disorders of biliary system

Cognito Cognito ergo ergo sum.sum.

DescartesDescartes

I think, therefore I am…!I think, therefore I am…!

2

CPC 4.2.3CPC 4.2.3

• Fay is a 42y woman who is a local real estate agent. You are a local GP. At a charity function last night She approached you and asked for your advice about her abdominal problems. You advised her to come in to see you at your surgery.

• Abdominal problems…(differential diagnosis)• Professional ethics…• Counseling, SNAP & five A’s…

3

CPC 4.2.3CPC 4.2.3Abdominal symptoms: Upper abdominal discomfort with

bloating & wind. Burps after meal, stomach feels full & windy. ? worsening.

Duration Symptoms for many months.Relation to food/fat Yes, makes it worse.Pain 3-4/10, ill defined, cramping.Nausea vomiting Nausea occasional, no

vomiting.Wt loss NoAnorexia NoDysphagia NoBowel habit constipation, No pus, blood PR.Diet usually eats once a day, often fast

foods. Little fruits & veggies. Lots of coffee….? Risk

4

CPC 4.2.3CPC 4.2.3

• Alchohol 2-3 glasses of wines/night. 12-15 on weekends, more when she finalizes a deal. (Hepatitis, pancreatitis, gall stones)

• Marriage Married to an accountant, no children but has 3 lap dogs. (hydatid dis, echinococcosis.)

• Medication She is on COCP, (Budd-Chiari sy)

• Allergies None• PMS Nil significant.• PSH Tonsillectomy & adenoidectomy at 5

years, appendicectomy at 14y. (Viral Hepatitis)

5

InvestigationsInvestigations

– Upper abdominal USS – numerous gallstones in thick-walled gallbladder

– LFT – elevated GGT*, Alk Phos normal*…?– Fasting glucose- 7.0 mmol/l– Lipid profile - Total Chol 7.2, Trig. 2.8, HDL

2.0, LDL-5.1.– Rectal examination – Hard stool in the

rectum, no hemorrhoids or fissures.

6

CPC 4.2.3 –Discuss D.D.CPC 4.2.3 –Discuss D.D.

– Gastritis – Peptic ulcer– Liver disease… many..!– Fatty liver *– Gallstones – chronic constipation *– irritable bowel syndrome– Diverticulosis / Diverticulitis– Pancreatitis - chronic– Any thing else ??

““Thought is Free & Powerful” Thought is Free & Powerful” --William Shakespeare--William Shakespeare

“Human mind is the “Human mind is the most powerful weapon in the world…!most powerful weapon in the world…!

- Osama bin laden…!- Osama bin laden…!

Pathology of Biliary DisordersPathology of Biliary Disorders

Dr. Shashidhar Venkatesh MurthyAssociate Prof. & Head of Pathology

School of Medicine.

Anatomy:Anatomy:

Physiology:Physiology:• Bile – Micelles of cholesterol, phospholipids, bile salts & bile pigmint

(bilirubin, biliverdin)

• Fat in food Cholecystokinin Bile secretion.

• Cholesterol (Fat crystal) - Bile salts (soap)

• Excess cholesterol, low bile salt Stone formation.

• Stasis, Inflammation, infection Ca

Biliary Disorders:Biliary Disorders:

• 95% - Chole-cystitis/lithiasis.95% - Chole-cystitis/lithiasis.• Extrahepatic Obstruction:Extrahepatic Obstruction:

– Dislodged gallstones – Ca. CBD, Ca. Head of pancreas.– inflammatory stricture of CBD – accidental surgical ligation of CBD.

• Intrahepatic Obstruction:Intrahepatic Obstruction:– Biliary atresia – congenital.– Primary Biliary cirrhosis – Sclerosing cholangitis. – Cystic fibrosis (mucosiscidosis) –

thick bile.

Common Disorders:• Cholecystitis• Cholelithiasis &

Choledocholithiasis.• Adeno Carcinoma

12

Cholecystitis:Cholecystitis:

Inflammation of gallbladder.

• Risk factors:Risk factors: – Most common Gallstones (FFFFFFFF…!)

