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This chapter focuses on malignant bowel obstruction (MBO), a common complication in women diagnosed with ovarian cancer, colorectal cancer, and other gynaecological malignancies. MBO generally afflicts 25–42 per cent of patients with advanced ovarian cancer, but rarely occurs in patients with endometrial cancer. MBO develops by the existence of mechanical obstruction from an extrinsic occlusion of the bowel lumen, intraluminal occlusion of the lumen, luminal obstruction due to tumour growth in the bowel wall, and adynamic ileus. Bowel obstruction can also be caused by other non-malignant factors such as adhesion, post-irridation bowel damage, hernias, and inflammatory bowel disease. Management of MBO includes pain management, pharmacological management, and non-pharmacological management. In patients with MBO, pharmacological treatment is generally successful. Only patients who are strictly considered as appropriate candidates for surgery and parenteral nutrition are given such treatments.

The extent of single nucleotide polymorphism is reviewed, together with insights gained into the nature of allelic architecture in terms of haplotypes, linkage disequilibrium and recombination. The utility of SNPs in defining genetic determinants of common disease is discussed including the rationale, results and diverse applications of the International HapMap Project. The recent development and application of genome-wide association studies is reviewed including the Wellcome Trust Case Control Consortium study of seven common diseases. Issues relating to design, analysis and interpretation of such studies are described. A detailed review of age-related macular degeneration and inflammatory bowel disease is presented, two common multifactorial diseases where genome-wide association studies have recently enjoyed considerable success. Research in these diseases illustrates the timeline of different approaches used in defining genetic determinants of common disease and how such analyses can provide novel insights into disease pathogenesis.

This chapter builds on a basic understanding of the central nervous system (CNS) as coordinator of regional gastrointestinal (GI) tract reflexes. The dorsal vagal complex in the CNS permissively governs the largely autonomous control by the enteric nervous system (ENS) of functions such as absorption, secretion and motility. The CNS actively coordinates voluntary and autonomic communication for complex behavioral functions, such as swallowing, emesis and defecation. The CNS and ENS communicate with inflammatory cells, endocrine cells and microbiota to maintain GI homeostasis and their dysfunction can give rise to clinical disorders. For example, stress or enteritis may predispose individuals to Irritable Bowel Syndrome in which altered bowel function is accompanied by visceral pain. Neural modulation of immune cells and release of inflammatory mediators may contribute to Inflammatory Bowel Diseases. Thus, the bi-directional brain-gut axis maintains GI health and its perturbation contributes to GI disorders.

Irritable bowel syndrome is one of the best models of gastrointestinal disorders to use as a model for understanding placebo mechanisms. Several brain regions are inhibited by a placebo treatment in patients suffering from irritable bowel syndrome. In general, gastrointestinal symptoms can be conditioned, which indicates that learning may play an important role. Subjective symptoms are more affected than objective symptoms in genitourinary disorders. In addition, expectation is known to be crucially involved in sexual functions.

This chapter explains via a case study the desired skills, attitudes, and knowledge necessary to diagnose and manage malignant bowel obstruction (MBO). It addresses several questions such as: What is the likelihood that the patient will develop bowel obstruction at some time during her cancer journey? What is the pathophysiology of MBO? What are the common symptoms of MBO? What are the indications for and outcomes of surgery in patients with MBO?

This chapter discusses colorectal cancer, which is the second most common malignancy in the United Kingdom. It has an incidence of 30,000 cases annually and is the cause of the deaths of over 20,000 people per year. The risk of developing colorectal cancer increases with age, with sharp probability from the age of 50 onwards. Colorectal cancer, or bowel cancer, develops by a sequence of events, from dysplasia through malignant transformation within the adenomatous polyp. This process is often linked with predisposing genetic factors and exposure to environmental carcinogens. This cancer is predominant in people with familial polyposis coli as well as hereditary non-polyposis colon cancers (HNCC). However, 25 per cent of colorectal cancer and polyposis is attributed to spontaneous genetic mutation and not family history. Other discussions in the chapter are the pathology of bowel cancer, management strategies of early-diagnosed colorectal disease, problems associated with recurrent and late-diagnosed colorectal disease, and palliation of late-diagnosed bowel cancer.

This chapter discusses symptom control in care of the dying. It is divided into three sections, each of which is written by a single author. The first section, written by Paul Glare, looks at the influence of the Liverpool Care Pathway for the Dying Patient (LCP) on symptom control, and the most common symptoms found in a dying patient. Pain management and managing agitation in dying patients are also studied. Andrew Dickman is the author of the second section, which focuses on the use of syringe drivers and managing respiratory tract secretions and dyspnoea in dying patients. Finally, the third section is prepared by Margaret Goodman, and it studies bowel care, micturition difficulties, mouth care, and mobility or pressure area care. Deciding when to stop administering nursing interventions is also discussed.

