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Esophageal Rupture

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681. Management of umbilical hernias associated with hepatic cirrhosis and ascites. Full Text available with Trip Pro

Management of umbilical hernias associated with hepatic cirrhosis and ascites. A series of 35 umbilical herniorraphies in patients with cirrhosis of the liver is reported. In this group there were eight significant complications (22%) and six deaths (16%). There was no evidence in this study of increased likelihood of esophageal variceal bleeding secondary to the interruption of portosystemic collaterals in the umbilical region. An aggressive surgical approach is indicated in cirrhotic patients (...) , with umbilical herniae complicated by incarceration, strangulation, rupture, ulceration, and leakage of ascitic fluid. On the other hand it is recommended, that repair of non-complicated umbilical herniae be delayed until the cirrhosis is stabilized, ascites has diminished and nutrition has been improved. In many instances herniorrhaphy may not be necessary after disappearance of ascites.

1975 Annals of Surgery

682. Boerhaave's syndrome: The importance of early diagnosis and treatment. Full Text available with Trip Pro

Boerhaave's syndrome: The importance of early diagnosis and treatment. Boerhaave's syndrome, spontaneous esophageal rupture, is associated with a 70% survival with surgical intervention. Mortality and morbidity are increased in direct proportion to the time between diagnosis and appropriate surgical intervention. Sepsis, hypovolemia and shock are the predominant causes of morbidity and mortality in Boerhaave's syndrome. Two cases of Boerhaave's syndrome are presented which were diagnosed (...) rapidly, and were managed surgically, resulting in survival of the patients. A review of the literature is also presented with emphasis on the clinical and roentgenologic methods of diagnosis of spontaneous esophageal rupture. Particular attention is given to the fact that early diagnosis and treatment will unquestionably reduce the morbidity of this syndrome.

1976 Annals of Surgery

683. Thoracic Aortic Aneurysms

are asymptomatic until complications (eg, thromboembolism, rupture, aortic regurgitation, dissection) develop. However, compression of adjacent structures can cause back pain (due to compression of vertebra), cough (due to compression of the trachea), wheezing, dysphagia (due to esophageal compression), hoarseness (due to left recurrent laryngeal or vagus nerve compression), chest pain (due to coronary artery compression), and . Erosion of aneurysms into the lungs causes hemoptysis or pneumonitis; erosion (...) ; other symptoms and signs are usually the result of complications (eg, dissection, compression of adjacent structures, thromboembolism, rupture). Risk of rupture is proportional to the size of the aneurysm. Diagnosis is made by CT angiography or transesophageal echocardiogram (TEE). Treatment is endovascular stent grafting or surgery. (See also .) Thoracic aortic aneurysms (TAAs) are abnormal dilatations of the aorta above the diaphragm. TAAs account for one fourth of aortic aneurysms. Men and women

2013 Merck Manual (19th Edition)

684. Risk Factors for Complications During Pregnancy

of transmission intrapartum. During pregnancy, bacterial vaginosis, gonorrhea, and genital chlamydial infection increase risk of and . Routine prenatal care includes screening tests for these infections at the first prenatal visit. Syphilis testing is repeated during pregnancy if risk continues and at delivery for all women. Pregnant women who have any of these infections are treated with antimicrobials. Treatment of bacterial vaginosis, gonorrhea, or chlamydial infection may prolong the interval from rupture (...) labor, and recurrent spontaneous abortion. Fibroids may grow rapidly or degenerate during pregnancy; degeneration often causes severe pain and peritoneal signs. (incompetence) makes preterm delivery more likely. Cervical insufficiency can be treated with surgical intervention (cerclage), vaginal progesterone , or sometimes a vaginal pessary. If, before pregnancy, women have had a myomectomy in which the uterine cavity was entered, cesarean delivery is required because uterine rupture is a risk