• Pathogenesis:Pathogenesis:– Obstruction, inflammation, infection.

• Types: Types: – Acute, Chronic, Cholesterosis.

• Complications: Complications: – Empyema, rupture.

Acute Cholecystitis:Acute Cholecystitis:• 90% Cholelithiasis. 10% non-calculous• Females common. • Outflow obstruction by a small gallstone.• Infection – E.coli. Empyema.• Risk of perforation, peritonitis, fistula

Gall stone ileus when stone enters GIT.• Serum amylase normal (high with pancreatitis).• Mild jaundice in 20% - obstructive.• Acute inflammation, hemorrhage, ede – neutrophils.• Gangrenous cholecystitis: when obstruction is severe

compromising blood supply. Green-black necrotic.

Chronic Cholecystitis:Chronic Cholecystitis:• Females.• Recurrent acute / chronic.• Thick fibrotic wall.• Thick bile – biliary gravel.• Diffuse infiltration by

chronic inflammatory cells.• Aschoff-Rokitansky

sinuses - glands being pushed through muscular layer. (black arrow). Due to increased luminal pressure (obstruction).

Cholesterosis: Strawberry GB.: Strawberry GB.

• Yellow-speckled strawberry apprearance.

• Cholesterol filled macrophages in the superficial mucosa.

• Clinically not significant. May present as chronic cholecystitis.

Cholesterolosis of gallbladder mucosa

Cholesterol filled Foamy macrophages in mucosal

folds

Complications of Cholecystitis:Complications of Cholecystitis:• Obstruction • Cholecystitis • Cholangitis• Biliary colic• Jaundice• Empyema• Liver abscess• Mucocele• Pancreatitis.• Peritonitis• Carcinoma• Fistula formation• Gall stone ileus.

Gallstone ileus

Cholelithiasis:Cholelithiasis:

• Cholelithiasis/gall stones – 95% of GB dis.• Incidence: West 20-40%, Asian 2-4%.• 70-80% asymptomatic • Mixed 80% - (cholesterol, ca+, bile, blood) • Pure 20% - Pigment *, Cholesterol.• Severe colicky Upper abdomen Rt shoulder.• Conjugated hyperbilirubinemia Obstruction.• Fat intolerance clay stools - typical in chronic.

Risk Factors: CholelithiasisRisk Factors: CholelithiasisCholesterol Stones:

• Race/Demog– Western• Age• Female sex • Oral contraceptives• Pregnancy• Obesity• Rapid weight reduction• Gallbladder stasis• Disorders of bile acid

metabolism• Hyperlipidemia

syndromes

Pigment Stones:

• Race/Demog – Asians• Hemolysis syndromes• Biliary infections

• Inflammatory bowel disorders.

• Ileal resection or bypass.• Cystic fibrosis• Chronic Pancreatitis.

• 80% Idiopathic.• 75% in American Pima

race.

Cholelithiasis:Cholelithiasis:

Crystallization of bile within biliary system.• Risk factors:Risk factors:

– female gender, obesity, diabetes mellitus (FFFFFFFF…!)

• Pathogenesis: Pathogenesis: • Cholesterol is made soluble by bile salts and lecithins.• More cholesterol or less bile salts chol. Monohydrate

crystals stone.• Four Etiologic factors.

– Supersaturation – excess Cholesterol – crystals.– Calcium Microprecipitation - Nucleation.– Stasis - Mucous trap crystals – aggregation– Stone growth.

Cholelithiasis:Cholelithiasis:• Morphology & Types: Morphology & Types:

– Mixed (Chol+Ca+Bile salt)* Multiple, faceted, yellow-grey.

– Rarely pure cholesterol-Yellow spiky.

– Bile pigment stones (black/brown).

– % Calcium = radio opaque

• Complications: Complications: – Obstruction cholecystitis,

– Empyema, liver abscess, perforation, fistulae, mucocele, Cholangitis,

– Pancreatitis, Obstructive jaundice, Gall stone ileus (intestinal obst),

– Carcinoma (rare).

