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Iron Zinc may reduce High intakes of supplemental zinc may reduce iron iron absorption hair loss in men 21 cheap propecia 1 mg. One study found a 56 percent decline in iron absorption when a supplemental dose of zinc and iron (administered in water) contained five times as much zinc as iron hair loss cure 2013 loreal buy propecia online from canada. However hair loss in men jogger order propecia toronto, when the same dose was given in a hamburger meal hair loss cure just like heaven cheap propecia 1 mg with amex, no effect on iron absorption was noted. Because zinc is involved in so many core areas of metabolism, the signs and symptoms of mild deficiency are diverse and inconsistent. Impaired growth velocity is the primary clinical feature and can be corrected with zinc supplementation. Other functions that respond to zinc supplementation include pregnancy outcome and immune function. Other ba sic and nonspecific signs and symptoms include the following: G rowth retardation A lopecia D iarrhea D elayed sexual maturation and impotence Eye and skin lesions Impaired appetite It is noteworthy that zinc homeostasis within the body is such that zinc defi ciency can occur with only modest degrees of dietary zinc restriction, while circulating zinc concentrations are indistinguishable from normal. Special Considerations Individuals susceptible to zinc deficiency: People with malabsorption syndromes, including sprue, Crohns disease, and short bowel syndrome are at risk of zinc deficiency due to malabsorption of zinc and increased urinary zinc losses. Ac rodermatitis enteropathica, an autosomal recessive trait, is a zinc malabsorp tion problem of an undetermined genetic basis. Other adverse effects include the following: Acute effects: Acute adverse effects of excess zinc include acute epigastric pain, nausea, vomiting, loss of appetite, abdominal cramps, diarrhea, and headaches. Doses of 225450 mg of zinc have been estimated to Copyright National Academy of Sciences. Factors such as stress, acute trauma, and infection can cause plasma zinc levels to drop. This is because zinc, mainly found in the germ and bran portions of grains, is lost during the milling process. The adverse effects associated with chronic intake of excess supplemental zinc include acute gastrointestinal effects and headaches, impaired immune function, changes in lipoprotein and cholesterol levels. In addition, although silicon has not been shown to cause adverse effects in humans, there is no justification for adding it to supplements. For boron, silicon, and vanadium, measurable re sponses by human subjects to dietary intake variations have also been demon strated. However, the available data were not as extensive and the responses were not as consistently observed as with vitamins and other minerals. How ever, the data indicate a need for continued study of these elements to deter mine their metabolic role, identify sensitive indicators, and more fully charac terize their specific functions in human health. Animal studies suggest a role for arsenic in the metabolism of methionine, in growth and reproduction, and in gene expression. Although some evidence does suggest a role in the metabolism of vitamin D and estrogen, further research is necessary. Nickel: the possible nutritional importance or biochemical function of nickel in humans has not been established. Nickel may serve as a cofactor or struc tural component of specific metalloenzymes of various functions, including hy drolysis and redox reactions and gene expression. Silicon: A functional role for silicon in humans has not yet been identified, although animal studies show that silicon may be involved in the formation of bone. There are some reports that vanadium may increase the action of insulin, but the potential mechanism of action is uncertain. Absorption, Metabolism, Storage, and Excretion Arsenic: Approximately 90 percent of inorganic arsenic from water is absorbed by the body; the amount absorbed of dietary arsenic is approximately 6070 percent. Once absorbed, inorganic arsenic is transported to the liver, where it is reduced to arsenite and then methylated. The mechanism of absorption has not been confirmed, but a passive (nonmediated) diffusion process is likely. Nickel: the absorption of dietary nickel is less than 10 percent and is affected by certain foods, including milk, coffee, tea, orange juice, and ascorbic acid. Most organs and tissues do not accumulate nickel, but in humans the thyroid and adrenal glands have relatively high concentrations. Because of the poor absorp tion of nickel, most ingested nickel is excreted in the feces. Absorbed nickel is excreted in the urine, with minor amounts secreted in the sweat and bile. Silicon in the blood exists almost entirely as silicic acid and is not bound to proteins. Most body silicon is found in the various connective tissues includ ing the aorta, trachea, bone, tendons, and skin. Absorbed vanadate is converted to the vanadyl cation, which can complex