2013 Merck Manual (19th Edition)

685. Hyperemesis Gravidarum

fatty degeneration, and may cause or esophageal rupture. Diagnosis Clinical evaluation (sometimes including serial weight measurements) Urine ketones Serum electrolytes and renal function tests Exclusion of other causes (eg, acute abdomen) Clinicians suspect hyperemesis gravidarum based on symptoms (eg, onset, duration, and frequency of vomiting; exacerbating and relieving factors; type and amount of emesis). Serial weight measurements can support the diagnosis. If hyperemesis gravidarum

2013 Merck Manual (19th Edition)

686. Overview of Thoracic Trauma

(Hamman sign or Hamman crunch). Hamman sign suggests and often tracheobronchial tree injury or, rarely, esophageal injury. Diagnosis Clinical evaluation Chest x-ray Sometimes other imaging studies (eg, CT, ultrasonography, aortic imaging studies) Clinical evaluation Five conditions are immediately life threatening and rapidly correctable: Massive hemothorax Diagnosis and treatment begin during the primary survey (see ) and are based first on clinical findings. Depth and symmetry of chest wall (...) with significant chest trauma. Chest x-ray is virtually always done. Results are usually diagnostic of certain injuries (eg, pneumothorax, hemothorax, moderate or severe pulmonary contusion, clavicle fracture, some rib fractures) and suggestive for others (eg, aortic disruption, diaphragmatic rupture). However, findings may evolve over hours (eg, in and diaphragmatic injury). Plain x-rays of the scapula or sternum are sometimes done when there is tenderness over those structures. In trauma centers

2013 Merck Manual (19th Edition)

687. Specific Poisons

generally Ingestion: Salty or soapy taste With large doses: Tremors, seizures, CNS depression, shock, renal failure Skin and mucosal contact: Painful superficial or deep burns Inhalation: Intense eye and nasal irritation, headache, dyspnea, sense of suffocation, glottal edema, pulmonary edema, bronchitis, pneumonia, mediastinal and subcutaneous emphysema due to bleb rupture Ingestion: Dilution with milk or water, IV glucose and saline, 10% Ca gluconate 30 mL IV (in children, 0.6 mL/kg) or 10% CaCl 2 10 (...) if needed to provide sedation Phenmetrazine See Amphetamines — Phenobarbital See Barbiturates — Phenols Carbolic acid Creosote Cresols Guaiacol Naphthols Corrosive effects, mucous membrane burns, pallor, weakness, shock, seizures in children, pulmonary edema, smoky urine, esophageal stricture (rare) Respiratory, cardiac, and circulatory failure Removal of clothing, washing of external burns with water, activated charcoal, pain relief, O 2 , respiratory support, correction of fluid imbalance, observation

2013 Merck Manual (19th Edition)

688. Evaluation of the Dental Patient

, primarily the lower Multiple bullae that rupture quickly, leaving hemorrhagic ulcers; includes Exfoliative cheilitis Chronic desquamation of superficial mucosal cells A locally destructive epithelial tumor thought to be a form of squamous cell carcinoma that usually regresses spontaneously Brownish black melanin spots, with GI polyposis Secondary (cold sore) Short-lived vesicle (≤ 1 day) followed by small painful ulcer (≤ 10 days) at the vermillion border (common) (wart) Pebbly surface Buccal mucosa (...) eyes Canker sores, Small painful ulcers (canker sores) or large, painful scarring ulcers (recurrent aphthous stomatitis) Bullae that rupture quickly, leaving ulcers; ocular lesions develop after oral lesions; found on alveolar mucosa and vestibules Venereally transmitted wart forming cauliflower-like clumps Dyskeratosis Occurs with erythroplakia (red), leukoplakia (white patch on mucous membrane that does not rub off), and mixed red and white lesions; precancerous Purple to dark-red lesions