Cholelithiasis – Complications.Cholelithiasis – Complications.

Gallstones + Chronic CholecystitisGallstones + Chronic Cholecystitis

Note:•Multiple, Faceted, golden yellow – grey stones.•thickened inflammed gall bladder.•Ulceration at neck suggest occlusion by small stone.

Cholecystitis & GallstonesCholecystitis & Gallstones• Note thickened

gallbladder wall.• Inflammation.• Mixed cholesterol &

bile pigment stones.

25

Gallstones (mixed)Gallstones (mixed)

Note: Yellowish shiny faceted stones, and thick inflammed gallbladder.

Pure Cholesterol Gallstones, bleeding.Pure Cholesterol Gallstones, bleeding.

Round, yellow, spiky, bleeding.

27

Cholesterol Gallstones, bleeding.Cholesterol Gallstones, bleeding.

Round, yellow, spiky, bleeding. Note thickened inflammed gall bladder.

28

Cholesterol Gallstones.Cholesterol Gallstones.

29

Pigment stones in hemolytic anemiaPigment stones in hemolytic anemia

Note: Dark Black friable soft stones – Bilirubin

Gall stones in CBDGall stones in CBD

Stones in CBD

Stonees in GB

20% of mixed chol. stones and >50% of pigment stones are radio-opaque

31

Cholecystitis & GallstonesCholecystitis & Gallstones

““What we think, we become” What we think, we become”

--Buddha--Buddha

Primary Biliary CirrhosisPrimary Biliary Cirrhosis

• Autoimmune, Chronic, progressive • Destruction of intrahepatic bile ducts, portal

inflammation & scarring – cholestasis.• Leading to cirrhosis and liver failure.• Females common (6:1)• Insidious onset of Pruritis & cholestatic jaundice.• Markedly high ALP, +ve antimitochondrial Ab.• Histopathology: Portal inflammation, bile stasis,

bile plugs & lakes, Later stages cirrhosis – Firm fibrotic, nodular, greenish, Shrunken.

Excess Bile - plugs

Bile Obstruction leading to Cholestasis & Cholangitis

Bile duct inflammation

Bile staining

Cholestasis: Bile “plugs”, Bile “lakes”

Bile PlugsBile Plugs

Bile LakesBile Lakes

Excess Bile

Bile plug

PBC – Microscopy:PBC – Microscopy:

PBC – Microscopy:PBC – Microscopy:

PBC – Microscopy:PBC – Microscopy:

PBC – Microscopy:PBC – Microscopy:

Macronodular Cirrhosis - PBCMacronodular Cirrhosis - PBC

Macronodular Cirrhosis - PBCMacronodular Cirrhosis - PBC

Biliary Atresia in a 3m child.Biliary Atresia in a 3m child.Dark bile stained liver tissue, cirrhosis & death before 2 years of age.

Neoplastic Disorders: (rare)Neoplastic Disorders: (rare)

• Benign tumours:– Bile duct adenoma, cystadenoma

• Malignant tumours: – Cholangiocarcinoma (Bile duct carcinoma)– Presents with Jaundice.

– Early spread with very poor prognosis.– Adenocarcinoma Ducts lined by cuboidal to

columnar mucin secreting cells separated by desmoplastic (fibrotic) stroma.

Cholangiocarcinoma: Gross Microscopy: Glands in desmoplastic (fibrous) stroma

““Outer world is the reflection Outer world is the reflection

of our inner world of our inner world (thoughts)(thoughts)””

--Baba--Baba

Carcinoma Gallbladder:Carcinoma Gallbladder:

• Females common• 5th-7th decade• Common - Lithiasis.• abdominal pain, anorexia,

High ALP. • Commonly Adenocarcinoma • Late diagnosis – Poor

prognosis.

Carcinoma Gallbladder:Carcinoma Gallbladder:

Note irregular glandular structures and clusters of similar cells.

Carcinoma Bile duct:Carcinoma Bile duct:• Usually an adenocarcinoma • Increased incidence in

ulcerative colitis • Presents with obstructive

jaundice – early diagnosis.