Pain control is a primary goal of palliative care. The World Health Organization (WHO) guidelines for pain control specify an escalating series of therapies, but the ultimate resource for the control of severe pain remains the opioids. Forty to forty-five percent of patients presenting for hospice care complain of constipation on admission. Work is needed to define the mechanisms by which opioids produce constipation. The secondary effects of opioid receptor activation also may be further defined and present new opportunities for pharmacological intervention. Those developing opioid alternatives, especially opioids with differing receptor affinities, have been unable to separate the analgesic properties from the side effects of opioids. Methods to optimize opioid use and traditional bowel care methods are being examined, but it is difficult at times to compare the results of interventions as the model and definition of success vary widely between publications.

This chapter discusses the management of non-pain symptoms in terminally ill patients. These symptoms include nausea and vomiting, constipation, bowel obstruction, dyspnea, and cachexia. The chapter explains the pathophysiology, principles of therapy and recommended treatment for each of these symptoms. It also suggests that palliative care should not be so much about what the practitioners do as about why they do it.

The plant Cannabis, which has been traditionally employed for the treatment of gastrointestinal ailments, contains both psychotropic phytocannabinoids, such as Δ‎⁹-tetrahydrocannabinol and nonpsychotropic phytocannabinoids (e.g. cannabidiol, cannabigerol, Δ‎⁹-tetrahydrocannabivarin, and cannabichromene). Such phytocannabinoids have been shown to modulate, through different mechanisms, a number of gastrointestinal functions, including gastric acid secretion, intestinal motility, visceral sensation, inflammation, and cell proliferation. This chapter focuses on the pharmacology and the potential therapeutic application of Cannabis-derived cannabinoids (phytocannabinoids) in gastrointestinal diseases, with a special reference to irritable bowel syndrome, inflammatory bowel disease, and colon cancer.

This chapter discusses gastrointestinal disorders of infancy and childhood, including biochemical and clinical abnormalities and factors to be considered in nutritional evaluation. Management of gastroesophageal reflux, liver disease, inflammatory bowel disease, and short bowel syndrome are specifically discussed, as are vitamin supplementation and enteral and parental nutrition.

“It’s a gut feeling.” Indeed, how and why do we get “gut feelings?” After the brain, the gut is the second most innervated bodily organ, diffusely interconnected with gastrointestinal afferent neurons. Whilst sensory neurons from the gut ascend by means of the spinal cord and vagal nerve to subcortical and higher cortical areas of the brain, caudally descending motor efferents from brain to gut seek to modulate gastrointestinal function. Such is the construct of the “brain–gut axis,” a bi-directional body nexus permitting constant information transfer between both brain and gut so as to provide us with visceral interoception. This chapter reviews the neurobiology of gut feelings and discuss their role in both physical and mental health and disease.

The chapter looks in detail at the marketing and branding of NFL football. It looks into the shift in the image of football from a sport to a brand and entertainment product. It discusses the significance of hiring Sara Levinson, former copresident of MTV, as the new president of NFL Properties. It presents an overview on various topics including the Iron John Super Bowl, the traditional masculine image of football, the harassment of Lisa Olson, and “Guy Culture”. It examines Levinson's research-driven marketing and branding approaches. A series of campaigns were developed to appeal and trigger passion among fans. The chapter also provides an insight into the reorganization of the NFL which was triggered by the resignation of Levinson.

This chapter shows how Calcutta psychiatrists position themselves vis-á-vis popular “superstitions” about psychopharmaceuticals, general physicians, practitioners of nonbiomedical treatments, and the pharmaceutical industry. Psychiatrists have shared the notion that Bengalis are too focused on their digestion, with the general opinion being that Bengalis take this concern to the extreme. For the doctors—almost all of whom are Bengalis themselves—“bowel obsession” is a cluster of ideas and practices that are centered on the fixed notion that if the belly is healthy, the whole body will be healthy, too. In that vein, the chapter reveals how psychiatrists try to manage “doctor-shopping” and overcome nonadherence to treatments, and focuses on how neurochemical imbalances are likened to humoral imbalances.