2013 Merck Manual (19th Edition)

689. Critical care - Shock

ulcer, esophageal varices, or ruptured aortic aneurysm. Bleeding may be overt (eg, hematemesis, melena) or concealed (eg, ruptured ectopic pregnancy). Hypovolemic shock may also follow increased losses of body fluids other than blood (see Table: ). Table Hypovolemic Shock Caused by Body Fluid Loss Site of Fluid Loss Mechanism of Loss Skin Thermal or chemical burn, sweating due to excessive heat exposure GI tract Vomiting, diarrhea Kidneys Diabetes mellitus or insipidus, adrenal insufficiency, salt (...) , cardiac tamponade, atrial tumor or clot Interference with ventricular emptying Pulmonary embolism Cardiogenic Impaired myocardial contractility Myocardial ischemia or MI, myocarditis, drugs Abnormalities of cardiac rhythm Tachycardia, bradycardia Cardiac structural disorder Acute mitral or aortic regurgitation, ruptured interventricular septum, prosthetic valve malfunction Symptoms and Signs Altered mental status (eg, lethargy, confusion, somnolence) is a common sign of shock. The hands and feet

2013 Merck Manual (19th Edition)

690. Monitoring and Testing the Critical Care Patient

is typically more significant than a single abnormal value. Possible indications for PACs are listed in Table . Table Potential Indications for Pulmonary Artery Catheterization Cardiac disorders Acute valvular regurgitation Complicated Complicated Ventricular septal rupture Hemodynamic instability* Assessment of volume status Hemodynamic monitoring Cardiac surgery Postoperative care in critically ill patients Surgery and postoperative care in patients with significant heart disease Pulmonary disorders (...) , the catheter may curl into a knot within the right ventricle (especially in patients with heart failure, cardiomyopathy, or increased pulmonary pressure). Pulmonary artery rupture occurs in < 0.1% of PAC insertions. This catastrophic complication is often fatal and occurs immediately on wedging the catheter either initially or during a subsequent occlusion pressure check. Thus, many physicians prefer to monitor pulmonary artery diastolic pressures rather than occlusion pressures. Noninvasive Cardiac Output

2013 Merck Manual (19th Edition)

691. Chest Pain

a diagnosis or at least the need to pursue further investigation (eg, abnormal aortic contour on chest x-ray suggests need for testing for ). Thus, if these initial test results are normal, thoracic aortic dissection, tension pneumothorax, and esophageal rupture are highly unlikely. However, in acute coronary syndromes, ECG may not change for several hours or sometimes not at all, and in PE, oxygenation may be normal. Thus, other studies may need to be obtained based on findings from the history (...) and minor, can be exacerbated by respiration, movement, or palpation of the chest. These findings are not specific for origin in the chest wall; about 15% of patients with acute MI have chest tenderness on palpation. Nitroglycerin may relieve pain of both myocardial ischemia and noncardiac smooth muscle spasm (eg, esophageal or biliary disorders); its efficacy or lack thereof should not be used for diagnosis. Associated findings may also suggest a cause. Fever is nonspecific but, if accompanied by cough

2013 Merck Manual (19th Edition)

692. Amyloidosis

hypoalbuminemia, edema, and anasarca or to end-stage renal disease. Hepatic involvement causes painless hepatomegaly, which may be massive. Liver function tests typically suggest intrahepatic cholestasis with elevation of alkaline phosphatase and later bilirubin, although jaundice is rare. Occasionally, develops, with resulting esophageal varices and ascites. Airway involvement leads to dyspnea, wheezing, hemoptysis, or airway obstruction. Infiltration of the myocardium causes a , eventually leading (...) and bilateral scalloped pupillary margins develop in several hereditary amyloidoses. Other manifestations include bruising, including bruising around the eyes (raccoon eyes), which is caused by amyloid deposits in blood vessels. Amyloid deposits cause weakening of the blood vessels, which may rupture after minor trauma, such as sneezing or coughing. Diagnosis Biopsy Amyloid typing Testing for organ involvement Diagnosis of amyloidosis is made by demonstration of fibrillar deposits in an involved organ

