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Dyspepsia in Pregnancy

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621. Angiomyolipoma, Kidney

right renal angiogram showing multiple avascular tumors. The tumors are small (same patient as in the previous image). Selective left renal angiogram showing 2 tumors, which are larger than those in the previous image (same patient as in the previous image). The final diagnosis was multiple renal angiomyolipomas in a patient with tuberous sclerosis. Ultrasonogram obtained in a 48-year-old man who presented with dyspepsia and right upper quadrant discomfort. The patient was referred for a gallbladder (...) attenuation interspersed with areas of fat attenuation. The final diagnosis was sporadic angiomyolipoma. Contrast-enhanced axial computed tomography scan obtained through the kidneys in the same patient as in the previous image. The image shows patchy tumor enhancement, with displacement of part of the normal lateral aspect of the renal cortex. Nonenhanced computed tomography (CT) scan obtained in a 28-year-old pregnant woman (at 26 weeks' gestation) who presented with sudden-onset right upper quadrant

2014 eMedicine Radiology

622. Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy (Follow-up)

. Medical management of AS, including , must be adjusted during pregnancy in accordance with the specific pregnancy profiles of the medications. Inpatient care is generally not necessary for patients with AS. The exceptions to this include patients with coexisting or extra-articular disease and those requiring surgery. Patients with extra-articular manifestations must be treated properly or referred to an appropriate specialist. These extra-articular manifestations include acute anterior uveitis (...) was not as effective in reducing certain inflammation-associated parameters as twice-daily celecoxib and diclofenac were. Give NSAIDs in full anti-inflammatory doses. Continuous treatment with NSAIDs appears to reduce radiographic progression in AS. [ ] Common toxicities involve the gastrointestinal (GI) tract (nausea, dyspepsia, ulceration, bleeding), the kidneys, and the central nervous system (CNS). Sulfasalazine Sulfasalazine is useful in AS patients who do not respond to or who have contraindications

2014 eMedicine.com

623. Therapeutic Injections for Pain Management (Diagnosis)

illness. [ ] Hyperglycemia in known diabetics warrants careful postprocedural monitoring. Other less serious side effects of corticosteroids include injection site hyperpigmentation, subcutaneous fat atrophy, peripheral edema, dyspepsia, and malaise. Systemic responses frequently occur even in local injections of corticosteroids. Allergic reactions to systemic glucocorticoids in slow-release formulations have been reported to occur up to 1 week after injection. [ ] Fluoroscopy and radiation safety

2014 eMedicine.com

624. Giardiasis (Follow-up)

following successful therapy. [ ] Appropriate fluid and electrolyte management is critical, particularly in patients with large-volume diarrheal losses. [ ] Treat children with acute or chronic diarrhea who manifest a failure to thrive, malabsorption, or other GI tract symptoms in whom Giardia organisms have been identified. [ ] Generally, do not treat asymptomatic persons who excrete the organism, except to prevent household transmission (eg, from toddlers to pregnant women or to patients (...) are at risk of spreading the infection should be isolated and treated. Pregnant Patients No consistent recommendations exist for the treatment of pregnant patients because of the potential adverse effects of anti- Giardia agents on the fetus. If possible, treatment should be avoided during the first trimester. Mildly symptomatic women should have treatment delayed until after delivery. If treatment is necessary, paromomycin can be used as systemic absorption is poor. [ ] If the patient is left untreated

2014 eMedicine.com

625. Glomerulonephritis, Chronic (Follow-up)

pressure. [ ] Among the adverse events attributed to therapy were dyspepsia, sedation, and photosensitive dermatitis. It is hoped that pirfenidone therapy will prove an effective means of slowing progressive fibrosis; however, more studies are needed. Role of antioxidants (bardoxolone) Cells have the ability to produce antioxidants, anti-inflammatory and detoxifying enzymes that are useful for cell viability, but this pathway is constantly being inhibited by an enzyme called KEAP. Inhibition of KEAP (...) (as of 31 December 2004). Ther Apher Dial . 2006. 10:476-97. . . Research Group on Progressive Chronic Renal Disease. Nationwide and long-term survey of primary glomerulonephritis in Japan as observed in 1,850 biopsied cases. Nephron . 1999. 82(3):205-13. . Blowey DL, Warady BA. Outcome of infants born to women with chronic kidney disease. Adv Chronic Kidney Dis . 2007. 14:199-205. . Imbasciati E, Gregorini G, Cabiddu G, Gammaro L, Ambroso G, Del Giudice A, et al. Pregnancy in CKD stages 3 to 5: fetal

