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In this phase, the stomach secretes hydrochloric acid and pepsin, digestive juices that help break down food. Phase 2: Set the stomach on start the gastric phase of digestion begins when food passes the cardiac sphincter, a circle of muscle at the end of the esophagus. The food exits the esophagus and enters the stomach, causing the stomach wall to distend. Gastric juice, a perfect complement to every meal Gastric juice secretions are highly acidic, with a pH of about 2. In addition to hydrochloric acid and pepsin, the gastric juices contain intrinsic factor (which helps the body absorb vitamin B12) and proteolytic enzymes (which help the body use protein). The gastric juices mix with the food, which becomes a thick, gruel-like material called chyme. Small intestine Nearly all digestion takes place in the small intestine, which is about 20 (6 m) long. Food passes from the stomach to the duodenum through a narrow opening called the pylorus. The duodenum also has an opening through which bile and pancreatic enzymes enter the intestine to neutralize the acidic chyme and aid digestion. The jejunum extends from the duodenum and forms the longest portion of the small intestine. Along with water and electrolytes, these nutrients are absorbed through the intestinal mucosa into the bloodstream for use by the body. The small intestine ends at the ileocecal valve, located in the lower right part of the abdomen. The ileocecal valve is a sphincter that controls the flow of digested material from the ileum into the large intestine and prevents reflux into the small intestine. Large intestine After chyme passes through the small intestine, it enters the ascending colon at the cecum, the pouchlike beginning of the large intestine. The large intestine absorbs nearly all of the water remaining in the chyme plus large amounts of sodium and chloride. The large intestine also harbors the bacteria Escherichia coli, Enterobacter aerogenes, Clostridium welchii, and Lactobacillus bifidus, which help produce vitamin K and break down cellulose into usable carbohydrates. Joining a mass movement In the lower part of the descending colon, long, relatively sluggish contractions cause propulsive waves known as mass movements. These movements propel the intestinal contents into the rectum and produce the urge to defecate. Accessory glands and organs the liver, gallbladder, and pancreas contribute several substances, such as enzymes, bile, and hormones, that are vital to the digestion of chyme. These structures deliver their secretions to the duodenum through the ampulla of Vater. Gallbladder the gallbladder is a small, pear-shaped organ nestled under the liver and joined to the larger organ by the cystic duct. Bile is a clear yellowish liquid that helps break down fats and neutralize gastric secretions in the chyme. You have a delivery Secretion of the hormone cholecystokinin causes the gallbladder to contract and the ampulla of Vater to relax. This allows the release of bile into the common bile duct for delivery to the duodenum. Pancreas the pancreas lies behind the stomach, with its head and neck extending into the curve of the duodenum and its tail lying against the spleen. These lobules of enzyme-producing cells release their secretions into small ducts that merge to form the pancreatic duct.

Mania occurring secondary to disease with distinctive features is immediately suggested by these features, as listed in Table 33. Some elaboration may be in order regarding mania secondary to cerebral infarction. This cause, of course, is suggested by the sudden onset of the clinical disturbance, with the mania being accompanied by various other more or less localizing signs: what is most remarkable here is the variety of structures which, if infarcted, may be followed by mania. Ictal mania is characterized by its paroxysmal onset, over seconds and the diagnosis of postictal mania is suggested when mania occurs shortly after a "flurry" of grand mal or complex partial seizures. Mania occurring as part of certain neurodegenerative or dementing diseases is suggested, in general, by a concurrent dementia, and in most cases the mania plays only a minor role in the overall clinical pictures. Neurosyphilis, however, is an exception to this rule, for in patients with general paresis of the insane (dementia paralytica) mania may dominate the picture. Of the miscellaneous or rare causes of mania, cerebral tumors are the most important to keep in mind, with mania being noted with tumors of the midbrain, tumors compressing the hypothalamus. In cases where such etiologic treatment is not possible, or not rapidly effective enough, pharmacologic measures are in order. Mood stabilizers, such as lithium or divalproex used in a fashion similar to that for the treatment of mania occurring in bipolar disorder, are commonly used: both lithium and divalproex are effective in the prophylaxis of mania occurring secondary to prednisone; case reports also support the use of lithium for mania secondary to zidovudine and divalproex for mania secondary to closed head injury. As between lithium and divalproex, in cases where there is a risk for seizures. Clinical Vignette 1 Liebson (2000) reported the case of a 53-year-old man with a right thalamic hemorrhage, who presented with headache and left-sided hemiparesis and hemianesthesia. Four days later he displayed signficant anosognosia for his hemiparesis; more remarkable, however, was the change in his mood. When he arrived on our ward 11 days after the stroke he was flirtatious with female staff and boasted of having fathered 64 children. His girlfriend was surprised when he kissed her in front of the staff because he had never publicly displayed affection before. He reported excellent energy and expansively invited all the staff to his home for Thanksgiving. Assessment and Differential Diagnosis In most cases of mania secondary to precipitants, the cause. The miscellaneous or rare causes represent the "zebras" in the differential of secondary mania, and are generally only resorted to when other investigations prove unrewarding. As a rule, it is very rare for mania to constitute the initial presentation of any of the disease or disorders listed in Table 33. In cases where emergent treatment is required, before lithium or divalproex could have a chance to become effective, oral or intramuscular lorazepam or haloperidol (in doses of 2 mg and 5 mg, respectively) may be utilized, again much as in the treatment of mania in bipolar disorder. Anxiety Disorder Due to a General Medical Condition with Panic Attacks or with Generalized Anxiety Definition Pathologic anxiety secondary to a general medical condition may occur in the form of well-circumscribed and transient panic attacks or in a generalized, more chronic form. As the differential diagnoses for these two forms of anxiety are quite different, it is critical clearly to distinguish between them. Panic attacks have an acute or paroxysmal onset, and are characterized by typically intense anxiety or fear which is accompanied by various "autonomic" signs and symptoms, such as tremor, diaphoresis and palpitations. Symptoms rapidly crescendo over seconds or minutes and in most cases the attack will clear within anywhere from minutes up to a half-hour. Although attacks tend to be similar one to another in the same patient, there is substantial interpatient variability in the symptoms seen. Generalized anxiety tends to be of subacute or gradual onset, and may last for long periods of time, anywhere from days to Epidemiology and comorbidity Relative to cases of primary mania. In certain settings, however, secondary mania may be so common as to merit a "top" position on the differential diagnosis; a prime example would be when prednisone is used in high doses, as in the treatment of multiple sclerosis or rheumatoid arthritis. Course Most cases of medication-induced mania begin to clear in a matter of days; for other causes, the course of the mania generally reflects the course of the underlying disease.