2013 Merck Manual (19th Edition)

693. Varices

. These varices partially decompress portal hypertension but can rupture, causing massive GI bleeding. The trigger for variceal rupture is unknown, but bleeding almost never occurs unless the portal/systemic pressure gradient is > 12 mm Hg. Coagulopathies caused by liver disease may facilitate bleeding. Esophageal Varices Image provided by David M. Martin, MD. Bleeding Esophageal Varix Image provided by David M. Martin, MD. See also the American College of Gastroenterology's practice guidelines on . Pearls (...) Endoscopy Evaluation for coagulopathy Both esophageal and gastric varices are best diagnosed by endoscopy, which may also identify varices at high risk of bleeding (eg, those with red markings). Endoscopy is also critical to exclude other causes of acute bleeding (eg, peptic ulcer), even in patients known to have varices; perhaps as many as one third of patients with known varices who have upper GI bleeding have a nonvariceal source. Because varices are typically associated with significant hepatic

2013 Merck Manual (19th Edition)

694. Herpes Simplex Virus (HSV) Infections

Physical or emotional stress Immunosuppression Unknown stimuli Generally, recurrent eruptions are less severe and occur less frequently over time. Diseases Caused by Herpes Simplex Virus Diseases include Mucocutaneous infection (most common), including Ocular infection ( ) CNS infection HSV rarely causes fulminant hepatitis in the absence of cutaneous lesions. In patients with HIV infection, herpetic infections can be particularly severe. Progressive and persistent esophagitis, colitis, perianal ulcers (...) -1) of tingling discomfort or itching, clusters of small, tense vesicles appear on an erythematous base. Clusters vary in size from 0.5 to 1.5 cm but may coalesce. Lesions on the nose, ears, eyes, fingers, or genitals may be particularly painful. Vesicles typically persist for a few days, then rupture and dry, forming a thin, yellowish crust. Healing generally occurs within 10 to 19 days after onset in primary infection or within 5 to 10 days in recurrent infection. Lesions usually heal

2013 Merck Manual (19th Edition)

695. Malaria

, gametocytes inside the mosquito reproduce sexually and produce infective sporozoites. When the mosquito feeds on another human, sporozoites are inoculated and quickly reach the liver and infect hepatocytes. The parasites mature into tissue schizonts within hepatocytes. Each schizont produces 10,000 to 30,000 merozoites, which are released into the bloodstream 1 to 3 wk later when the hepatocyte ruptures. Each merozoite can invade an RBC and there transform into a trophozoite. Trophozoites grow, and most (...) develop into erythrocyte schizonts; schizonts produce further merozoites, which 48 to 72 h later rupture the RBC and are released in plasma. These merozoites then rapidly invade new RBCs, repeating the cycle. Some trophozoites develop into gametocytes, which are ingested by an Anopheles mosquito. They undergo sexual union in the gut of the mosquito, develop into oocysts, and release infective sporozoites, which migrate to the salivary glands. Plasmodium life cycle. The malaria parasite life cycle

2013 Merck Manual (19th Edition)

696. Smoking Cessation

Which of the following illicit drugs is most likely to cause intractable seizures, tachycardia, hypertension, and hyperthermia when a drug packet with the drug used in body packing ruptures? Anabolic steroids Cocaine Heroin Marijuana NEWS & VIDEOS High-Quality, Plant-Based Diet Tied to Lower Risk for CVD Mortality THURSDAY, March 7, 2019 (HealthDay News) -- Increasing consumption of high-quality, plant-based foods decreases the risk for death from cardiovascular disease (CVD), according to a study (...) only Contraindicated by history of seizure, eating disorder, or MAOI use within the past 2 wk Nicotine gum If smoking > 30 min after waking: 2 mg If smoking 30 min after waking: 4 mg Schedule for both dosage strengths: 1 q 1–2 h for wk 1–6 1 q 2–4 h for wk 7–9 1 q 4–8 h for wk 10–12 Up to 6 mo Mouth soreness Dyspepsia OTC only Slow chewing and parking between cheek and gum recommended to maximize blood levels and minimize gastric and esophageal irritation; can be a challenge to use enough gum

