Treatment of pain

Treatment of pain

The treatment of the pain depend on the causes of the pain and also on types of the pain either acute or chronic pain

Drugs used in treatment of the pain

These drugs can be classified into three steps used as analgesic ladder means used first mild drugs effects to moderate and potent analgesic

Analgesic ladder

Steps 1 Simple analgesics such as paracetamol and non steroids anti-inflammatory drugs NSAIDs

Steps 2 used compound analgesic such as co-proxamol or co-codamol

Steps 3 Used opiate such as morphine

Which routes of these drugs can be taken

The route of administration of analgesic can by given by oral route or intramuscular route intravenous route by either continuous infusion or by patient controlled analgesia subcutaneous, transdermal such as dermal patches sublingual  such an under the tongue rectal through anal canal inhalational epidural and spinal nearly by all route

Paracetamol

Mild analgesic has no anti-inflammatory activity

Non- steroidal anti-inflammatory drugs

   

Such as ibuprofen,diclofenac

Has anti- inflammatory,analgesic and antipyretic actions

Mechanism of action acts by inhibition  synthesis of prostaglandins by inhibition of the enzyme cylco-oxygenase

They acts mainly peripherally but have some central action

Opioid analgesics

Examples morphine diamorphine fentanyl

  Causes analgesia euphoria and anxiolysis

Acts centrally and peripherally at opiate receptors such as mu kappa and delta receptors

Patient controlled analgesia

 More common used nowadays for postoperative pain which it is given by patient demands when patient feel pain can pressing a special controlled pump connected to the patient by a button on his hand on pressing it leads to release the analgesia

Treatment of chronic pain

Chronic pain is pain persists for long time period when it would be expected that healing is complete for more see here

 

  Treatment of chronic pain need functional rehabilitation

Drugs can be used to treated chronic pain are

Non steroids anti-inflammatory drugs

Long acting opioids eg transdermal fentanyl

Anti-epileptics drugs eg gabapentin ,lamotrigene

Antidepressants drugs for neuropathic pain

Treatment of cancer pain

Follow the analgesic ladder may require opioid analgesia as above

Aim for regular oral medication

Radiotherapy can provide pain relieve

Regional coeliac plexus block

CT- guided stereotactic per-cutaneous destructive procedures

  

Treatment the causes of the pain

 Causes types of the pain see here

tags:pain,treatment

  

Pain causes types and treatment

Pain causes types and treatment

Definition of pain

Someone feels an unpleasant sensation and bad emotional experience associated with actual or potential tissue damage , pain is considered as protective mechanism

Pain is also considered a good sign because it give us attention to the site of the disease which pain arise from it so it can be deal with it to make investigations and treatment that disease causing pain but sometimes the site of the pain not always indicated affection of the subjacent organ

Types of pain

Pain can arise from any part of the body which can be arise from the skin called skin pain or muscle pain nerve pain bone pain visceral pain joint pain ligament pain or cancer pain

Pain may be either acute or chronic pain
  
Acute pain

Which occur suddenly either due to medical or surgical diseases

  

Chronic pain

Which take longer duration than acute one and may persists for long periods such pain may resist to medical treatment such as chronic diseases like osteoarthritis, rheumatoid arthritis or due to behavioral and psychological problems such as depression or anxiety or due to neural changes in the dorsal horn ,spinal cord and brain lead to plasticity of the central nervous system eg phantom limb pain and pain of the peripheral neuropathy

Types of chronic pain

May be skeletal , spinal , joint , muscle or neuropathic eg burning

Commonly back pain and headache

Perception of pain

There is individual variations from person to others to feel the severity of the pain some one may become more sensitive to the pain more than others

This occurs in the thalamus and sensory cortex  which either referred pain or visceral pain such as

