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Hemorrhoid Coagulation

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181. Deep Venous Thrombosis (Overview)

laboratory studies to be considered include the following: D-dimer testing Coagulation studies (eg, prothrombin time and activated partial thromboplastin time) to evaluate for a hypercoagulable state See for more detail. Management Treatment options for DVT include the following: Anticoagulation (mainstay of therapy) - Heparins, warfarin, factor Xa inhibitors, and various emerging anticoagulants Pharmacologic thrombolysis Endovascular and surgical interventions Physical measures (eg, elastic compression (...) in the legs and PE. DVT is the presence of coagulated blood, a thrombus, in one of the deep venous conduits that return blood to the heart. The clinical conundrum is that symptoms (pain and swelling) are often nonspecific or absent. However, if left untreated, the thrombus may become fragmented or dislodged and migrate to obstruct the arterial supply to the lung, causing potentially life-threatening PE See the images below. Venous thrombus. Pulmonary embolus. DVT most commonly involves the deep veins

2014 eMedicine Surgery

183. Portal Hypertension

. Gastric varices bleed less frequently than esophageal varices, but when they do bleed, the hemorrhage is more severe. Barium study findings of varices in other parts of the gastrointestinal tract Gastric antral and duodenal varices are sometimes seen, usually in association with gastric fundal and esophageal varices. Duodenal varices appear as lobulated filling defects on barium study and are demonstrated best with the patient in a prone position. Internal hemorrhoids frequently are found in patients

2014 eMedicine Radiology

186. Therapeutic Injections for Pain Management (Diagnosis)

can be identified by median branch nerve blocks and then ameliorated with radio-frequency neurotomy or chemical neurolysis. New technologies have evolved, such as the use of spinal cord stimulators and a host of intradiskal procedures, including electrothermal coagulation, percutaneous mechanical disk decompression, laser disc decompression and radiofrequency intradiskal/annular neurolysis. Other new treatment methods include vertebroplasty and kyphoplasty for vertebral fractures. Fluoroscopy

2014 eMedicine.com

187. Lower Gastrointestinal Bleeding: Surgical Perspective (Diagnosis)

: Complete blood cell (CBC) count Serum electrolytes levels (eg, sequential multiple analysis 7 [SMA7]) Coagulation profile, including activated partial thromboplastin time (aPTT), prothrombin time (PT), platelet count, and/or bleeding time (bleeding time is only recommended in patients with bleeding disorders and in those using antiplatelet agents) Helical computed tomography (CT) scanning of the abdomen and pelvis can be used when a routine workup fails to determine the cause of active GI bleeding (...) bleeding, the patient may require invasive hemodynamic monitoring to direct therapy. Hemostasis Once the bleeding site is localized, nonsurgical therapeutic options that may be considered include the following: Diverticular bleeding: Colonoscopy with bipolar probe coagulation, epinephrine injection, or metallic clips Recurrent bleeding: Resection of the affected bowel segment Angiodysplasia: Thermal therapy (eg, electrocoagulation, argon plasma coagulation) Conservative management, including nothing

2014 eMedicine Surgery

188. Perioperative DVT Prophylaxis

to be considered include the following: D-dimer testing Coagulation studies (eg, prothrombin time and activated partial thromboplastin time) to evaluate for a hypercoagulable state See for more detail. Management Treatment options for DVT include the following: Anticoagulation (mainstay of therapy) - Heparins, warfarin, factor Xa inhibitors, and various emerging anticoagulants Pharmacologic thrombolysis Endovascular and surgical interventions Physical measures (eg, elastic compression stockings and ambulation (...) is the presence of coagulated blood, a thrombus, in one of the deep venous conduits that return blood to the heart. The clinical conundrum is that symptoms (pain and swelling) are often nonspecific or absent. However, if left untreated, the thrombus may become fragmented or dislodged and migrate to obstruct the arterial supply to the lung, causing potentially life-threatening PE See the images below. Venous thrombus. Pulmonary embolus. DVT most commonly involves the deep veins of the leg or arm, often

2014 eMedicine.com

189. Esophageal Varices (Diagnosis)

examination): Suggests upper gastrointestinal (GI) bleeding Hemorrhoids See for more detail. Diagnosis Laboratory testing Complete blood count Liver disease–associated blood tests (eg, aspartate aminotransferase [AST], alanine aminotransferase [ALT], bilirubin, alkaline phosphatase [ALP]) Type and cross-match Coagulation studies (prothrombin time [PT], partial thromboplastin time [PTT], international normalized ratio [INR]): Prolonged INR is suggestive of impaired hepatic synthetic function Albumin (...) from portal gastropathy Mental status changes: May indicate the presence of portosystemic encephalopathy Increasing abdominal girth: May indicate ascites formation Abdominal pain and fever: May indicate spontaneous bacterial peritonitis, although this disease also presents without symptoms Hematochezia: May indicate bleeding from portal colopathy or enlarged hemorrhoids Signs of portosystemic collateral formation include the following: Anterior abdominal wall dilated veins: May indicate umbilical

