitate from solution. The resulting concretions have a claylike consistency and are termed brown pigment stones. Unlike cholesterol or black pigment gallstones, which form almost exclusively in the gallbladder, brown pigment gallstones often form de novo in the bile ducts. Brown pigment gallstones are unusual in the United States but are fairly common in some parts of Southeast Asia, possibly related to liver fluke infestation. Mixed gallstones Cholesterol gallstones may become colonized with bacteria and can elicit gallbladder mucosal inflammation. Lytic enzymes from bacteria and leukocytes hydrolyze bilirubin conjugates and fatty acids. As a result, over time, cholesterol stones may accumulate a substantial proportion of calcium bilirubinate and other calcium salts, producing mixed gallstones. Large stones may develop a surface rim of calcium resembling an eggshell that may be visible on plain x-ray films. Pneumothorax (pl. pneumothoraces) is an abnormal collection of air or gas in the pleural space that separates the lung from the chest wall, and that may interfere with normal breathing. A primary pneumothorax is one that occurs without an apparent cause and in the absence of significant lung disease, while a secondary pneumothorax occurs in the presence of pre-existing lung pathology. Occasionally, the amount of air in the chest increases markedly when a one-way valve is formed by an area of damaged tissue, leading to a tension pneumothorax. This condition is a medical emergency that can cause steadily worsening oxygen shortage and low blood pressure. Unless reversed by effective treatment, these sequelae can progress and cause death.

Pneumothoraces can be caused by physical trauma to the chest (including blast injury), or as a complication of medical or surgical intervention. Symptoms typically include chest pain and shortness of breath. Diagnosis of a pneumothorax by physical examination alone can be difficult or inconclusive (particularly in smaller pneumothoraces), so a chest X-ray or computed tomography (CT) scan is usually used to confirm its presence. Small spontaneous pneumothoraces typically resolve without treatment and require only monitoring. This approach may be most appropriate in subjects who have no significant underlying lung disease. In larger pneumothoraces, or when there are marked signs and/or symptoms, the air may be extracted with a syringe or a chest tube connected to a oneway valve system. Occasionally, surgical interventions are required when tube drainage is unsuccessful, or as a preventative measure, if there have been repeated episodes. The surgical treatments usually involve pleurodesis (which induce the layers of pleura to stick together) or pleurectomy (the surgical removal of pleural membranes). Primary spontaneous pneumothorax (PSP) tends to occur in young people without underlying lung problems, and usually causes limited signs and symptoms. Chest pain and sometimes mild breathlessness are the usual predominant presenting features.[1][2] Half of those with primary spontaneous pneumothorax are unaware of the potential danger in their condition and wait several days to seek medical attention.[3] PSP occurs more commonly during changes in atmospheric pressure and during exposure to loud music, explaining to some extent why episodes of pneumothorax may happen in clusters.[2] It is rare for a PSP to cause a tension pneumothorax.[1] Secondary spontaneous pneumothorax (SSP), by definition, occurs in individuals with significant underlying lung disease. Signs and symptoms in SSP tend to be more severe than in PSP, as the unaffected lung is generally not capable of replacing the loss of function in the affected lung. Hypoxemia (decreased blood oxygen levels) is usually present and may be observed as cyanosis (blue discoloration of the lips and skin). Hypercapnia (accumulation of carbon dioxide in the blood) is sometimes encountered; this may cause confusion and - if very severe may result in coma. The sudden onset of breathlessness in someone with chronic obstructive pulmonary disease, cystic fibrosis, or other serious lung disease should therefore prompt investigations to identify the possibility of a pneumothorax. [1][3] Traumatic pneumothorax occurs most commonly when the chest wall is pierced, such as when a stab wound or gunshot wound allows air to enter the pleural space, or because some other mechanical injury to the lung compromises the integrity of the involved structures. Traumatic pneumothoraces have been found to occur in up to half of all cases of chest trauma, with only rib fractures being a more common problem in this group. The pneumothorax can be occult (not readily apparent) in half of these cases, but may enlarge - particularly if mechanical ventilation is required.[2] They are also encountered in patients already receiving mechanical ventilation for some other indication.[2] In pneumothorax, breath sounds (audible using a stethoscope) may be diminished on the affected side, partly because air in the pleural space dampens the transmission of sound. Measures of the conduction of vocal vibrations to the surface of the chest may be altered - percussion of the chest may be perceived as hyperresonant (like a booming drum), and vocal resonance and tactile fremitus can both be noticeably decreased. Importantly, the volume of the pneumothorax can show limited correlation with the intensity of the symptoms experienced by the victim,[3] and