Referred pain

In this type of the pain from its name called referred pain in which the pain arise from organ and felt in other site  or is felt somewhere else than the real site of the lesion eg the referred shoulder pain due to diaphragmatic irritation by the phrenic and supraclavicular nerves both arise from the fourth cervical segment

 by mechanism in which the branches of visceral pain fibres synapse in the spinal cord with some of the same second order neurones that receive pain fibres from the skin therefore when the visceral pain fibres are stimulated pain signals from the viscera can be conducted through second neurones which normally conduct pain signals from the skin . the person perceives the pain as originating in the skin itself

Visceral pain

Viscera have sensory receptors for no other modality of sensation except pain , localized damage to viscera rarely causes severe pain , stimuli that cause diffuse stimulation of the nerve ending in a viscus can cause pain which is very severe eg distension of a hollow viscus 

Visceral pain from the thoracic and abdominal cavities is transmitted through sensory nerve fibres which runs in sympathetic nerves these fibres are C fibres which transmit burning and aching pain 

Some visceral pain fibres enter the spinal cord through the sacral parasympathetic nerves including those from distal colon rectum and bladder

Visceral pain fibres may enter the cord by the cranial nerves eg the glossopharyngeal and vagus nerves which transmit pain from the pharynx trachea and upper oesophagus

If a diseases affecting a viscus spreads to the parietal wall surrounding the viscera the pain perceived will be sharp and intense the parietal wall is innervated from spinal nerves including the fast A fibres

 

Pain localization

Visceral pain

Is referred to various dermatomes on the body surface in which the position of the pain feeling depend on the segment of the body from which the organ developed embryologically for example the heart originated in the neck and upper thorax therefore the visceral pain fibres from the surface of the heart enter the spinal cord from cervical 3 to thoracic 5( C3 to T5) that is why myocardial infarction patient feel pain in the neck

also pain from organs derived from the fore-gut is felt in the upper abdomen , pain from organs derived from the mid-gut is felt in the mid-abdomen and pain from organs derived from the hind-gut is felt in the lower abdomen

Parietal pain

Such as from parietal peritoneum the pain is transmitted by spinal nerves which supply the external body surface example is acute appendicitis which start as colic pain around the umbilicus and then shift or move to the right iliac fossa this is due to the nerve supply of the appendix and the umbilical region both arise from the tenth dorsal or thoracic segment of the spinal cord  at first the inflammation is confined to the appendix and the pain is referred to the umbilical area (visceral pain) but later on the peritoneum is involved and the pain is felt over the lesion itself in the right iliac fossa  (parietal pain

Radiating pain

In which the pain shoots from the original focus or lesion site towards other parts sharing the same nerve supply for example renal colic the pain shoots from the lion to the groin testis and inner side of the tight by genitofemoral nerve and also in biliary colic it radiate from the right hypochondirum to the lower angle of the scapula by seventh to ninth thoracic segments

Pain classification

Pain can be classified into either nociception or non nociception

Nociception pain

The physiological experience of pain is called nociception  which may somatic or visceral pain

Somatic pain

In which the pain is felt from the skin muscle joints bone ligaments is termed somatic pain

Any person has pain receptors by which he can feel the temperature (hot or cold) vibration  muscle stretching sprains cut wound or any injury causing tissue damage

Somatic pain commonly well localized and sharp pain and pain become worse or increased by movement or touching the affected area

Visceral pain

In which the pain is felt from the internal body organs or body cavity such as abdominal cavity which containing the small and large intestine liver spleen kidney thorax cavity which containing both lungs and the heart and the pelvic cavity which containing the ovaries urinary bladder uterus

  

The pain receptor feel inflammation stretching and tissue ischemia the visceral pain is poorly localized pain either colicky or cramping pain see above for more details

Non nociception pain

Which means no specific pain receptors

Which either sympathetic or neuropathic or nerve pain

Neuropathic or nerve pain

Which either arise from central nerve system where the pain originated from the nerve between the spinal cord and the brain or from the peripheral nerve system where the pain originated from the nerves between the tissue and spinal cord 