The main characteristics of generalized anxiety disorder (GAD) are chronic pathological worry, other manifestations of nonphobic anxiety, and various symptoms of tension. Physical symptoms of anxiety are usually less prominent in GAD than in panic disorder, but they can still be an important component of clinical presentation. Behaviors that are often seen in other anxiety disorders, such as overt avoidance, are conspicuously absent. Unlike all other anxiety disorders, it is more likely for GAD in clinical setting to co-occur with a primary condition for which help has been sought–usually depression or other anxiety disorder–than to be the main reason for seeking professional help. Generalized anxiety disorder is one of the more controversial members of the family of anxiety disorders: it seems that almost every aspect of GAD has provoked debates that do not show signs of abating. Paradox, disagreement, debate, and controversy are the words most commonly associated with GAD. It is small wonder then that the list of ‘‘hot topics’’ related to GAD could be very long indeed. Listed below is a selection of issues thought to represent adequately a more comprehensive list…. 1. What are the characteristic features of GAD that would help in its conceptualization? Pathological worry, other cognitive aspects of anxiety, manifestations of tension, and/or (some) symptoms of autonomic arousal? What combination of these features would ensure that GAD is diagnosed adequately and recognized in clinical practice? 2. What is the relationship between pathological worry and GAD? 3. How can different views on what constitutes the essence of GAD be reconciled? Is GAD a single entity or are there two or more ‘‘types’’ of GAD with distinct clinical characteristics? 4. How is GAD related to depressive disorders, other anxiety disorders, and personality disturbance? Where are its boundaries? In view of its close relationship with depression, should GAD be classified along with depression and perhaps renamed accordingly? 5. Can GAD exist on its own, without depression or other anxiety disorders? What could be features specific enough for GAD that would allow it to establish itself as an independent and valid psychopathological and diagnostic entity? 6. What are the pathophysiological correlates of pathological worry and other aspects of chronic anxiety in GAD? 7. What are the underlying mechanisms and purpose of pathological worry in GAD? What is the meaning of chronic anxiety?

This chapter explores the catacombs and sewers of Paris: a maze of underground galleries that were essential to the proper functioning of the city above them. They create a vast network that resemble the vascular, respiratory and digestive systems of the human body. Unlike London, Paris was built with the very material taken from what later became the hole-ridden foundations of the city. To prevent Paris from collapsing, Louis XVI created an administration for the inspection and maintenance of the disused underground quarries of the city and its suburbs. At the same time, the Parisians increasingly complained and petitioned against the pestilential air exhaled by the city’s graveyards, as their grounds were as swollen as the belly of a corpse under the pressure of the gases of decomposition. This led to the closure of the graveyards and the relocation of the remains in the underground ossuary of Montsouris.

This article explores the texts and visual representations of the ‘saints of the bowels’ in order to establish an anthropological classification of aching bellies in early-modern France. A web of symbols is found in the materiality of the viscera. Thus, this article argues that representations of the belly as cave-like mirrors some images of the bowels of the earth. The “Saints of the Entrails”, St Erasmus and St Mammes, and Saint Elmo, all of whom were eviscerated during their martyrdom, represented many popular beliefs of rural communities who conflated images of the soil and images of the belly.

We can never know who committed the first murder with arsenic or even who discovered the deadly nature of arsenical compounds. Although the natural arsenic minerals orpiment and realgar are poisonous, they are not particularly effective as murder weapons because they are insoluble and highly coloured, so that feeding them undetected to the intended victim would not be easy. The most reliable form in which to administer arsenic, knowing that it would succeed in killing someone, would have to be as the oxide. This is not a naturally occurring substance but it was easily obtained. When copper ores that had arsenic as an impurity were smelted, the arsenic was oxidized and emitted as white smoke, some of which sublimed (changed directly from a solid to a vapour) onto the walls of flues and chimneys of the smelter, from where it could be gathered. When people talk of ‘arsenic’ they are almost invariably referring to its oxide, whose chemical formula is As2O3, with arsenic atoms bonded to oxygen atoms. Over the centuries this has had many names such as white arsenic, arsenious oxide, arsenious acid (because it dissolves in water to form an acidic solution), arsenic trioxide, and its proper chemical name, arsenic(III) oxide. I shall call it by the name which is still in common use even among chemists: arsenic trioxide. Some murderers used solid arsenic trioxide, stirring it into foods like stews, porridge, or rice pudding to disguise it, but the more usual method was to dissolve it in something that the victim would drink. Not only is arsenic trioxide soluble, but the solution in which it is dissolved does not betray its presence because it is colourless and almost tasteless; if anything it imparts a slightly sweetish taste to the water. Yet even with such advantages favouring the would-be poisoner, it was still possible to fail to kill, either by not understanding arsenic trioxide’s simple chemistry or misjudging the dose required. Sometimes the ignorance and incompetence of murderers worked in their favour because repeated small doses of the poison gave the impression that the victim was suffering from some deep-seated illness, so that when a final fatal dose was administered the end was not unexpected.

This chapter contains 50 questions, which exactly match the proportions of topic areas found in the European Specialty Examination in Gastroenterology and Hepatology (ESEGH), and is designed to act as a mock-examination for use in the final stages of preparation. The questions are unique to this chapter and therefore add to the coverage of the curriculum over and above that in preceding sections.