with ferritin and transferrin in plasma and body fluids. Very little absorbed vanadium re mains in the body; whatever does remain is found primarily in the liver, kid neys, and bone. Because of the low absorption of ingested vanadium, most excretion occurs through the feces. Adding to that a maximum intake from water of 2 mg/day provides a total intake of less then 5 mg/day of boron at this percentile. The risk of adverse effects resulting from excess intake of nickel from food and supplements appears to be very low at the highest intakes noted above. Increased risks are likely to occur from environmental exposures or from the consumption of contaminated water. Although silicon has not been shown to cause adverse effects in humans, there is no justification for adding it to supplements. Caution should be exercised regarding the consumption of vanadium supplements by these individuals. Because of the widespread use of high-dose (60 mg/day) supplemental va nadium by athletes and other subgroups. Vanadium in the forms of vanadyl sulfate (100 mg/day) and sodium metavanadate (125 mg/day) has been used as a supplement for diabetic pa tients. The risk of adverse effects resulting from excess intake of vanadium from food is very unlikely. Because of the high doses of vanadium present in some supple ments, increased risks are likely to result from excess intake. Based on a national survey conducted in six Canadian cities from 1985 to 1988, the foods that contained the highest concentrations of ar senic were fish, meat and poultry, bakery goods and cereals, and fats and oils. Major contributors of inorganic arsenic are raw rice, flour, grape juice, and cooked spinach. Boron: Fruit-based beverages and products, tubers, and legumes have been found to have the highest concentrations of boron. Other studies have reported that the top ten foods with the highest concentration of boron were avocado, peanut butter, peanuts, prune and grape juices, chocolate powder, wine, pe cans, and granola-raisin and raisin-bran cereals. When both content and total food consumption (amount and frequency) were considered, the five major contributors were found to be coffee, milk, apples, dried beans, and potatoes, which collectively accounted for 27 percent of the dietary boron consumption. Coffee and milk are generally low in boron, but they tend to be high dietary contributors because of the volume at which they are consumed. Nickel: Nuts and legumes have the highest concentrations of nickel, followed by sweeteners, including chocolate powder and chocolate candy. Major con tributors to nickel intake are mixed dishes and soups (1930 percent), grains and grain products (1230 percent), vegetables (1024 percent), legumes (3 Copyright National Academy of Sciences. Major contributors of nickel to the Canadian diet include meat and poultry (37 percent), bakery goods and cereals (19 percent), soups (15 percent), and vegetables (11 percent). Cooking acidic foods in stainless-steel cookware can increase the nickel content of these foods. Silicon: Plant-based foods contain higher concentrations of silicon than do animal-based foods. Beer, coffee, and water appear to be the major contributors of silicon to the diet, followed by grains and vegetables. Silicate additives that have been increasingly used as antifoaming and anticaking agents in foods can raise the silicon content of foods, but the bioavailability of these additives is low.

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How frequent are dysplasia Dysplasia and adenocarcinoma have a and adenocarcinoma in the prevalence of 3%9% hair loss in men rings order propecia 1 mg visa. Endoscopic surveillance should be performed hair loss in men39 s wearhouse buy propecia 5 mg visa, with multiple biopsies to hair loss hormone imbalance purchase discount propecia line check for dysplasia hair loss cure epilepsy cheap propecia line. Other than Barrett esopha Male gender, Caucasian, obesity, and gus and chronic smoking (possibly). Alcohol consumption gastroesophageal re ux, and Helicobacter pylori are not what additional risk factors associated with increased risk of exist for the development of esophageal adenocarcinoma. Although squamous cell carcinoma factor for squamous cell accounted for the majority of esophageal carcinoma of the esophagus What are the risk factors for Smoking, alcohol intake, presence of squamous cell carcinoma of achalasia, history of caustic injury to the the esophagus Pain of esophageal origin may radiate to the neck, arm, or jaw and can be aggravated by stress and exercise. Painful swallowing, most commonly expe rienced with esophageal mucosal lesions What are the symptoms and Odynophagia, dysphagia, fever, and signs of esophageal occasionally bleeding infections What is the treatment for Fluconazole, ketoconazole, nystatin, or esophageal infection with amphotericin B Candida In some cases, histology may reveal changes that are speci c for, or pathognomic of, a distinct cause of gastritis. When endoscopy does not reveal any mucosal erosions, but