2014 eMedicine.com

190. Portal Hypertension (Diagnosis)

examination): Suggests upper gastrointestinal (GI) bleeding Hemorrhoids See for more detail. Diagnosis Laboratory testing Complete blood count Liver disease–associated blood tests (eg, aspartate aminotransferase [AST], alanine aminotransferase [ALT], bilirubin, alkaline phosphatase [ALP]) Type and cross-match Coagulation studies (prothrombin time [PT], partial thromboplastin time [PTT], international normalized ratio [INR]): Prolonged INR is suggestive of impaired hepatic synthetic function Albumin (...) from portal gastropathy Mental status changes: May indicate the presence of portosystemic encephalopathy Increasing abdominal girth: May indicate ascites formation Abdominal pain and fever: May indicate spontaneous bacterial peritonitis, although this disease also presents without symptoms Hematochezia: May indicate bleeding from portal colopathy or enlarged hemorrhoids Signs of portosystemic collateral formation include the following: Anterior abdominal wall dilated veins: May indicate umbilical

2014 eMedicine.com

191. Lower Gastrointestinal Bleeding: Surgical Perspective (Treatment)

of active bleeding. Transfuse packed red blood cells (PRBCs) to maintain the hemoglobin level above 7 g/dL. Initial resuscitation involves establishing large-bore IV access and administration of normal saline. Besides ordering routine laboratory studies (eg, complete blood cell (CBC) count, electrolyte levels, and coagulation studies), blood should be typed and cross-matched. The patient's blood loss and hemodynamic status should be ascertained, and in cases of severe bleeding, the patient may require (...) be performed initially. [ , ] Once the bleeding site is localized, therapeutic options include coagulation and injection with vasoconstrictors or sclerosing agents. In cases of diverticular bleeding, bipolar probe coagulation, epinephrine injection, and metallic clips may be used. [ ] If recurrent bleeding is present, the affected bowel segment can be resected. In cases of angiodysplasia, thermal therapy, such as electrocoagulation or argon plasma coagulation, is generally successful. Angiodysplastic

2014 eMedicine Surgery

193. Deep Venous Thrombosis and Thrombophlebitis (Diagnosis)

) are required The main laboratory studies to be considered include the following: D-dimer testing Coagulation studies (eg, prothrombin time and activated partial thromboplastin time) to evaluate for a hypercoagulable state See for more detail. Management Treatment options for DVT include the following: Anticoagulation (mainstay of therapy) - Heparins, warfarin, factor Xa inhibitors, and various emerging anticoagulants Pharmacologic thrombolysis Endovascular and surgical interventions Physical measures (eg (...) thrombosis in the legs and PE. DVT is the presence of coagulated blood, a thrombus, in one of the deep venous conduits that return blood to the heart. The clinical conundrum is that symptoms (pain and swelling) are often nonspecific or absent. However, if left untreated, the thrombus may become fragmented or dislodged and migrate to obstruct the arterial supply to the lung, causing potentially life-threatening PE See the images below. Venous thrombus. Pulmonary embolus. DVT most commonly involves

2014 eMedicine Emergency Medicine

194. Anemia, Acute (Diagnosis)

intravenous (IV) sites and mucous membranes may be due to disseminated intravascular coagulation (DIC). Patients with alcoholic liver disease may have spider angiomata, caput medusae, umbilical hernias, and hemorrhoids. Acute blood loss may result in agitation. When blood loss exceeds 40% of total volume, the patient may lose consciousness. With chronic anemia, the patient may have a hyperdynamic heart, with a prominent point of maximal impulse (PMI), a systolic flow murmur, and occasionally an S 3 (...) (TTP) is rare. Arteriolar lesions with localized platelet thrombi and fibrin deposits lead to thrombocytopenia and hemolytic anemia. The tissue hypoxia from occlusion of the vessels in the affected organ causes the symptoms of TTP. However, the cause of the occlusion remains unknown. Microangiopathic hemolytic anemia, thrombocytopenia, normal coagulation test results, and renal and neurologic abnormalities should lead the physician to the diagnosis. (ITP) is an autoimmune disease often precipitated

