This document provides an overview of approaches to gastrointestinal bleeding. It discusses the common clinical presentations including hematemesis, melena, hematochezia, and occult bleeding. For hematemesis, the most common causes are discussed such as stress ulcers, Mallory-Weiss tears, peptic ulcer disease, gastroesophageal varices, and Dieulafoy's lesion. For hematochezia, common causes include colonic diverticula, internal hemorrhoids, colon cancer, and inflammatory bowel disease. The document provides details on evaluating each potential cause and characteristics to consider in the clinical history and examination.
Definitions of GI bleeding
GI Bleeding include Upper and Lower of GIB
Causes of GI bleeding
Pathogenesis of GI bleeding
Diagnosis of GI bleeding
Clinical of GI bleeding
Management of GI bleeding
Recommendation of GI bleeding
Clinical guideline of GI bleeding
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Definitions of GI bleeding
GI Bleeding include Upper and Lower of GIB
Causes of GI bleeding
Pathogenesis of GI bleeding
Diagnosis of GI bleeding
Clinical of GI bleeding
Management of GI bleeding
Recommendation of GI bleeding
Clinical guideline of GI bleeding
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Approach to patient with upper GIT bleeding
Approach to patient with upper GIT bleeding
Approach to patient with upper GIT bleeding
Approach to patient with upper GIT bleeding
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
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The prostate is an exocrine gland of the male mammalian reproductive system
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
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This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
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Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
2. CLINICAL SITUATIONS IN GI BLEEDING
5 Common clinical situations:
1. HEMATEMESIS – Bright red blood / coffee ground vomitus
2. MELENA – black tarry foul smelling stool
3. HEMATOCHEZIA – Bright red / maroon blood per rectum
4. OCCULT GI BLEEDING – detected by occult screening blood test
5. Symptomatic blood loss – patients present only with symptoms of blood loss / anemia
(no visible blood loss)
3. APPROACH TO GI BLEEDING
HEMATEMESIS – means vomiting of blood , whether bright red, dark and
clotted, or coffee ground vomitus
4. CAUSES OF HEMATEMESIS
• Ulcerative or erosive diseases
VERY COMMON
CAUSES
• Oesophageal varices
• Mallory-weiss tears
• Ulcerative oesophagitis
COMMON CAUSES
• Vascular malformations
• Aorto-enteric fistula
• Tumors of oesophagus or stomach
UNCOMMON CAUSES
5. Ulcerative and erosive causes
STRESS ULCERS :
• In critically ill patients, physiologic stress predisposes to ulcer
• Risk factors – Multiorgan failure, mechanical ventilation, hypotension (in sepsis), intracranial
injury(cushing ulcer), severe burns(curling ulcer)
Intracranial injury Direct vagal stimulation Acid hypersecretion
Systemic acidosis ↓ intracellular pH of
mucosal cells
Mucosal injury
Splanchnic
vasoconstriction
Hypoxia and ↓ blood
flow
Acute ulceration
•Hematemesis or bleed via nasogastric tube in ICU patient
• Falling hematocrit
• nasogastric aspirate of coffee ground material and melena
6. HEMATEMESIS – COMMON CAUSES
MALLORY - WEISS TEAR :
• Classic history of vomiting, retching ot coughing preceding hematemesis
• Seen in alcoholics
• Tears occur in the gastro-oesophageal junction
• Bleeding occurs in tears involving underlying esophageal or venous plexus
• Patients with portal hypertension – massive bleeding
Antecedent nausea, retching, vomiting followed by hematemesis
History of alcohol ingestion
Diagnosis made after ruling out other concominant signs and
symptoms
7.