Cholangiocarcinoma:• Adeno Ca with biliary

differentitation.• Intrahepatic or extrahepatic.• Thoratrast exposure.• Increasing incidence. ? toxin

Carcinoma Bile duct:Carcinoma Bile duct:

Adenocarcinoma:Adenocarcinoma:

Norm

al

Adeno Ca

Carcinoma Bile duct:Carcinoma Bile duct:

Great wars & Great creations Great wars & Great creations start first in human mind…!start first in human mind…!

-- Thoughts are seeds with potential. -- Thoughts are seeds with potential.

38y F, Obese, abdominal colicky pain, Gallbladder: 38y F, Obese, abdominal colicky pain, Gallbladder: ? Type of stones? Type of stones

1 2 3 4 5

95%

2% 2%2%0%

A. Pure cholesterolB. Mixed cholesterol.C. Pigment D. CalciumE. Triple phosphate.

38y F, Obese, abdominal colicky pain, Gallbladder: 38y F, Obese, abdominal colicky pain, Gallbladder: ? Type of stones? Type of stones

1 2 3 4 5

0%

89%

2%0%

9%

A. Pure cholesterolB. Mixed cholesterol.C. Pigment D. CalciumE. Triple phosphate.

A 45y mildly obese woman, 1-week history of upper abdominal pain, fever, shaking chills, and occasional vomiting. Physical examination shows severe right upper quadrant tenderness. Laboratory studies include serum bilirubin of 1.0 mg/dL, AST of 25 U/L, ALT of 35 U/L, alkaline phosphatase of 220 U/L (high), WBC of 14,000/µL, and amylase of 95 U/L (normal). An ultrasound examination of the abdomen reveals a normal-appearing liver and bile duct and thickening of the wall of the

gallbladder. Most likely diagnosis?

1 2 3 4 5

88%

2% 4%4%2%

1. Acute Cholecystitis2. Acute Pancreatitis3. Carcinoma pancreas4. Carcinoma Gall bladder5. Primary biliary cirrhosis.

40y Black woman, indigestion, abdominal pain, 40y Black woman, indigestion, abdominal pain, Gallbladder: Gallbladder: Most likely associated disease?Most likely associated disease?

1 2 3 4 5

0%4%

86%

2%8%

1. Chronic Pancreatitis2. Diabetes mellitus3. Familial hypercholesterolemia4. Hyperparathyroidism5. Sickle cell disease

69y M, Massive GI bleeding, jaundice. 69y M, Massive GI bleeding, jaundice. Section of liver Section of liver ? Pathogenesis? Pathogenesis

1 2 3 4 5

4%

14%

4%4%

75%

1. Cholangiocarcinoma2. Hepatocellular carcinoma3. Metastatic carcinoma4. Liver abscesses5. Tuberculosis.

38y F, Obese, abdominal colicky pain, Gallbladder: 38y F, Obese, abdominal colicky pain, Gallbladder: ? Diagnosis? Diagnosis

1 2 3 4 5

75%

6%2%

18%

0%

A. CholecystitisB. CholesterosisC. AdenocarcinomaD. CholelithiasisE. Primary Biliary Cirrhosis.

38y F, Obese, abdominal colicky pain, Gallbladder: 38y F, Obese, abdominal colicky pain, Gallbladder: Most likely metabolic abnormality?Most likely metabolic abnormality?

1 2 3 4 5

11%

0%

89%

0%0%

1.Decreased bilirubin conjugation.2.Decreased serum albumin.3.Increased bilirubin uptake4.Increased hepatic calcium secretion.5.Increased hepatic cholesterol secretion.

Complications of Cholelithiasis include all the Complications of Cholelithiasis include all the following following EXCEPTEXCEPT::

1 2 3 4 5

9%4%

65%

9%13%

A. Secondary Biliary CirrhosisB. Recurrent CholangitisC. Liver AbscessD. Chronic PancreatitisE. Primary Biliary cirrhosis.