2014 eMedicine Emergency Medicine

195. Superficial Thrombophlebitis (Treatment)

is present in an affected area. [ ] In the case of thrombosis of a hemorrhoid, evacuation of the thrombus, though very painful, usually provides rapid relief. Magnesium sulfate compresses may also be used to alleviate swelling and pain, though surgery is sometimes necessary to remove the clot from the hemorrhoid. Next: Compression Stockings Long-leg, heavy-gauge elastic stockings or multiple elastic (Ace) bandages are indicated when the patient becomes ambulatory. Gradient compression stockings (...) compressibility of vein secondary to intraluminal thrombus. Courtesy of Wikimedia Commons ©Nevit Dilmen. Blood coagulation (thrombin) and protein C pathways. Courtesy of Wikimedia Commons ©John H Griffin, PhD. of 3 Tables Contributor Information and Disclosures Author Khanjan H Nagarsheth, MD, MBA Assistant Professor of Surgery, Department of Vascular Surgery, University of Maryland Medical System Khanjan H Nagarsheth, MD, MBA is a member of the following medical societies: Academic Surgical Congress

2014 eMedicine Surgery

196. Lower Gastrointestinal Bleeding: Surgical Perspective (Overview)

: Complete blood cell (CBC) count Serum electrolytes levels (eg, sequential multiple analysis 7 [SMA7]) Coagulation profile, including activated partial thromboplastin time (aPTT), prothrombin time (PT), platelet count, and/or bleeding time (bleeding time is only recommended in patients with bleeding disorders and in those using antiplatelet agents) Helical computed tomography (CT) scanning of the abdomen and pelvis can be used when a routine workup fails to determine the cause of active GI bleeding (...) bleeding, the patient may require invasive hemodynamic monitoring to direct therapy. Hemostasis Once the bleeding site is localized, nonsurgical therapeutic options that may be considered include the following: Diverticular bleeding: Colonoscopy with bipolar probe coagulation, epinephrine injection, or metallic clips Recurrent bleeding: Resection of the affected bowel segment Angiodysplasia: Thermal therapy (eg, electrocoagulation, argon plasma coagulation) Conservative management, including nothing

2014 eMedicine Surgery

198. Superficial Thrombophlebitis (Follow-up)

is present in an affected area. [ ] In the case of thrombosis of a hemorrhoid, evacuation of the thrombus, though very painful, usually provides rapid relief. Magnesium sulfate compresses may also be used to alleviate swelling and pain, though surgery is sometimes necessary to remove the clot from the hemorrhoid. Next: Compression Stockings Long-leg, heavy-gauge elastic stockings or multiple elastic (Ace) bandages are indicated when the patient becomes ambulatory. Gradient compression stockings (...) compressibility of vein secondary to intraluminal thrombus. Courtesy of Wikimedia Commons ©Nevit Dilmen. Blood coagulation (thrombin) and protein C pathways. Courtesy of Wikimedia Commons ©John H Griffin, PhD. of 3 Tables Contributor Information and Disclosures Author Khanjan H Nagarsheth, MD, MBA Assistant Professor of Surgery, Department of Vascular Surgery, University of Maryland Medical System Khanjan H Nagarsheth, MD, MBA is a member of the following medical societies: Academic Surgical Congress

2014 eMedicine Surgery

199. Lower Gastrointestinal Bleeding: Surgical Perspective (Follow-up)

of active bleeding. Transfuse packed red blood cells (PRBCs) to maintain the hemoglobin level above 7 g/dL. Initial resuscitation involves establishing large-bore IV access and administration of normal saline. Besides ordering routine laboratory studies (eg, complete blood cell (CBC) count, electrolyte levels, and coagulation studies), blood should be typed and cross-matched. The patient's blood loss and hemodynamic status should be ascertained, and in cases of severe bleeding, the patient may require (...) be performed initially. [ , ] Once the bleeding site is localized, therapeutic options include coagulation and injection with vasoconstrictors or sclerosing agents. In cases of diverticular bleeding, bipolar probe coagulation, epinephrine injection, and metallic clips may be used. [ ] If recurrent bleeding is present, the affected bowel segment can be resected. In cases of angiodysplasia, thermal therapy, such as electrocoagulation or argon plasma coagulation, is generally successful. Angiodysplastic

2014 eMedicine Surgery

200. Snake Envenomation, Rattle (Follow-up)

estimates as high as 50% exist), is characterized by the following: Local effects - Puncture wounds only Systemic effects - None Coagulation abnormalities - No laboratory evidence of coagulation abnormalities and no clinical evidence of abnormal bleeding or clotting Minimal or mild envenomation is characterized by the following: Local effects - Swelling, pain, tenderness, and/or ecchymosis confined to the immediate bite area Systemic effects - None Coagulation abnormalities - No laboratory evidence (...) of coagulation abnormalities and no clinical evidence of abnormal bleeding or clotting Moderate envenomation is characterized by the following: Local effects - Swelling, pain, tenderness, and/or ecchymosis extending beyond the immediate bite area but involving less than the entire part Systemic effects - Present but not life threatening; may include nausea, vomiting, oral paresthesias or unusual tastes, fasciculations (myokymia), mild hypotension (systolic blood pressure <90 mm Hg), mild tachycardia (heart

2014 eMedicine Emergency Medicine

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