Cross National Collaborative Group (1992) the changing rate of major depression: Cross-national comparisons. Poster presented at Third International Congress on the Disorders of Personality, Cambridge, Massachusetts. An increasing amount of data indicates that mania and hypomania do not typically take the classic, euphoric, optimistic form that appears to be the polar opposite of depression. Rather, hyperactivation appears to be the core symptom of mania and hypomania while mood itself is quite variable; dysphoria and depression rather than euphoric mood are the rule rather than the exception; and patients rate their quality of life during mania or hypomania as worse than or no better than normal, rather than being enhanced as commonly supposed. Criteria for these episodes are reviewed in greater detail in the subsequent section on diagnosis. Previously, persons with depressive and hypomanic episodes were grouped under the broad "bipolar disorder not otherwise specified", which included a variety of unusual presentations. Similarly, the effectiveness of medications such as lithium renders purely psychosocial theories untenable. An integrative biopsychosocial mindset will likely be the most successful approach to treatment, as Engel articulated for all illnesses, both medical and psychiatric. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment. Note: Mixed-like episodes that are clearly caused by somatic antidepressant treatment. Interestingly, rates of unipolar depression in fi rst-degree relatives are about twofold elevated over those in the general population.

As the air pressure in the pleural cavity becomes positive, the lung collapses on the affected side. A leak within the lung Closed pneumothorax occurs when air enters the pleural space from within the lung. This causes increased pleural pressure and prevents lung expansion during inspiration. It may be called traumatic pneumothorax when blunt chest trauma causes lung tissue to rupture, resulting in air leakage. On inspiration, the mediastinum shifts toward the unaffected lung, impairing ventilation. On expiration, the mediastinal shift distorts the vena cava and reduces venous return. The usual cause is rupture of a subpleural bleb (a small cystic space) at the surface of the lung. This causes air leakage into the pleural spaces; then the lung collapses, causing decreased total lung capacity, vital capacity, and lung compliance-leading, in turn, to hypoxia. What to look for Although the causes of traumatic and spontaneous pneumothorax vary greatly, the effects are similar. Such treatment consists of bed rest; careful monitoring of blood pressure, pulse, and respiratory rate; pulse oximetry; oxygen administration; and, possibly, aspiration of air with a large-bore needle attached to a syringe. If more than 30% of the lung collapses, a thoracostomy tube is typically placed in the second intercostal space in the midclavicular line to try to reexpand the lung. If blood is present in the pleural space, a second thoracostomy tube is placed in the fourth, fifth, or sixth intercostal space to drain the blood. Treatment for recurring spontaneous pneumothorax is thoracotomy and pleurectomy, which causes the lung to adhere to the parietal pleura. Traumatic Traumatic pneumothorax requires thoracostomy tube insertion and chest drainage and may also require surgical repair. A largebore needle is inserted into the pleural space through the second intercostal space. If large amounts of air escape through the needle after insertion, the needle is left in place until a thoracostomy tube can be inserted. Sequential chest X-rays show whether thoracostomy was effective in resolving pneumo thorax. How it happens Pulmonary edema may result from left-sided heart failure caused by arteriosclerotic, cardiomyopathic, hypertensive, or valvular heart disease. Off balance Normally, pulmonary capillary hydrostatic pressure, capillary oncotic pressure, capillary permeability, and lymphatic drainage are in balance. When this balance changes, or the lymphatic drainage system is obstructed, pulmonary edema results. If colloid osmotic pressure decreases, the hydrostatic force that regulates intravascular fluids is lost because nothing opposes it. Fluid flows freely into the interstitium and alveoli, impairing gas exchange and leading to pulmonary edema. How pulmonary edema develops In pulmonary edema, diminished function of the left ventricle causes blood to pool there and in the left atrium.