biopsies reveal an in ammatory in ltrate What is the most common H. What are some other causes Lymphocytic gastritis, and atrophic of nonerosive gastritis What are the symptoms and Nausea, vomiting (often with undigested signs of gastroparesis Nuclear medicine solid-phase gastric emptying studies are dif cult to standard ize, but they are commonly used (half-life 90 minutes suggests delayed emptying). A combination of intestinal and systemic manifestations resulting from the early delivery of large amounts of osmotically active food and liquids to the small bowel Who gets dumping Primarily, patients who have undergone syndrome What are the symptoms of Hypotension, dizziness, tachycardia, and dumping syndrome Octreotide can slow gastric emptying, as well as inhibit the release of insulin and other vasoactive intestinal hormones. Mucosal erosions or ulcerations, usually shallow, usually involving the body and fundus of the stomach, which occur in the setting of severe underlying medical illness Chapter 5 / Gastroenterology 217 What is a Curling ulcer A possible mechanism of ulcer formation is the loss of plasma volume, leading to sloughing of the gastric mucosa. Apart from the stomach, it may also develop in the proximal part of the duodenum and the distal esophagus. The 2 major risk factors are mechanical ventila tion for 48 hours and coagulopathy. Prevalence increases with age and is more common in African Americans and Hispanics because of socioeconomic and possible genetic factors. What medical conditions Gastritis (both acute and chronic have been associated with forms), intestinal metaplasia of the H. Factors believed to play a role include the following: Downregulation of important mucosal defense factors Increased gastric acid secretion Gastric metaplasia in the duodenum, which may provide a focus for the H. Histologic study Giemsa or Warthin Starry stains provide direct microscopic visualization of H. Brush cytology may be an acceptable alternative when gastric biopsies are undesirable. May be less accurate in patients older than 50 years and in patients with cirrhosis. How long should it take for With acid-suppressing medication, most an ulcer to heal Thus, with the exception of large or giant ulcers, most will heal within 812 weeks. Calcium stimulation test may also be useful (as intravenous calcium stimulates gastrin secretion). When feasible, surgical excision of the primary gastrinoma should be attempted, as this is the only curative option. Rarely, more radical surgeries, such as antrectomy with vagotomy or total gastrectomy, are required. Other interventions, including octreotide, chemotherapy, and emboliza tion of tumors, have not yet been shown to have consistent bene t. Watery stool Absence of pus, blood, or mucus Persistent diarrhea, despite 2448-hour fast Stool osmolality equal to plasma osmolality, with stool osmotic gap 50 mOsm/kg H2O Calculated stool osmolality 2([stool Na ] [stool K ]) Stool osmotic gap measured osmolarity calculated osmolarity What are the causes of Enterotoxinsexposure to toxins from secretory diarrhea Abrupt onset of diarrhea lasting 23 weeks List the common causes of Infection (most common), drugs, acute diarrhea. Chapter 5 / Gastroenterology 229 What are the features of In ammation, mucosal invasion, blood bacterial infections of the and fecal leukocytes in the stool colon What are the causes of Campylobacter (most common); bacterial infections in the Salmonella (poultry); Shigella (day-care colon What are the causes of Giardia (well water), Cryptosporidium, parasitic infections of the Microsporida, Isospora small bowel What are the features of In ammation, mucosal invasion, blood parasitic infections of the and fecal leukocytes colon What organism causes Diphyllobothrium latum (sh parasitic infection of the tapeworm)causes B12 de ciency small intestine What organism causes Entamoeba species (especially parasitic infection of the Entamoeba histolytica), Trypanosoma colon What characterizes small Large-volume, watery, greasy stools with bowel diarrhea What diagnostic tests might Proctosigmoidoscopy or colonoscopy, be useful for evaluating especially for bloody diarrhea and to rule patients with diarrhea For acute diarrhea, correction of uid and electrolyte abnormalities and reduction of symptoms (with selective use of adsorbents, antisecretory drugs, opiate derivatives, anticholinergic agents, and antimicrobial agents) Clinical pearls Avoid antibiotic therapy in enteric Salmonella infection because a prolonged carrier state may be induced. Antimotility agents must be used with caution in patients with in ammatory diarrhea. Steatorrheagreasy, bulky, foul-smelling stools that oat Weight loss Symptoms corresponding to vitamin de ciencies What causes impaired Abnormal epitheliumintrinsic absorption Diminished amounts of the brush border enzyme, lactase, resulting in a decreased ability to break down lactose Who is affected by lactase Most common in African Americans, de ciency Asians, Eskimos, and Central and South Americans Chapter 5 / Gastroenterology 233 What is celiac sprue Also known as gluten-sensitive enteropathy Who is affected by celiac Can occur at any age. What dermatologic manifes Dermatitis herpetiformis tation is associated with celiac sprue Positive serologies support the diagnosis; histology of small-bowel biopsies con rms it. You can also test for the IgA anti-endomysial antibody via immuno u orescence, which is the antigen for the anti-endomysial antibody. What does a small-bowel Findings are characteristic, but not diag biopsy show in celiac sprue An acquired form of sprue of unclear etiology, infrequently encountered in the continental United States, that often improves with antibiotic therapy What is Whipple disease Tropheryma whippelii How is the diagnosis of By Congo red stain of a rectal, gastric, or amyloidosis made What is malabsorbed after Calcium, folic acid, and iron proximal small-bowel resec tion What causes impaired Pancreatic exocrine insuf ciency, bile digestion (maldigestion) What are the causes of bile Any disorder of bile acid enterohepatic acid insuf ciency Why does malabsorption of Bile salt deconjugation occurs, resulting fat and fat-soluble vitamins in impaired micelle formation, and subse occur with small-bowel quent malabsorption of these substances. What is the treatment for Attempt to correct the underlying cause, small-bowel bacterial over suppress bacterial growth with antimicro growth Clinical pearl Always consider malabsorption when the triad of anemia, weight loss, and diarrhea is identi ed.

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Screening for celiac disease in a North American population: sequential serology and gastrointestinal symptoms hair loss cure 9000 buy propecia 5mg low price. Is there any requirement for celiac disease screening routinely in postmenapausal women with osteoporosis Unkilned and large amounts of oats in the coeliac disease diet: a randomized hair loss thyroid generic propecia 1 mg otc, controlled study hair loss cure just like heaven quality 5 mg propecia. Diagnosing mild enteropathy celiac disease: A Randomized hair loss cures generic 5 mg propecia amex, controlled clinical study. Coeliac disease screening in children: assessment of a novel anti-gliadin antibody assay. A simple validated gluten-free diet adherence survey for adults with celiac disease. A Prospective comparative study of five measures of gluten-freediet adherence with celiac disease. Alimentary Pharmacology & Therapeutics 2007;26(9):1227-1235 First Principles of Gastroenterology and Hepatology A. Gluten measurement and its relationship to food toxicity for celiac disease patients. Seasonality of birth month of children with celiac disease differs from that in the general population and between sexes and is linked to family history and environmental factors. Validation study of villous atrophy and small intestinal inflammation in Swedish biopsy registers. A blinded pilot comparison of capsule endoscopy and small bowel histology in unresponsive celiac disease. Correlation analysis of celiac sprue tissue transglutaminase and deamidated gliadin IgG/IgA. Long-Term follow-up of 61 coeliac patients diagnosed in childhood: evolution toward latency is possible on a normal diet. In vivo real-time imaging of human duodenal mucosal structures in celiac disease using endocytoscopy. Effective detection of human leukocyte antigen risk alleles in celiac disease using tag single nucleotide polymorphisms. Toward the assessment of food toxicity for celiac patients: characterization of monoclonal antibodies to a main immunogenic gluten peptide. Primary intestinal intraepithelial natural killer-like T-cell lymphoma: case report of a distinct clinicopathologic entity. Quality of life in celiac disease patients: prospective analysis on the importance of clinical severity at diagnosis and the impact of treatment. Electrochemical immunosensor for detection of celiac disease toxic gliadin in foodstuff. Gluten intake interferes with the humoral immune response to recombinant hepatitis B vaccine in patients with celiac disease. Regional variation in celiac disease risk within Sweden revealed by the nationwide prospective incidence register. The everyday life of adolescent coeliacs: issues of importance for compliance with the gluten-free diet. Prevalence of dental enamel defects in celiac patients with deciduous dentition: a pilot study. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 2008;106(1):74-78. Hippocampal sclerosis in refractory temporal lobe epilepsy is associated with gluten sensitivity. Diagnostic value of endoscopic markers for celiac disease in adults: a multicentre prospective Italian study. Lymphocytic gastritis and celiac disease in indian children: evidence of a positive relation. In vitro differentiation of human monocytes into dendritic cells by peptic-tryptic digest of gliadin is independent of genetic predisposition and the presence of celiac disease. Canadian Association of Gastroenterology Consensus Rubio-Tapia A, et al Celiac disease and persistent symptoms. Clinical Staging and survival in refractory celiac disease: A single center experience. Tetraploid and hexaploid wheat varieties reveal large differences in expression of alpha-gliadins from homoeologous Gli-2 loci. Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: celiac disease and gluten sensitivity. Clinical Trial: cyclophosphamide pulse therapya promising therapeutic alternative in refractory celiac disease. Pathogenesis, epidemiology, and clinical manifestations of celiac disease in adults. Antagonist peptides of the gliadin T-cell stimulatory sequences: a therapeutic strategy for celiac disease. Long-Term follow-up of individuals with celiac disease: an evaluation of current practice guidelines. Deamidation of gliadin peptides in lamina propria: implications for celiac disease. Effect of intravenous immunoglobulin on cerebellar ataxia and neuropathic pain associated with celiac disease. The propensity for deamidation and transamidation of peptides by transglutaminase 2 is dependent on substrate affinity and reaction conditions. Dissecting the T cell response to hordeins in celiac disease can develop barley with reduced immunotoxicity. Review article: minimizing tuberculosis anti-tumour necrosis factor-alpha treatment of inflammatory bowel disease. Defining the optimal response criteria for the Crohns disease activity index for induction studies in patients with mildly to moderately active crohns disease. Risk factors associated with progression to intestinal complications of Crohns disease in a population based cohort. Commercial assays to assess gluten content of gluten-free foods: why they are not created equal. Immunoglobulin A anti-tissue transglutaminase antibody deposits in the small intestinal mucosa of children with no villous atrophy. A modified extraction protocol enables detection and quantification of celiac disease related gluten proteins from wheat. Journal of Chromatography B, Analytical Technologies in the Biomedical Life Sciences 2009;877(10):975-982 van Dommelen P, et al. Screening rules for growth to detect celiac disease: a case-control simulation study. Incidence of enteropathy-associated T-cell lymphoma: a nation-wide study of a population based registry in the Netherlands. The presence of small intestinal intraepithelial gamma/delta T-lymphocytes is inversely correlated with lymphoma development in refractory celiac disease. Age-related clinical, serological, and histopathological features of celiac disease. Detection of celiac disease and lymphocytic enteropathy by parallel serology and histopathology in a population based study. Prospective human leukocyte antigen, endomysium immunoglobulin A antibodies, and transglutaminase antibodies testing for celiac disease in children with Down syndrome. The evidence base for interventions used to maintain remissions in Crohns Disease. How long is it advisable to prolong maintenance treatment of patients with ulcerative colitis Genome-wide association defines more than 30 distinct susceptibility loci for Crohns disease. Inflammatory bowel disease: clinical aspects and established and evolving therapies. Blood-based biomarkers can differentiate ulcerative colitis from crohns disease and noninflammatory diarrhea.

An abdominal radiograph demonstrates an air-filled extreme hair loss cure buy cheapest propecia, kidney-beanshaped structure in the left upper quadrant hair loss on arms buy line propecia. Which of the following is the most appropriate management of echinococcal liver cysts A 28-year-old woman who is 15 weeks pregnant has new onset of nausea hair loss university of pennsylvania cheap propecia express, vomiting hair loss cure timeline order propecia without a prescription, and right sided abdominal pain. Which of the following is the most common nonobstetric surgical disease of the abdomen during pregnancy A 56-year-old woman has nonspecific complaints that include an abnormal sensation when swallowing. A 65-year-old man who is hospitalized with pancreatic carcinoma develops abdominal distention and obstipation. Which of the following is the most appropriate initial management of this patient Discontinuation of anticholinergic medications and narcotics and correction of metabolic disorders c. A 48-year-old man presents with jaundice, melena, and right upper quadrant abdominal pain after undergoing a percutaneous liver biopsy. Which of the following is the most appropriate first line of therapy for major hemobilia A 30-year-old female patient who presents with diarrhea and abdominal discomfort is found at colonoscopy to have colitis confined to the transverse and descending colon. He is referred to a gastroenterologist to be evaluated for inflammatory bowel disease (Crohn disease versus ulcerative colitis). Which of the following indications for surgery is more prevalent in patients with Crohn disease Fistulas between the colon and segments of intestine, bladder, vagina, urethra, and skin d. Investigation reveals a microcytic anemia and erosive gastritis on upper endoscopy. Cessation of smoking, decreased caffeine