8. Ulcerative and erosive causes
PEPTIC ULCER DISEASE : Imbalance between damaging and protective factors of mucosa
Zollinger
ellison
syndrome
Hyperparat
hyroidism
Chronic renal
failure
↑ acid
production
Normal
mucosal
defence
Normal acid
secretion
H.pylori
NSAIDS
Cigarette
smoking
Corticosteroids
Reduced
mucosal
defence
ABDOMINAL PAIN,NAUSEA,VOMITING, HEMATEMESIS OR MALENA
ABDOMINAL DISCOMFORT IMPROVED WITH FOOD
H/O NSAIDS USE, EPIGASTRIC TENDERNESS
9. HEMATEMESIS – COMMON CAUSES
GASTROESOPHAGEAL VARICES : Esophageal and gastric varices are venous collaterals
that develop as a a result of systemic or segmental portal hypertension
Massive upper GI Bleeding (HEMATEMESIS,HYPOTENSION ,TACHYCARDIA)
H/O of chronic liver disease/cirrhosis
Manifestations of cirrhosis - Jaundice, telangiectasia, splenomegaly, ascites,
encephalopathy, Caput medsae
↑Liver enzymes, coagulopathy, thrombocytopenia
Causes : -
prehepatic thrombosis (eg: portal or splenic vein)
hepatic disease (cirrhosis)
alcoholic liver disease
viral hepatitis
10. GASTROESOPHAGEAL VARICES
• Resistance to portal blood flow and enhanced portal blood flow
• In the presence of angiogenic factors and increased nitrous oxide production in the splanchnic
vascular bed, splanchnic arteriolar vasodilatation and increased cardiac output increase portal
venous blood inflow.
• Collaterals develop in response to the portal hypertension at sites of communication between
the portal and systemic circulations. In comparison to other collaterals, gastroesophageal
varices are important due to their risk of rupture and bleeding.
13. HEMATEMESIS - UNCOMMON CAUSES
DIEULAFOY’s LESION :
• It is a dilated abberant submucosal vessel that erodes the overlying epithelium and it is not
associated with a primary ulcer
• Etiology not known
•Difficult to clinically differentiate from other causes
•Diagnosis is best made with endoscopy
•Not associated with an ulcer or any mass lesion
•Endoscopy reveals active arterial pumping from a site
•Dieulafoy’s lesion mostly seen in lesser curvature 6cm from the
gastro-esophageal junction
15. HEMATEMESIS – UNCOMMON CAUSES
WATERMELON STOMACH or GASTRIC ANTRAL VASCULAR ECTASIA:
• Characteristic endoscopic appearance of tudinal rows of erythematous mucosa radiating from
pylorus into antrum
• Ectatic or sacculated mucosal vessels seen in endoscopy resembles the stripes of watermelon.
• Diagnosis made by endoscopy
Chronic bleeding
Patients present with – occult blood positive stools, IDA, Requiring
repeated transfusions
Acute or massive upper GI bleed – can occur occasionally
17. HEMATEMESIS – UNCOMMON CAUSES
AORTO-ENTERIC FISTULA :
• Direct communication between the aorta and the gastro-intestinal tract
• Most common cause : Infected prosthetic aortic graft eroding into the intestine
• Other causes : penetrating ulcer, tumor invasion, foreign body perforation
• Though rare it is associated with high mortality rate if left undiagnosed and untreated
• 3rd or 4th portion of duodenum is the most common site.
•Hematemesis or hematochezia
•Followed by massive bleed resulting in hemorrhagic shock
•>50% - associated with back pain or abdominal pain
•<50% - Fever, association with sepsis
•H/O of prosthetic aortic graft or abdominal aortic aneurysms
19. TUMORS OF OESOPHAGUS OR STOMACH
• Neoplasms account for less than 3% of acute upper GI bleed
• lipomas
• polyps
• Blue rubber bleb nevus syndrome
Benign lesions
• Adenocarcinoma
• Lymphoma
• Carcinoid tumor
• Colon cancer
• Lung cancer, breast cancer
Malignant tumors
(Primary or metastatic)
Luminal obstruction or ulceration causes DYSPHAGIA/ODYNOPHAGIA
Duodenal tumors – chronic nausea, vomiting, bezoar formation
HEMOCCULT – POSITIVE STOOLS, IDA, Endoscopy reveals an ulcerated mass,
anorexia, weight loss
20. Points to remember
• Amount of blood loss
• History of peptic ulcer disease
• Signs of chronic liver disease
• Recent ingestion of nsaids,aspirin,warfarin?