62y F, Abd. Pain & jaundice. Gall bladder biopsy ? Diag62y F, Abd. Pain & jaundice. Gall bladder biopsy ? Diag

1 2 3 4 5

14%

2% 2%

10%

71%

A. CholecystitisB. CholesterosisC. AdenocarcinomaD. Aschoff-Rokitansky

sinusesE. Primary Biliary Cirrhosis.

38y F, jaundice. Gall bladder 38y F, jaundice. Gall bladder ? Pathogenesis? Pathogenesis

1 2 3 4 5

97%

0% 0%2%2%

A. Excess BilirubinB. Low cholesterolC. Low Bile SaltsD. Infection.E. Cholestasis.

34y M, alcholic, mild icterus and malaise 6 months. 34y M, alcholic, mild icterus and malaise 6 months.

Liver biopsy.Liver biopsy. ? diagnosis ? diagnosis

1 2 3 4 5

39%

2% 3%

54%

2%

1. Acute alcoholic Hepatitis2. Chronic Persistent Hepatitis.3. Hepatitis C infection4. Fatty Liver5. Alcoholic Cirrhosis

42y M, alcoholic, recurrent fatigue. 42y M, alcoholic, recurrent fatigue. Liver biopsy.Liver biopsy. ? Diagnosis ? Diagnosis

1 2 3 4 5

5%

18%

4%0%

73%

1. Acute Hepatitis2. Chronic Active hepatitis.3. Chronic Persistant hepatitis.4. Fulminant Hepatitis.5. Cirrhosis.

26y fem, medical student, day before pathology exam presents with 26y fem, medical student, day before pathology exam presents with mild scleral icterus. Physical Examination normal, Liver function tests: mild scleral icterus. Physical Examination normal, Liver function tests: Protein total-7.9, Albumin 4.8 g/dl, AST-36 U.L, ALT 16 U/L, ALP-36 Protein total-7.9, Albumin 4.8 g/dl, AST-36 U.L, ALT 16 U/L, ALP-36 U/L, Total Bilirubin 4.9, direct 0.7 mg/dl. Icterus resolves week later U/L, Total Bilirubin 4.9, direct 0.7 mg/dl. Icterus resolves week later after exams. after exams. Most likely diagnosis?Most likely diagnosis?

1 2 3 4 5

2% 0%

19%

9%

70%

1. Alcoholic hepatitis.2. Primary biliary cirrhosis.3. Gilbert Syndrome.4. Acute HAV infection.5. Acetaminophen poisoning.

Viral serology interpretation:Viral serology interpretation:HBsAg Positive, Anti HBcAg PositiveAnti HBcAg IGM NegativeAnti HBsAg Negative

1 2 3 4 5

40%

6%

0%2%

52%

A. Acute Viral Hepatitis

B. Immunised against Hep. B

C. Chronic Hepatitis B

D. Hepatitis B carrier stage

E. Fulminant hepatitis B

CPC-2.3– CCPC-2.3– Core ore LLearning earning IIssuesssues::Major CLI:• Pathology of Cholecystitis – Acute, Recurrent & Chronic.

Gross, Microscopy & complications.• Pathology of Cholelithiasis – Causes, Types, Morphology

Gross & Micro, Complications (choledocholithiasis)

Minor CLI:• Carcinoma of gall bladder & biliary tract.• Primary Biliary cirrhosis.• Parasites & other forms of biliary atresia,.

““The ancestor of every action is a The ancestor of every action is a thought.”thought.”

--Ralph Waldo Emerson--Ralph Waldo Emerson

34y M, alcoholic, homosexual- icterus and 34y M, alcoholic, homosexual- icterus and fever 6 months. Liver biopsy.fever 6 months. Liver biopsy. ? diagnosis ? diagnosis

A. Acute HepatitisB. Chronic active Hepatitis.C. Cirrhosis CarcinomaD. Fulminant HepatitisE. Hepatitis Cirrhosis

34y M, icterus and fever. 34y M, icterus and fever. Liver biopsy.Liver biopsy. ? diagnosis ? diagnosis

1 2 3 4 5

0% 0% 0%0%0%

1. Acute Hepatitis2. Chronic Persistent Hepatitis.3. Chronic active Hepatitis4. Fulminant Hepatitis5. Cirrhosis

56y chronic alcoholic, 2 days fever, abdomen distended, 56y chronic alcoholic, 2 days fever, abdomen distended, tender, tap yielded cloudy yellow fluid with 98% neutrophils, tender, tap yielded cloudy yellow fluid with 98% neutrophils, Blood culture E.coli. Patient dies 3 days later. Image shows Blood culture E.coli. Patient dies 3 days later. Image shows his liver. his liver. Most Likely diagnosis?Most Likely diagnosis?