2014 eMedicine.com

626. Giardiasis (Treatment)

following successful therapy. [ ] Appropriate fluid and electrolyte management is critical, particularly in patients with large-volume diarrheal losses. [ ] Treat children with acute or chronic diarrhea who manifest a failure to thrive, malabsorption, or other GI tract symptoms in whom Giardia organisms have been identified. [ ] Generally, do not treat asymptomatic persons who excrete the organism, except to prevent household transmission (eg, from toddlers to pregnant women or to patients (...) are at risk of spreading the infection should be isolated and treated. Pregnant Patients No consistent recommendations exist for the treatment of pregnant patients because of the potential adverse effects of anti- Giardia agents on the fetus. If possible, treatment should be avoided during the first trimester. Mildly symptomatic women should have treatment delayed until after delivery. If treatment is necessary, paromomycin can be used as systemic absorption is poor. [ ] If the patient is left untreated

2014 eMedicine Emergency Medicine

627. Myocardial Infarction (Diagnosis)

): Fatigue Chest discomfort Malaise Typical chest pain in acute MI has the following characteristics: Intense and unremitting for 30-60 minutes Substernal, and often radiates up to the neck, shoulder, and jaw, and down the left arm Usually described as a substernal pressure sensation that also may be characterized as squeezing, aching, burning, or even sharp In some patients, the symptom is epigastric, with a feeling of indigestion or of fullness and gas The patient’s vital signs may demonstrate

2014 eMedicine Emergency Medicine

628. Cholelithiasis (Diagnosis)

and unpredictable episodes Pain that is localized to the epigastrium or right upper quadrant, sometimes radiating to the right scapular tip Pain that begins postprandially, is often described as intense and dull, typically lasts 1-5 hours, increases steadily over 10-20 minutes, and then gradually wanes Pain that is constant; not relieved by emesis, antacids, defecation, flatus, or positional changes; and sometimes accompanied by diaphoresis, nausea, and vomiting Nonspecific symptoms (eg, indigestion, dyspepsia (...) , European or Native American ancestry, and increasing age. Other risk factors include the following: Obesity Pregnancy Gallbladder stasis Drugs Heredity The metabolic syndrome of truncal obesity, insulin resistance, type II diabetes mellitus, hypertension, and hyperlipidemia is associated with increased hepatic cholesterol secretion and is a major risk factor for the development of cholesterol gallstones. Cholesterol gallstones are more common in women who have experienced multiple pregnancies. A major

2014 eMedicine.com

629. Choledocholithiasis (Diagnosis)

, indigestion, dyspepsia, belching, or bloating) Patients with the lithogenic state or asymptomatic gallstones have no abnormal findings on physical examination. Distinguishing uncomplicated biliary colic from acute cholecystitis or other complications is important. Key findings that may be noted include the following: Uncomplicated biliary colic – Pain that is poorly localized and visceral; an essentially benign abdominal examination without rebound or guarding; absence of fever Acute cholecystitis – Well (...) , European or Native American ancestry, and increasing age. Other risk factors include the following: Obesity Pregnancy Gallbladder stasis Drugs Heredity The metabolic syndrome of truncal obesity, insulin resistance, type II diabetes mellitus, hypertension, and hyperlipidemia is associated with increased hepatic cholesterol secretion and is a major risk factor for the development of cholesterol gallstones. Cholesterol gallstones are more common in women who have experienced multiple pregnancies. A major

2014 eMedicine.com

630. Biliary Disease (Diagnosis)

and secreted into the bile, stimulates prostanoid synthesis by gallbladder mucosa and promotes mucus hypersecretion, while inhibitors of prostaglandin inhibit mucus secretion. Finally, gallbladder hypomotility and bile stasis appear to promote gallstone formation and growth, which may be important in diabetes, pregnancy, oral contraceptive use in women, and prolonged fasting in critically ill patients on total parenteral nutrition. More recent research suggests that elevated levels of four circulating (...) symptomatic before complications develop. Biliary-type pain, the typical clinical presentation, is due to the obstruction of the bile duct lumen. The predictive value of other complaints (eg, intolerance to fatty food, indigestion) is too low to be clinically helpful. The incidence of gallbladder cancer developing in the setting of cholelithiasis is low, about 0.1% per year. Two main types of gallstones exist. Cholesterol stones (85%) These are divided into two subtypes—pure (90%-100% cholesterol