Such pain can be arise from never compression or entrapping eg carpet tunnel syndrome or from nerve degeneration eg brain stroke brain ischemia or from disc herniation or torn which causes nerve compression and inflammation or nerve infection or nerve injury

Sympathetic pain

Which arise from the sympathetic nervous system

This is a type from non nociception pain in which there is no specific pain receptors which commonly arise from bone fractures or soft tissue injuries of the upper or lower limbs

What are the harmful effects of untreated acute pain

If the acute pain not treated rapid it may causing the following effects on the different body system such as

Cardiovascular effects

The pain can causes raised pulse rate tachycardia and elevated blood pressure hypertension and increased myocardial oxygen consumption which is very serious in cardiac patient or patient with myocardial infarction

Respiratory effects

The patient become unable to cough adequately lead to sputum retention chest infection atelectasis 

Gastrointestinal effects

Reduced gastric emptying and bowel movement lead to vomiting and ileus

Genito-urinary effects
Urine retention

Musculoskeletal effcts

Muscle spasm and immobility

Psychological effects

Anxiety ,fear and sleeplessness

Neuroendocrine effects

Secretion of catecholamines such as adrenaline and catabolic hormones leading to increased metabolism and oxygen consumption which promotes sodium and water retention and hyperglycemia

Cancer pain

This type of pain arise either from either the cancer itself which rare cancer causes pain or from the cancer secondaries or metastasis which is common causing pain such as bone pain or visceral pain the cancer pain characterized by it is severe boring constant pain not relieved by rest or usual analgesic may need for narcotic for relieved it is due to a combination of neuropathic pain due to invasion of the nerve and nociception due to tissue damage

Treatment of pain

Pain treatment depend on the causes of the pain and on types of pain either acute or chronic pain see here

  

tags:causes,pain,types,treatment

EXPLAINING CEREBRAL ANEURYSM

EXPLAINING CEREBRAL ANEURYSM

Definition

  An aneurysm is focal dilatation of the vessel wall

Types

,  Is most often a balloon-like outpouching, but may also be fusiform

Site

 Aneurysms usually occur at branch points of major vessels e.g, internal carotid artery (lCA) bifurcation, or at the origin of smaller vessels e.g., posterior communicating artery or ophthalmic artery

 

 Approximately 85% of aneurysms arise from the anterior circulation (carotid) and 15% from the posterior circulation

vertebrobasilar

 

 Risk of aneurysm

Aneurysms are thin-walled and at risk for rupture. The major cerebral vessels, and therefore aneurysms, lie in the subarachnoid space. Rupture results in  subarachnoid hemorrhage (SAH) . The aneurysmal tear may be small and seal quickly or not

SAH may consist of a thin layer of blood in the CSF spaces, or thick layers of blood around the brain and extending into brain parencbyma. resulting in a clot with mass effect. The meningeal linings of the brain are sensitive

 

Symptoms and signs

 SAH usu­ally results in a sudden, severe thunderclap headache. A patient will classically describe the worst headache of my life. Present­ing neurologic symptoms may range from mild headache to coma to sudden death. The Hunt-Hess grading system categorizes patients clinically

Investigations

Patients with symptoms suspicious for SAH should have a head

CT immediately. Acute SAH appears as a bright signal in the fis­sures and CSF cisterns around the base of the brain

CT is rapid, noninvasive, and approximately 95% sensi­tive. Patients with suspicious symptoms but negative head CT should undergo lumber puncture

  Lumbar puncture (LP)  with Xanthochromia and high red blood cells counts is consistent with SAH , negative CT and LP essentially rules out SAH

Patients diagnosed with SAH  require four vessels cerebral angiography within 24 hours to assess for aneurysm or other vascular malformation

 Catheter angiography remains the gold standard for assessing the patients cerebral vasculature SAH

Treatment

Patients should be admitted to the neurologic ICU  hunt Hess grade 4 to 5 patients require intubation and hemodynamic monitoring and stabilization