1 2 3 4 5

0% 0% 0%0%0%

1. A1 antitrypsin deficiency2. HEV infection3. Hereditary hemochromatosis4. Primary sclerosing cholangitis5. Alcoholic cirrhosis

58y M, alcoholic, distended abdomen & icterus. 58y M, alcoholic, distended abdomen & icterus. Liver biopsy. Liver biopsy. ? diagnosis? diagnosis

1 2 3 4 5

0% 0% 0%0%0%

1. Chronic active hepatitis.2. Chronic Persistant hepatitis.3. Hepatocellular carcinoma.4. Cirrhosis5. Chronic alcoholic hepatitis.

Viral serology interpretation:Viral serology interpretation:

1 2 3 4 5

0% 0% 0%0%0%

HBsAg Negative, Anti HBcAg NegativeAnti HBcAg IGM NegativeAnti HBsAg PositiveA. Acute Viral Hepatitis

B. Immunised against Hep. BC. Past Hepatitis BD. Hepatitis B carrier stageE. Fulminant hepatitis B

69y Female, Chronic bronchitis. Died following 69y Female, Chronic bronchitis. Died following chronic Cardiac failure. Liver specimen. chronic Cardiac failure. Liver specimen. Likely Likely diagnosis?diagnosis?

1 2 3 4 5

0% 0% 0%0%0%

1. Alcoholic Hepatitis 2. Dubin-Johnson Syndrome3. Alcoholic cirrhosis4. Nutmeg liver5. Metastatic deposits

Viral serology interpretation:Viral serology interpretation:

1 2 3 4 5

0% 0% 0%0%0%

HBsAg Negative, Anti HBsAg PositiveAnti HBcAg PositiveAnti HBcAg IGM Negative

A. Acute Viral Hepatitis BB. Immunised against Hep. BC. Past Hepatitis BD. Hepatitis B carrier stageE. Carrier state of Hepatitis B

59y Male, Alcoholic, presents with fatigue, anorexia. 59y Male, Alcoholic, presents with fatigue, anorexia. Normal liver function tests. Liver specimen. Normal liver function tests. Liver specimen. Likely diagnosis?Likely diagnosis?

1 2 3 4 5

0% 0% 0%0%0%

A. Dubin-Johnson SyndromeB. Alcoholic cirrhosisC. Alcoholic HepatitisD. Fatty LiverE. Nutmeg liver

Histopathology Image is from lung biopsy of a 61 year Histopathology Image is from lung biopsy of a 61 year male chronic smoker. What is the most likely type of male chronic smoker. What is the most likely type of carcinoma?carcinoma?

1 2 3 4 5

0% 0% 0%0%0%

1. Small cell carcinoma2. Adenocarcinoma3. Metastatic deposits4. Squamous carcinoma5. Lung abscesses

The gross image of lung specimen from a 59year The gross image of lung specimen from a 59year old male heavy smoker presented with high fever, old male heavy smoker presented with high fever, shortness of breath. shortness of breath. Likely type of pneumonia?Likely type of pneumonia?

1 2 3 4 5

0% 0% 0%0%0%

1. Lobar pneumonia2. Interstitial pneumonia 3. Broncho pneumonia4. Fungal pneumonia5. Carcinomatous pneumonia

42y male smoker presented with recurrent cough & 42y male smoker presented with recurrent cough & dyspnoea. Image shows cut section of his lung. dyspnoea. Image shows cut section of his lung. What is the most likely diagnosis?What is the most likely diagnosis?