2014 eMedicine.com

631. Biliary Colic (Diagnosis)

pregnancy, elderly population, obesity, certain ethnic groups (Northern European and Hispanic), weight loss, and liver transplant patients. [ ] The phrase "fair, female, fat, and fertile" summarizes the major risk factors for development of gallstones. Although gallstones and cholecystitis are more common in women, men with gallstones are more likely to develop cholecystitis (and more severe cholecystitis) than women with gallstones. [ ] Some oral contraceptives or estrogen replacement therapy may (...) increase the risk of gallstones. Drugs that have been associated with cholecystitis include octreotide and ceftriaxone. [ , ] In addition, the incidence of sludge or stone formation during pregnancy is 5.1% in the second trimester, 7.9% in the third trimester, and 10.2% at 4-6 weeks postpartum. [ , ] Age increases rates of gallstones, cholecystitis, and common bile duct stones. Elderly patients are more likely to go from asymptomatic gallstones to serious complications of gallstones without gallbladder

2014 eMedicine.com

632. Esophagitis (Diagnosis)

on the underlying disease. Esophagitis is commonly seen in adults and is uncommon in childhood. Infectious esophagitis. Candida esophagitis. Double-contrast esophagram shows linear plaquelike lesions in the esophagus, with normal intervening mucosa. Signs and symptoms The history and physical examination findings vary according to the type of esophagitis present. Symptoms of reflux esophagitis (the most common type) may include the following: Heartburn, or dyspepsia (the most common symptom) Water brash (...) factors. Reflux esophagitis Factors or conditions that may increase the risk of reflux esophagitis include the following: Pregnancy Obesity Scleroderma Smoking Alcohol, coffee, chocolate, fatty or spicy foods Certain medications (eg, beta blockers, nonsteroidal anti-inflammatory drugs [NSAIDs], theophylline, nitrates, alendronate, calcium-channel blockers) Mental retardation requiring institutionalization Spinal cord injury Immunocompromised state Radiation therapy for chest tumors Helicobacter pylori

2014 eMedicine.com

633. Eating Disorder: Pica (Follow-up)

are not mentally disabled. Among individuals with intellectual disability, pica occurs most often in those aged 10-20 years. [ ] Infants and children commonly ingest paint, plaster, string, hair, and cloth. Older children tend to ingest animal droppings, sand, insects, leaves, pebbles, and cigarette butts. Adolescents and adults most often ingest clay or soil. In young pregnant women, the onset of pica frequently occurs during their first pregnancy in late adolescence or early adulthood. Although the pica (...) with developmental disabilities. It has also been observed in females during pregnancy. In some societies, pica is a culturally sanctioned practice and is not considered pathologic. Although pica can impair physical functioning, it rarely causes impairment of social functioning, which is typically associated with comorbid disorders. The most common of these disorders are autism spectrum disorder, intellectual disability, and, to a lesser degree, schizophrenia and obsessive-compulsive disorder (OCD). When pica

2014 eMedicine Pediatrics

634. High-Altitude Cardiopulmonary Diseases (Follow-up)

. This treatment may be unnecessary, but it is given to mimic sea-level oxygenation and to promote the transition from fetal to adult physiology. Physicians who care for infants and children with borderline oxygen saturations at their local altitude must consider these changes when they advise parents about travel to a high elevation. [ ] Pregnant women may also benefit from discussing travel to high altitude with their physician. Acetazolamide should generally be avoided and travel may be contraindicated (...) resources, visit eMedicineHealth's . Also, see eMedicineHealth's patient education article . Next: Effects of Chronic Hypoxia The chronic hypoxia associated with moderate altitudes can affect the fetus. Birth weights and uterine blood flow are decreased, placental morphology may be different. Moreover, the incidence of and -induced is increased at high altitudes. Maternal at high altitudes can have an additive effect. Travel by pregnant women from low to high altitude, and vice versa, can initiate

2014 eMedicine Pediatrics

635. Hereditary Periodic Fever Syndromes (Follow-up)

DNA antibodies, rash, abdominal pain, dyspepsia, vomiting, and weakness. Allergic reactions may occur (< 2%), but anaphylaxis has not been observed. Rare events include lymphadenopathy, malignancies (including lymphoma), membranous glomerulopathy, myocardial infarction, mouth ulcer, multiple sclerosis, myocardial ischemia, pancreatitis, polymyositis, pulmonary embolism, renal calculus, sarcoidosis, thrombophlebitis, vasculitis (cutaneous), and pancytopenia. Etanercept is class B in pregnancy (...) , thrombocytopenia) have been reported in cases of acute intoxication but are rarely observed in the usual doses given orally. Colchicine-related myopathy has been rarely described with lower doses (used commonly for FMF). Toxicity is more common with intravenous therapy and when given together with other drugs that are metabolized by CYP3A4, such as erythromycin and cimetidine. Colchicine is pregnancy category C (PO formulation) or D (parenteral formulation). Colchicine is known to arrest mitotic and meiotic