Tension pneumothorax Although multiple definitions exist, a tension pneumothorax is generally considered to be present when a pneumothorax leads to significant impairment of respiration or blood circulation.[4] The most common findings in people with tension pneumothorax are chest pain and respiratory distress, often with an increased heart rate (tachycardia) and rapid breathing (tachypnea) in the initial stages. Other findings may include quieter breath sounds on one side of the chest, low oxygen levels and blood pressure, and displacement of the trachea away from the affected side. Rarely, there may be cyanosis (bluish discoloration of the skin due to low oxygen levels), altered level of consciousness, a hyperresonant percussion note on examination of the affected side with hyperexpansion and decreased movement, pain in the epigastrium (upper abdomen), displacement of the apex beat (heart impulse), and resonant sound when tapping the sternum.[4] This is a medical emergency and may require immediate treatment without further investigations (see below).[3][4] Tension pneumothorax may also occur in those receiving mechanical ventilation, in which case it may be difficult to spot as the person is typically sedated; it is often noted because of a sudden deterioration in condition. [4] Recent studies have shown that the development of tension features may not always be as rapid as previously thought. Deviation of the trachea (windpipe) to one side and the presence of raised jugular venous pressure (distended neck veins) are not reliable as clinical signs.[4] Introduction to fracture Bones form the skeleton of the body and allow the body to be supported against gravity and to move and function in the world. Bones also protect some body parts, and bone marrow is the production center for blood products. Bone is not a stagnant organ. It is the body's reservoir of calcium and is always undergoing change under the influence of hormones. Parathyroid hormone increases blood calcium levels by leeching calcium from bone, while calcitonin has the opposite effect, allowing bone to accept calcium from the blood. What causes a fracture? When outside forces are applied to bone it has the potential to fail. Fractures occur when bone cannot withstand those outside forces. Fracture, break, or crack all mean the same thing. One term is not better or worse than another. The integrity of the bone has been damaged and the bone structure fails and a fracture occurs. Broken bones hurt for a variety of reasons including:

The nerve endings that surround bones contain pain fiber. These fibers may become irritated when the bone is broken or bruised. Broken bones bleed, and the blood and associated swelling (edema) causes pain. Muscles that surround the injured area may go into spasm when they try to hold the broken bone fragments in place, and these spasms may cause further pain.

Often a fracture is easy to detect because there is obvious deformity. However, at times it is not easily diagnosed. It is

important for the physician to take a history of the injury to decide what potential problems might exist. Moreover, fractures don't always occur in isolation, and there may be associated injuries that need to be addressed. Fractures can occur because of direct blows, twisting injuries, or falls. The type of forces or trauma applied to the bone may determine what type of injury that occurs. Some fractures occur without any obvious trauma due to osteoporosis, the loss of calcium in bone (for example a compression fracture of the vertebrae of the back). Descriptions of fractures can be confusing. They are based on:

storage and voiding symptoms are evaluated using the International Prostate Symptom Score (IPSS) questionnaire, designed to assess the severity of BPH.[3] BPH can be a progressive disease, especially if left untreated. Incomplete voiding results in stasis of bacteria in the bladder residue and an increased risk of urinary tract infection. Urinary bladder stones are formed from the crystallization of salts in the residual urine. Urinary retention, termed acute or chronic, is another form of progression. Acute urinary retention is the inability to void, while in chronic urinary retention the residual urinary volume gradually increases, and the bladder distends. This can result in bladder hypotonia. Some patients that suffer from chronic urinary retention may eventually progress to renal failure, a condition termed obstructive uropathy. A spinal cord injury (SCI) refers to any injury to the spinal cord that is caused by trauma instead of disease.[1] Depending on where the spinal cord and nerve roots are damaged, the symptoms can vary widely, from pain to paralysis to incontinence.[2][3] Spinal cord injuries are described at various levels of "incomplete", which can vary from having no effect on the patient to a "complete" injury which means a total loss of function. Treatment of spinal cord injuries starts with restraining the spine and controlling inflammation to prevent further damage. The actual treatment can vary widely depending on the location and extent of the injury. In many cases, spinal cord injuries require substantial physical therapy and rehabilitation, especially if the patient's injury interferes with activities of daily life. Spinal cord injuries have many causes, but are typically associated with major trauma from motor vehicle accidents, falls, sports injuries, and violence. Research into treatments for spinal cord injuries includes controlled hypothermia and stem cells, though many treatments have not been studied thoroughly and very little new research has been implemented in standard care. Signs observed by a physician and symptoms experienced by a patient will vary depending on where the spine is injured and the extent of the injury. These are all determined by the area of the body that the injured area of the spine innervates. A section of skin innervated through a specific part of the spine is called a dermatome, and spinal injury can cause pain, numbness, or a loss of sensation in the relevant areas. A group of muscles innervated through a specific part of the spine is called a myotome, and injury to the spine can cause problems with voluntary motor control. The muscles may contract uncontrollably, become weak, or be completely unresponsive. The loss of muscle function can have additional effects if the muscle is not used, including atrophy of the muscle and bone degeneration. A severe injury may also cause problems in parts of the spine below the injured area. In a "complete" spinal injury, all function below the injured area are lost. In an "incomplete" injury, some or all of the functions below the injured area may be unaffected. If the patient has the ability to contract the anal sphincter voluntarily or to feel a pinprick or touch around the anus, the injury is considered to be incomplete. The nerves in this area are connected to the very lowest region of the spine, the sacral region, and retaining sensation and function in these parts of the body indicates that the spinal cord is only partially damaged. A complete injury frequently means that the patient has little hope of functional recovery.[citation needed] The relative incidence of incomplete injuries compared to complete spinal cord injury has improved over the past half century, due mainly to the emphasis on better initial care and stabilization of spinal cord injury patients.[8] Most patients with incomplete injuries recover at least some function.[citation needed] In addition to sensation and muscle control, the loss of connection between the brain and

Where in the bone the break has occurred How the bone fragments are aligned Whether any complications exist Whether the skin is intact

The first step in describing a fracture is to decide if it is open or closed. If the skin over the break is disrupted, then an open fracture exists. The skin can be cut, torn, or abraded (scraped), but if the skin's integrity is damaged, the potential for an infection to get into the bone exists. Since the fracture site in the bone communicates with the outside world, these injuries often need to be cleaned out aggressively and many times require anesthesia in the operating room to do the job effectively. Compound fracture was the previous term used to describe an open fracture. Benign prostatic hyperplasia (BPH), benign enlargement of the prostate (BEP), adenofibromyomatous hyperplasia and incorrectly referred to benign prostatic hypertrophy, is an increase in size of the prostate. BPH involves hyperplasia (an increase in the number of cells) rather than hypertrophy (a growth in the size of individual cells), but the two terms are often used interchangeably, even amongst urologists.[1] It involves hyperplasia of prostatic stromal and epithelial cells, resulting in the formation of large, fairly discrete nodules in the periurethral region of the prostate. When sufficiently large, the nodules compress the urethral canal to cause partial, or sometimes virtually complete, obstruction of the urethra, which interferes with the normal flow of urine. It leads to symptoms of urinary hesitancy, frequent urination, dysuria (painful urination), increased risk of urinary tract infections, and urinary retention. Although prostate specific antigen levels may be elevated in these patients because of increased organ volume and inflammation due to urinary tract infections, BPH does not lead to cancer or increase the risk of cancer.[citation needed] Adenomatous prostatic growth is believed to begin at approximately age 30 years. An estimated 50% of men have histologic evidence of BPH by age 50 years and 75% by age 80 years. In 40-50% of these patients, BPH becomes clinically significant.[2] Benign prostatic hyperplasia symptoms are classified as storage or voiding. Storage symptoms include urinary frequency, urgency (compelling need to void that cannot be deferred), urgency incontinence, and voiding at night (nocturia). Voiding symptoms include urinary stream, hesitancy (needing to wait for the stream to begin), intermittency (when the stream starts and stops intermittently), straining to void, and dribbling. Pain and dysuria are usually not present. These