• History of retching before hematemesis(mallory-weiss)?
22. HEMATOCHEZIA
• Passage of bright red blood per rectum
• Also associated with passage of maroon stools
• Most common presentation of lower GI bleed
CAUSES:
•Colonic diverticula
•Internal hemorrhoids
•Colonic angiomas
•Colon cancer
•Ischemic colitis
•Inflammatory bowel disease
•Meckel’s diverticulum
23. COLONIC DIVERTICULA
• Diverticula are are herniations of colonic mucosa and submucosa through the muscular layers
of the colon
• Colonic diverticula are formed when colonic tissue is pushed by the intra-luminal pressure
• Common location – left colon
PAINLESS HEMATOCHEZIA
MILD LEFT LOWER QUADRANT DISCOMFORT
BLEEDING – MILD TO SEVERE
MOST COMMON CAUSE OF LOWER GI BLEED IN ADULTS
25. INTERNAL HAEMORRHOIDS
• PLEXUS OF VEINS JUST ABOVE THE SQUAMO COLUMNAR JUNCTION
• Characterised by bright red blood per rectum
• Blood often coats outside the stool
• Bleeding is usually painless
• Should be differentiated from external hemmorhoids, rectal varices, fissures.
• Particularly associated with constipation and straining stool
27. COLON CANCER
• Most patients presents with occult gastrointestinal bleeding
• Hematochezia not very common
• In patients over 40 years
Recent change in bowel habits- constipation or diarrhea
Some cases palpable mass on abdominal or rectal examination
PAINLESS OCCULT BLEED –most common manifestation
IRON DEFICIENCY ANEMIA
28. INLAMMATORY BOWEL DISEASE
• Inflammatory bowel disease (IBD) is an immune-mediated chronic intestinal condition
• Ulcerative colitis (UC) and Crohn's disease (CD) are the two major types of IBD
• IBD is currently considered an inappropriate
• The major symptoms of UC are diarrhoea, rectal bleeding, tenesmus and crampy abdominal
pain
• Patients with proctitis usually pass fresh blood or blood-stained mucus, either mixed with
stool or streaked onto the surface of a normal or hard stool
• Look for Extraintestinal manifestations
Immune response to the endogenous commensal microbiota within the
intestines,intestinal epithelial dysfunction with or without some component of
autoimmunity,
30. ISCHEMIC COLITIS
• Results from mucosal hypoxia
• Hypoperfusion of intramural vessels intestinal wall rather than large vessel occlusion
• Associated with atherosclerosis/vasculitis
• Invovlement is only segmentel because of collateral circulation
Sudden lower left quadrant pain with HAEMATOCHEZIA and DIARRHOEA
31. MECKEL’s DIVERTICULUM
• Commonest cause of gastrointestinal bleeding in children
• A congenital anomaly of gastrointestinal tract with incomplete obliteration of vitelline duct,
leaving an ileal diverticulum
• Classically 5cm long, 20cm from ileocecal valve
• Not all cases are associated with bleeding , 20% cases with heterotrophic mucosa
•Hemorrhage :in ectopic gastric mucosa present –peptic ulceration–painless
maroon rectal bleed or melaena
•Diverticulitis (presents like appendicitis)
•Intussusception
33. POINTS TO REMEMBER IN BLOOD PER RECTUM
• Amount of bleed and colour of blood
• Blood on toilet paper(local anal pathology) ?
• Blood coated stool Pattern of bowel habits – hemorrhoids?
• Diarrhoea &mucus per rectum – IBD?
• Family history of colorectal ca
• Age – children(meckel diverticulum)
34. MELAENA
• All patients with active melaena assumed to be upper GI bleed
• Admission warranted – even haemodynamically stable because of suspicion of internal bleed
• Melaena - source may not be from upper GI – in such case polyps, cancer, diverticula
(by colonoscopy)
• If negative finding in colonoscopy and upper GI endoscopy – small bowel investigastion done
• Small bowel symptoms ? & evaluation
• IBD, Small bowel tumors, meckel’s diverticulum