intake, and avoidance of large meals before lying down b. She is admitted to the hospital and undergoes upper endoscopy that is negative for any lesions. Colonoscopy is performed and no bleeding sources are identified, although the gastroenterologist notes blood in the right colon and old blood coming from above the ileocecal valve. A 32-year-old woman undergoes an uncomplicated appendectomy for acute appendicitis. The pathology report notes the presence of a 1-cm carcinoid tumor in the tip of the appendix. A 58-year-old man presents with a bulge in his right groin associated with mild discomfort. On examination the bulge is easily reducible and does not descend into the scrotum. Which of the following changes is most concerning for possible strangulation requiring emergent repair of the hernia Cholecystectomy with resection of the extrahepatic biliary tract and Roux-en-Y hepaticojejunostomy b. A 36-year-old man is in your intensive care unit on mechanical ventilation following thoracotomy for a 24-hour-old esophageal perforation. Which of the following findings on upper endoscopy would be most suspicious for stress gastritis Multiple, shallow lesions with discrete areas of erythema along with focal hemorrhage in the antrum b. Multiple, shallow lesions with discrete areas of erythema along with focal hemorrhage in the fundus c. Multiple deep ulcerations extending into and through the muscularis mucosa in the antrum d. Multiple deep ulcerations extending into and through the muscularis mucosa in the fundus. Single deep ulceration extending into and through the muscularis mucosa in the fundus 351. A 35-year-old man presents with right upper quadrant pain, fever, jaundice, and shaking chills. Ultrasound of the abdomen demonstrates gallstones, normal gallbladder wall thickness, and common bile duct of 1. An 88-year-old man with a history of end-stage renal failure, severe coronary artery disease, and brain metastases from lung cancer presents with acute cholecystitis. After a weekend drinking binge, a 45-year-old man presents to the hospital with abdominal pain, nausea, and vomiting. On physical examination, the patient is noted to have tenderness to palpation in the epigastrium. A 54-year-old man presents with sudden onset of massive, painless, recurrent hematemesis. Upper endoscopy is performed and reveals bleeding from a lesion in the proximal stomach that is characterized as an abnormally large artery surrounded by normal-appearing gastric mucosa. Which of the following is the most appropriate surgical management of this patient During an appendectomy for acute appendicitis, a 4-cm mass is found in the midportion of the appendix. Which of the following findings is most likely to be associated with the carcinoid syndrome It demonstrates a large gallstone in the cystic duct but also a polypoid mass in the fundus. Which of the following is an indication for cholecystectomy for a polypoid gallbladder lesion An alcoholic man has been suffering excruciating pain from chronic pancreatitis recalcitrant to analgesics and splanchnic block. A patient who has a total pancreatectomy might be expected to develop which of the following complications A 61-year-old woman with a history of unstable angina complains of hematemesis after retching and vomiting following a night of binge drinking. Endoscopy reveals a longitudinal mucosal tear at the gastroesophageal junction, which is not actively bleeding. Which of the following is the next recommended step in the management of this patient Expectant management Questions 362 to 365 Select the most appropriate diagnosis for each patient. On laboratory findings he has elevated levels of bilirubin and alkaline phosphatase. A 36-year-old woman presents with right upper quadrant abdominal pain and jaundice. On laboratory results she has leukocytosis and elevated levels of bilirubin and alkaline phosphatase. Ultrasound demonstrates gallstones, normal gallbladder wall thickness, no pericholecystic fluid, and a common bile duct of 1. On laboratory results he has no leukocytosis and normal levels of bilirubin, alkaline phosphatase, amylase, and lipase. On laboratory results she has no leukocytosis with normal levels of bilirubin and alkaline phosphatase. Ultrasound demonstrates gallstones, normal gallbladder wall thickness, no pericholecystic fluid, and a common bile duct of 3 mm. Questions 366 to 369 Select the most appropriate surgical procedure for each patient. A 37-year-old man with a 10-year history of ulcerative colitis who has a sessile polyp 10 cm from the anal verge with high-grade dysplasia. A 60-year-old woman with recurrent squamous cell carcinoma of the anus after chemoradiation. A 68-year-old woman with fecal incontinence who presents with a large fixed adenocarcinoma 3 cm from the anal verge. A 33-year-old man with a history of Crohn disease presents with severe abdominal pain and fever. On examination, his heart rate is 130 beats per minute, blood pressure 105/62 mm Hg, and 3 temperature 38.

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