2013 Merck Manual (19th Edition)

697. Alcohol Toxicity and Withdrawal

Body Packing and Body Stuffing Which of the following illicit drugs is most likely to cause intractable seizures, tachycardia, hypertension, and hyperthermia when a drug packet with the drug used in body packing ruptures? Anabolic steroids Cocaine Heroin Marijuana NEWS & VIDEOS Becoming Active in Middle Age Still Offers Health Benefits FRIDAY, March 8, 2019 (HealthDay News) -- Becoming physically active in middle age may provide comparable health benefits to long-term participation in leisure-time (...) fatal adverse effects. Chronic heavy alcohol intake typically leads to liver disorders (eg, fatty liver, alcoholic hepatitis, ); the amount and duration required vary (see ). Patients with a severe liver disorder often have coagulopathy due to decreased hepatic synthesis of coagulation factors, increasing the risk of significant bleeding due to trauma (eg, from falls or vehicle crashes) and of (eg, due to gastritis, from esophageal varices due to ); alcohol abusers are at particular risk of GI

2013 Merck Manual (19th Edition)

698. Tobacco

of the following illicit drugs is most likely to cause intractable seizures, tachycardia, hypertension, and hyperthermia when a drug packet with the drug used in body packing ruptures? Anabolic steroids Cocaine Heroin Marijuana NEWS & VIDEOS History of Cycling Weight May Up Risk for Heart Disease in Women FRIDAY, March 8, 2019 (HealthDay News) -- A history of weight cycling (HWC), or yo-yo dieting, is associated with poorer cardiovascular health in women, according to a study presented at the... SOCIAL MEDIA (...) , tends to accelerate decline in pulmonary functions. Coughing and dyspnea on exertion are common. Less common yet serious smoking-related disorders include age-related macular degeneration, noncardiac vascular diseases (eg, stroke, aortic aneurysm), other cancers (eg, bladder, cervical, colorectal, esophageal, kidney, laryngeal, liver, oropharyngeal, pancreatic, stomach, throat, acute myeloid leukemia), diabetes, pneumonia, rheumatoid arthritis, and tuberculosis. In addition, smoking is a risk factor

2013 Merck Manual (19th Edition)

699. Portal Hypertension

Tumors Video Overview of Jaundice SOCIAL MEDIA Add to Any Platform Loading , MD, Sidney Kimmel Medical College at Thomas Jefferson University Click here for Patient Education NOTE: This is the Professional Version. CONSUMERS: Topic Resources Portal hypertension is elevated pressure in the portal vein. It is caused most often by cirrhosis (in developed countries), schistosomiasis (in endemic areas), or hepatic vascular abnormalities. Consequences include esophageal varices and portosystemic (...) of vasoactive substances (eg, endothelins, nitric oxide), various systemic mediators of arteriolar resistance, and possibly swelling of hepatocytes. Over time, portal hypertension creates portosystemic venous collaterals. They may slightly decrease portal vein pressure but can cause complications. Engorged serpentine submucosal vessels (varices) in the distal esophagus and sometimes in the gastric fundus can rupture, causing sudden, catastrophic . Bleeding rarely occurs unless the portal pressure gradient

2013 Merck Manual (19th Edition)

700. Hemoptysis

neck veins, peripheral edema) Dyspnea while lying flat (orthopnea) or appearing 1–2 h after falling asleep (paroxysmal nocturnal dyspnea) ECG BNP measurement Echocardiography Pulmonary artery rupture Recent placement or manipulation of a pulmonary artery catheter Emergency chest CT angiography or emergency pulmonary angiography Abrupt onset of sharp chest pain, increased respiratory rate and heart rate, particularly in patients with known CT angiography or V/Q scanning Doppler or duplex studies (...) sounds or murmur that might support a diagnosis of heart failure and elevated pulmonary pressure. The abdominal examination should focus on signs of hepatic congestion or masses, which could suggest either cancer or hematemesis from potential esophageal varices. The skin and mucous membranes should be examined for ecchymoses, petechiae, telangiectasia, gingivitis, or evidence of bleeding from the oral or nasal mucosa. If the patient can reproduce hemoptysis during examination, the color and amount

2013 Merck Manual (19th Edition)

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