1 2 3 4 5

0% 0% 0%0%0%

1. Emphysematous bullae2. Panlobular emphysema3. Centrilobular emphysema4. Chronic Bronchitis + Emphysema.5. Smokers lung with Silicosis

46 year male on treatment for lymphoma presents with 46 year male on treatment for lymphoma presents with pallor, shortness of breath and mild jaundice. Image pallor, shortness of breath and mild jaundice. Image shows his blood film appearance. shows his blood film appearance. What is the most What is the most likely type of anemia?likely type of anemia?

1 2 3 4 5

0% 0% 0%0%0%

1. Anemia of chronic disorder2. Megaloblastic anemia3. Hemolytic anemia4. Aplastic anemia5. Iron deficiency Anemia

12 year old girl presents with two week history of fever 12 year old girl presents with two week history of fever and joint pain. The image shows her heart specimen. and joint pain. The image shows her heart specimen. What feature of the disease is shown by the arrow?What feature of the disease is shown by the arrow?

1 2 3 4 5

0% 0% 0%0%0%

1. MI with pericarditis.2. Bacterial endocarditis3. Pancarditis4. Endocarditis5. Pericarditis

78year female presents with prolonged weakness, 78year female presents with prolonged weakness, fatigue and anemia. She has palpable spleen & few fatigue and anemia. She has palpable spleen & few enlarged cervical Lymphnodes. Image shows her enlarged cervical Lymphnodes. Image shows her blood film. blood film. What is the most likely diagnosis?What is the most likely diagnosis?

1 2 3 4 5

0% 0% 0%0%0%

1. Acute myeloid leukaemia2. Acute lymphatic leukaemia3. Chronic myeloid leukaemia4. Chronic lymphatic leukaemia5. Non-hodgkins lymphoma

Self Assessment is the key…!Self Assessment is the key…!

Retention of Learning

Time Delay No review Review

7 Days 33% 83%

63 Days 14% 70%

Whether new information is "stored" or "dumped" depends, then, on our Interest, Reciting, Writing &

Reviewing the information.Source: http://www.web-us.com/memory/human_memory.htm

85

Reminder….Reminder….

• Online quiz, Winners club, Authors Online quiz, Winners club, Authors club.club.– Not compulsory now… * Important..– Formative – Does not affect your results.– Personal road sign.. Where am I going ?– Time limited… Am I in time ?– Procrastination doesn’t help.

• Please evaluate me..!Please evaluate me..!

86

Living becomes a glorious experience Living becomes a glorious experience only when there is tolerance and love. only when there is tolerance and love. Willingness to compromise with other Willingness to compromise with other

people’s ways of living and people’s ways of living and cooperation in common tasks, these cooperation in common tasks, these make happy and successful societies.make happy and successful societies.

Divine Discourse, 17th February 1980 - Baba.Divine Discourse, 17th February 1980 - Baba.

Love is Selfless Service. Love is Selfless Service.

87

5 A’s & SNAP 5 A’s & SNAP • Ask: 1. patients with diabetes, hypertension,

hyperlidaemia, obesity or existing vascular disease• Assess: 2.Number of cigarettes or equivalent/day,

Dependance 3.readiness to change/motivation• Advise: 4.provide written information, 5.motivational

interviewing • Assist: 6.NRT ? Bupropion(Zyban) 7.Support• Arrange: 8.referral to QUIT 9.follow up with the GP

SNAP Counseling: Smoking, Nutrition, Alcohol & Physical Activity.

Silence…Silence…

88

To the question "Who am I?" the only relevant answer is silence. You need to discard all answers in words, including "I am Nothing" or "I am the Cosmic Self" or "I am the Self" - and just stick to the question "Who am I?". All other answers are just thoughts. Thoughts can never be complete. Only Silence is complete.

Thoughts are not the goal in themselves. Their goal is Silence. When you ask the question "Who am I?" you get no answer, there is silence. That is the real answer. For your soul is solidified silence. This solidified silence is wisdom, is knowledge.

The easy way to silence the thoughts is to arouse the feelings. For, through feelings only peace, joy and love dawn. And they are all your very nature.

- Sri Sri Ravishankar