, The current standard of care for ruptured aneurysms requires early aneurysmal occlusion there are two options for occlusion

 The patient may under go craniotomy with  microsurgical dissection and placement of a titanium clip across the aneurysm neck to exclude the aneurysm from the circulation and reconstitute the lumen of the parent vessel

The second option is to take the patient to the interventional neuroradiology suite for en­dovascular placement of looped titanium coils inside the aneurysm dome. The coils support thrombosis and prevent blood flow into the aneurysm

Factors favoring craniotomy and clipping

Include young age, good medical condition, and broad aneurysm necks

Factors favoring coiling

Include old age or medically-frail patients and narrow aneurysm necks

Clipping results in a more definitive cure, because coils can move and compact over time, requiring repeat angiograms and placement of additional coils

The decision to clip or coil is com­plex and should be fully explored

 Debate also continues regarding optimal care for unruptured intracranial aneurysms

SAH patients often require I to 3 weeks of lCU care after

aneurysm occlusion for medical complications that accompany neu­rologic injury. In addition to routine ICU concerns, SAH patients are also at risk for cerebral vasospasm

In vasospasm, cerebral arteries constrict pathologically and can cause ischemia or stroke from 4 to 21 days after SAH

Current vasospasm prophylaxis includes maintaining hypertension and mild hypervolemia to optimize perfusion, and administering nimodipine, a calcium channel blocker that may

decrease the incidence and degree of spasm

 Neurointerventional

Options for treating symptomatic vasospasm are intra-arterial papaverine and balloon angioplasty

, Aneurysmal SAH has an approximate mortality rate of 50% in the first month. Approximately one-third of survivors returns to pre­ SAH function, and the remaining two-thirds have mild to severe disability. Most require rehabilitation after hospitalization

tags:cerebral,explaining,aneurysm

EXPLAINING OF PITUITARY GLAND TUMOURS

EXPLAINING OF PITUITARY GLAND TUMOURS

 

 Introduction

In order to understanding the pituitary gland tumours it should be first known the important anatomy of the pitiuitary

The pituitary gland  or hypophysis cerebri is the master gland  in the body

It is an endocrine gland which secreted many hormones in the blood It very small in size a pea sized

It is intracranial structures which present in the middle cranial fossa It is lies in bony cavity like structure called sella trucica

It is composite structure consists of three parts the anterior intermediate and posterior lobe

Hormones secreted by anterior pituitary by its cells

Acidophilic cells secreted somatotropic or growth hormone and prolactin

Basophilic cells secreted adrenocorticotropic hormone (ACTH) , thyroid stimulating hormone (TSH) follicular and luteinzing hormones (FSH and  LH

 

Hormones secreted by posterior pituitary

Oxytocin and vasopressin or antiduritic hormones

 Pituitary gland tumours can be classified as follow

Classification of Pituitary tumours

Endocrine active	Clinical syndrome	Secretory product
Acromegaly gigantism	Growth hormone GH 20%	Somatrophic
Cushing,s disease	Adrenocorticotrophic hormone ACTH 15%	Corticotrophic
Amenorrhoea galactorrhoea impotence	Prolactin PRL 40%	Prolactinoma
Hyperthyroidism	Thyroid stimulating hormone TSH 1%	Thyrotrophic
Behaves as endocrine inactive	Follicle stimulating hormone FSH Luteinising hormone LH  1-2%	Gonadotrophic
Hyothyroidism	Alpha subunit 20%	Endocrine inactive

Pituitary tumours account for 8% of all intracranial tumours.  they were classified according to their staining characteristics seen on light microscopy. However, the three types (chromophobe, acidophilic and basophilic) did not corre­spond closely with the clinical syndromes of pituitary hyper­secretion. The subsequent development of immunological staining techniques and electron microscopy provided a more refined classificanon of pituitary tumours. It is now correct to classify pituitary tumours according to their size(micro­adenomas < 10 mm), mesoadenomas (10-20 mm) and macro­adenomas (> 20 mm) and whether they are endocrine active or inactive . These features will also determine their presentation.