the rest of the body can have specific effects depending on the location of the injury. Determining the exact "level" of injury is critical in making accurate predictions about the specific parts of the body that may be affected by paralysis and loss of function. The level is assigned according to the location of the injury by the vertebra of the spinal column. While the prognosis of complete injuries are generally predictable since recovery is rare, the symptoms of incomplete injuries can vary and it is difficult to make an accurate prediction of the outcome. A Jackson-Pratt drain, JP drain, or Bulb drain, is a surgical drainage device used to pull excess fluid from the body by constant suction. The device consists of a flexible rubber bulbshaped something like a hand grenade -- that connects to an internal drainage tube. Removing the bulb's plug, squeezing air out of the bulb and replacing the plug creates suction in the drainage tubing. Another method involves folding the drain in half while it is uncapped, then while folded, recapping the drain. This action causes fluid to be gradually sucked out of the body and into the bulb itself. The bulb may be repeatedly opened to remove the collected fluid and squeezed again to restore suction. It is best to empty drains before they are more than half full to avoid the discomfort of the weight of the drain pulling on the internal tubing Patients or caretakers can "strip" the drains by taking a damp towel or piece of cloth and bracing the portion of the tubing closest to the body with their fingers, run the cloth down the length of the tube to the drain bulb. One can also put a little bit of lotion or mineral oil on their fingertips to lubricate the tube to make stripping easier. The portion of the tube closest to the exit point of the drain from the body should be gripped first, and once the length of the drain is stripped, the end closest to the bulb should then be released. This increases the level of suction and helps to move clots through the drainage tube into the bulb. Hemorrhoids (US English) or haemorrhoids (UK /hmrdz/), are vascular structures in the anal canal which help with stool control.[1][2] They become pathological or piles[3] when swollen or inflamed. In their physiological state they act as a cushion composed of arterio-venous channels and connective tissue that aid the passage of stool. The symptoms of pathological hemorrhoids depend on the type present. Internal hemorrhoids usually present with painless rectal bleeding while external hemorrhoids present with pain in the area of the anus. Recommended treatment consists of increasing fiber intake, oral fluids to maintain hydration, NSAID analgesics, sitz baths, and rest. Surgery is reserved for those who fail to improve following these measures.[4] ClassificationThere are two types of hemorrhoids, external and internal, which are differentiated via their position with respect to the dentate line.[3] ExternalExternal hemorrhoids are those that occur below the dentate line. They may actually be concealed from view however. Specifically, they are varicosities of the veins draining the territory of the inferior rectal arteries, which are branches of the internal pudendal artery. They are sometimes painful,

and often accompanied by swelling and irritation. Itching, although often thought to be a symptom of external hemorrhoids, is more commonly due to skin irritation. The skin irritation may be brought about by the inflammation of the external hemorrhoid which in turn leads to a barely noticeable watery discharge and skin irritation. External hemorrhoids are prone to thrombosis: if the vein ruptures and/or a blood clot develops, the hemorrhoid becomes a thrombosed hemorrhoid.[5] Internal Internal hemorrhoids are those that occur above the dentate line. Specifically, they are varicosities of veins draining the territory of branches of the superior rectal arteries. As this area lacks pain receptors, internal hemorrhoids are usually not painful and most people are not aware that they have them. Internal hemorrhoids, however, may bleed when irritated. Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated hemorrhoids. Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they are pushed outside the anus. If the anal sphincter muscle goes into spasm and traps a prolapsed hemorrhoid outside the anal opening, the supply of blood is cut off, and the hemorrhoid becomes a strangulated hemorrhoid. Internal hemorrhoids can be further graded by the degree of prolapse.[3][6]

Grade I: No prolapse. Grade II: Prolapse upon defecation but spontaneously reduce. Grade III: Prolapse upon defecation and must be manually reduced. Grade IV: Prolapsed and cannot be manually reduced. Hemorrhoid cushions are a part of normal human anatomy and only become a pathological disease when they experience abnormal changes. There are three cushions present in the normal anal canal.[3] They are important for continence, contributing to at rest 1520% of anal closure pressure and act to protect the anal sphincter muscles during the passage of stool.[2]