2014 eMedicine Pediatrics

636. Giardiasis (Follow-up)

following successful therapy. [ ] Appropriate fluid and electrolyte management is critical, particularly in patients with large-volume diarrheal losses. [ ] Treat children with acute or chronic diarrhea who manifest a failure to thrive, malabsorption, or other GI tract symptoms in whom Giardia organisms have been identified. [ ] Generally, do not treat asymptomatic persons who excrete the organism, except to prevent household transmission (eg, from toddlers to pregnant women or to patients (...) are at risk of spreading the infection should be isolated and treated. Pregnant Patients No consistent recommendations exist for the treatment of pregnant patients because of the potential adverse effects of anti- Giardia agents on the fetus. If possible, treatment should be avoided during the first trimester. Mildly symptomatic women should have treatment delayed until after delivery. If treatment is necessary, paromomycin can be used as systemic absorption is poor. [ ] If the patient is left untreated

2014 eMedicine Pediatrics

637. Eating Disorder: Pica (Treatment)

are not mentally disabled. Among individuals with intellectual disability, pica occurs most often in those aged 10-20 years. [ ] Infants and children commonly ingest paint, plaster, string, hair, and cloth. Older children tend to ingest animal droppings, sand, insects, leaves, pebbles, and cigarette butts. Adolescents and adults most often ingest clay or soil. In young pregnant women, the onset of pica frequently occurs during their first pregnancy in late adolescence or early adulthood. Although the pica (...) with developmental disabilities. It has also been observed in females during pregnancy. In some societies, pica is a culturally sanctioned practice and is not considered pathologic. Although pica can impair physical functioning, it rarely causes impairment of social functioning, which is typically associated with comorbid disorders. The most common of these disorders are autism spectrum disorder, intellectual disability, and, to a lesser degree, schizophrenia and obsessive-compulsive disorder (OCD). When pica

2014 eMedicine Pediatrics

638. Child Abuse and Neglect: Sexual Abuse (Overview)

conditions Findings with no expert consensus on interpretations with respect to sexual contact or trauma (formerly Indeterminate findings) Findings diagnostic of trauma and/or sexual contact Residual or healing injuries Injuries of blunt force penetrating trauma Infection that confirms mucosal contact with infected bodily secretions (ie, indicating that contact was most likely sexual) Findings diagnostic of sexual contact (ie, pregnancy or sperm directly taken from a child’s body) See for more detail (...) with appropriate medications In postmenarchal children, consider the possibility of pregnancy Recognize the overriding need for emotional support and attention When sexual abuse is seriously suspected or has been diagnosed, ensure that it is reported to the appropriate child protective services (CPS) agency When sexual abuse is being considered, consider reporting it, depending on the perceived risk to the child Keep well-documented medical records; legal proceedings may occur over long periods, and the health

2014 eMedicine Pediatrics

639. Celiac Disease (Overview)

, they have been shown to recognize specific gluten peptides presented through interaction with DQ2 or DQ8 molecules. Gluten is a complex macromolecule that contains abundant proline and glutamine residues, rendering it largely indigestible. Under usual circumstances, gluten is left (in part) unabsorbed by the GI tract. Gluten is composed of glutenins and gliadins, the alcohol-water soluble fraction. These gliadins are further divided into alpha, gamma, and omega fractions based on electrodensity (...) , D'Amato M. Detection of celiac disease and lymphocytic enteropathy by parallel serology and histopathology in a population-based study. Gastroenterology . 2010 Jul. 139(1):112-9. . Bach JF. The effect of infections on susceptibility to autoimmune and allergic diseases. N Engl J Med . 2002 Sep 19. 347(12):911-20. . Mårild K, Stephansson O, Montgomery S, Murray JA, Ludvigsson JF. Pregnancy outcome and risk of celiac disease in offspring: a nationwide case-control study. Gastroenterology . 2012 Jan. 142

2014 eMedicine Pediatrics

640. Eating Disorder: Pica (Overview)

are not mentally disabled. Among individuals with intellectual disability, pica occurs most often in those aged 10-20 years. [ ] Infants and children commonly ingest paint, plaster, string, hair, and cloth. Older children tend to ingest animal droppings, sand, insects, leaves, pebbles, and cigarette butts. Adolescents and adults most often ingest clay or soil. In young pregnant women, the onset of pica frequently occurs during their first pregnancy in late adolescence or early adulthood. Although the pica (...) with developmental disabilities. It has also been observed in females during pregnancy. In some societies, pica is a culturally sanctioned practice and is not considered pathologic. Although pica can impair physical functioning, it rarely causes impairment of social functioning, which is typically associated with comorbid disorders. The most common of these disorders are autism spectrum disorder, intellectual disability, and, to a lesser degree, schizophrenia and obsessive-compulsive disorder (OCD). When pica

2014 eMedicine Pediatrics

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