Clinical features

  The most common en­docrine syndromes are Cushing's disease due to adrenocorticotropic hormone (ACTH) secretion, Forbes-Albright syndrome due to pro­lactin secretion, and acromegaly due to growth hormone secretion. 

Pituitary tumours arise in the sella turcica and can expand up into the suprasellar cisterns, compressing the optic chiasm above and resulting In visual failure (classically a bitemporal hemianopia

Careful assessment of the visual fields, visual acuity and optic fundi is therefore essential. They may also invade laterally into the cavernous sinuses on each side, compressing the third to sixth cranial nerves.

Endocrine disturbance is due to either hypopituitarism due to compression on the gland or excess secretion of a particular pituitary hormone.

Prolactin­ secreting tumours are usually found in younger women and cause loss of libido, infertility, amenorrhoea and galactorrhoea. 

Corticotrophin-producing tumours cause Cushing's disease owing to cortisol excess. 
The principal features are moon face abdominal striae, buffalo hump, hypertension and diabetes mellitus.

Acromegalyis due to an overproduction of growth hormone.

The disease is disfiguring, causing prognathism and overgrowth of include hypertension, cardomyopathy, diabetes mellitus, exces­sive sweating, arthralgias and lassitude 

Haemorrhage Into a macroadenoma, known as pituitaryapoplexy, can precipitate an acute presentation with abrupt headache, hypopituitarismand visual failure decreased mental status, and endocrine dysfunction.
Diabetes Insipidus, a product of direct hypothalamic involvement, is usually indicative of a craninopharyngioma or metastatic lesion and is rarely caused by pituitary adenomas.

Investigations

Diagnosis is confirmed by laboratory assessment of pituitary endocrine function, neuroradiological Imaging and formal visual assessment.

Radioimmunoassaywill identify the hormone being secreted. It is important, particularly with acute presentations, to exclude a prolactinoma as (the majority of these will respond rapidly to treatment with the dopamine agonist bromocriptine. 
Prolactin levels above 200 ng ml are usually diagnostic. Non-functiomng macroadenomas may cause hyperprolactinaemia due to distortion of the pituitary stalk or impingement on the hypothalamus.

This is because the latter produces prolactin-inhibiting factor, which, under normal circumstances, suppresses prolactin levels to below 15 ng ml . 

Diagnosis of Cushing's disease is made by radioimmunoassay of adrenocorticotrophic hormone (ACTH) in the peripheral blood and petrosal venous sinus sampling to detect a brain-peripheral concentration gradient

With the exception of some patients with Cushing's disease MRI of the sella will confirm diagnosis of an intrasellar mass the resolution of MRI will also detect all but the smallest less than 2 mm tumours and any extrasellar extension

Treatment

Treatment depends on the endocrine disturbance present and the effect of compression of adjacent neural structures. 
For pro­lactinomas, dopamine agonist therapy should be commenced which may causes shrinkage of it. 

Surgical excision

Is reserved for macroadenomas compressing the optic chiasm, growth hormone-secreting tumours causing acromegaly and ACTH-secreting tumours causing Cushing's disease 
 Surgery is indicated in patients with prolactinomas who are not responding to medical treatment  or when unwanted side-effects occur or has  persistent mass effect or endocrinal dysfunction . 

This is usually performed via a trans-sphenoidal route, although the Transcra­nial route can be used.
 The aim is to preserve normal pituitary function if possible Surgery should be covered with parenteral hydrocortisone, and frequently vasopressin is required

Radiotherapy 

Is used for subtotal resections and for persistent hypersecretion of pituitary hormones. 
The long-term follow-up of non-functioning pituitary adenomas has shown  to be recurrent indicating that there is perhaps a more extensive role for this modality and that postoperative patients should be more closely followed up.
 

tags:pituitary,tumours,explaining,gland