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Answers Case study level 1 – ulcerative colitis – see page 1 1a What is ulcerative colitis? Ulcerative colitis is an inflammatory disease of the lower gastrointestinal tract 160 mg kamagra super amex, which results in episodes of diarrhoea discount 160 mg kamagra super with mastercard. There may also be extraintestinal symp- toms, including anaemia, arthritis, dermatological problems and eye disorders. The exact causes are unclear, although there are several theories, which include genetic, environmental and microbial factors, possibly associated with an inap- propriate immune response. Although anyone can develop ulcerative colitis it appears to be most common in developed countries, and the risk appears greater if a first-degree relative has the disease. Patients most commonly present at 20–40 years of age and some studies suggest that ulcerative colitis is slightly more common in women than men. Gastrointestinal case studies 9 3a What is the active ingredient of Predsol and what class of drugs does it come from? Corticosteroids have anti-inflammatory and immunosuppressive effects, which reduce the causes of the diarrhoea and thereby settle the disease. Corticosteroids can also cause increased appetite, weight gain, insomnia, depression, osteoporosis, peptic ulceration and glucose intolerance, leading to diabetes. Immunosupression caused by this type of treatment can lead to an increased susceptibility to infection. Therefore patients taking corticosteroids (usually in high doses) should not be given live vaccines. Although systemic absorption of the prednisolone from the enema probably does occur, especially when the colon is particularly inflamed, corticosteroids usually have less systemic effects when given this way. Furthermore, by giving an enema, the drug is being delivered directly to its site of action – remember that in ulcerative colitis the disease is confined to the lower gastrointestinal tract. She could self-administer: I tablets (either plain or enteric coated) I suppositories I foam enemas. This is because they will enter the bloodstream in greater amounts by the oral route and have systemic effects. It is usually recommended that corticosteroids are used in the lowest possible dose for the shortest possible period of time.

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Subepithelial fibrosis order kamagra super 160 mg without prescription, often beginning in the inferomedial fornix and semilunar fold areas discount 160 mg kamagra super with mastercard, leading to progressive conjunctival shrinkage and symblepharon a. Conjunctival scar formation observed as lacy subconjunctival cicatrization, often linear, paralleling the eyelid margin, associated with trichiasis b. With progression, shortening of conjunctival fornix with symblepharon between the bulbar and palpebral conjunctiva c. Lagophthalmos with exposure of the ocular surface; abnormal position of the eyelids and eyelashes including entropion, trichiasis, madarosis, and distichiasis 8. Corneal findings, may include punctate epithelial erosions, pannus, neurotrophic keratopathy, and subepithelial opacification 9. Skin lesions: non-scarring skin bullae of extremities and groin, or as erythematous plaques of the head; hyper or hypopigmentation b. Oral lesions, including bullae of the mouth, nose, pharynx, or larynx; desquamative gingivitis; and esophageal strictures D. Serial photographs or detailed record keeping of sequential slit-lamp biomicroscopic examinations to evaluate presence, extent, and progression of subconjunctival scarring, fornix foreshortening, and symblepharon 2. Conjunctival biopsy for severe or progressive disease (See Conjunctival biopsy), including examination of cellular histopathology and immunopathology (linear deposition of immunoglobulin G, immunoglobulin A, and/or complement along epithelial basement membrane) c. Severe or progressive conjunctival inflammation from autoimmune or infectious disease B. Exogenous exposure to inciting agent, including allergen, topical medication, or noxious chemical reagent C. For immune-mediated diseases, topical and systemic immunosuppressive therapy when indicated 4. For infectious etiology, aggressive topical or oral antibiotic or antiviral therapy B. Daily lysis of symblepharon formation during active phase of the disease but remains controversial 3. Ocular surface reconstruction with amniotic membrane grafting or mucous membrane grafting Additional Resources 1. Immunoglobulin E mediated mast cell degranulation triggering inflammatory cascade with the release of histamine and other mediators, including prostaglandins, thromboxanes, and leukotrienes 3. These various inflammatory agents, in conjunction with chemotactic factors, increase vascular permeability and result in the migration of eosinophils and neutrophils B.

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Both cell types generic kamagra super 160mg without a prescription, in conjunction with enteric microbiota produce a variety of signalling molecules that can activate a number of receptors on extrinsic primary afferent neurons buy kamagra super 160 mg with visa. Therefore, endocrine, neuronal and immune signals are all integrated and are sent to specific brain regions and may alter cognition, mood and emotions. The stomach is predominantly governed by vago-vagal reflexes, thus signals arising from extrinsic and intrinsic neurons are relatively weak. In the intestines, intrinsic primary afferent neurons and enteric motorneurons are important for intestinal function afferents are much stronger in the intestine, which are reliant on these signals [17]. Inter- estingly, some of these intrinsic afferents are normally unresponsive to mechanical stimuli, and only become responsive during periods of inflammation [33]. These terminals contain chemosensitive receptors, which are responsive to the peptides released by these cells [34]. These include receptors for orexigenic (hunger inducing) or anorexigenic (satiety inducing) peptides. Additionally, the receptors for anorexogenic peptides were found to be downregulated by fasting, while those for orexigenic peptides were upregulated, creating a greater impulse to eat. These reports reflect the phenotypic plasticity of vagal afferents depending on the homeostatic state [36]. A single layer of columnar intestinal epithelial cells forms the barrier between 100 trillion micro- organisms and the host [37]. With the observation that intestinal immune cells remain predominantly hyporeactive to the commensal bacteria that live in symbiosis within us, yet are hyperreactive against pathogens, alludes to the fact that the intestinal immune system can identify commensal bacteria from pathogens and generate appropriate responses in order to maintain normal well-being [40]. As the epithelial layer samples the luminal environment, lymphoid structures (including Peyer’s patches) located in the lamina propria in the intestine deal with immune insults [40] through specialised immune cells that sample antigens from or on microorganisms deliver them to antigen processing cells in Peyer’s patches, and dendritic cells in the lamina propria, which can extend their dendritic arbours through the epithelial tight junctions to sample the luminal environment. These cells possess a myriad of receptors that can recognise pathogen associated molecular patterns [41].