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Hemorrhoid Coagulation

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122. Therapeutic Injections for Pain Management (Overview)

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

123. Lower Gastrointestinal Bleeding (Overview)

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. Multiple criteria are used for establishing (...) 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 by mouth (NPO) and IV hydration in patients with ischemic

2014 eMedicine.com

124. Oral Manifestations of Systemic Diseases (Overview)

for GERD in adults is proton pump inhibitors (PPIs), although H2-receptor antagonists are also beneficial. [ ] Patients may also benefit from decreased consumption of acidic foods and beverages. [ ] Patients with xerostomia should consider discontinuing medications that may exacerbate hyposalivation or use a salivary supplement. [ ] Also see . Chronic liver disease The liver has numerous synthetic, storage, and excretory functions. The liver synthesizes many of the coagulation factors necessary (...) , alcoholic liver disease, and nonalcoholic fatty liver disease, although countless other conditions can cause CLD. [ ] CLD is a leading cause of mortality and morbidity both in the United States and around the world. [ ] The systemic manifestations of CLD are numerous and beyond the scope of this article. They can be classified as those due to synthetic dysfunction (eg, coagulopathies, hypoalbuminemia), portal hypertension (eg, ascites, esophageal varices, hemorrhoids), bilirubin secretion (eg, jaundice

2014 eMedicine.com

125. Lower Gastrointestinal Bleeding (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.com

126. Elective Abortion (Treatment)

reduction includes the following: Intracardiac injection (potassium chloride or digoxin) Cord occlusion techniques, such as embolization with alcohol or enbucrilate gel; Nd:YAG laser photocoagulation; fetoscope cord ligation; bipolar cord coagulation; and monopolar cord coagulation Selective reduction procedures are not included in the statistics for second-trimester abortions. For the rare condition of monochorionic twins, selective reduction cord occlusion techniques are reported by Challis et al

2014 eMedicine.com

127. Normal and Abnormal Puerperium (Follow-up)

ice applied to the perineum to reduce the swelling and to help with pain relief. Conventional treatment is to use ice for the first 24 hours after delivery and then switch to warm sitz baths. However, little evidence supports this method over other methods of postpartum perineum treatment. Pain medications are helpful both systemically as nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotics and as local anesthetic spray to the perineum. Hemorrhoids are another postpartum issue likely (...) to affect women who have vaginal deliveries. Symptomatic relief is the best treatment during this immediate postpartum period because hemorrhoids often resolve as the perineum recovers. This can be achieved by the use of corticosteroid creams, witch hazel compresses, and local anesthetics in addition to a bowel regimen that avoids constipation. Tampon use can be resumed when the patient is comfortable inserting the tampon and can maintain it without discomfort. This often takes longer for the woman who

2014 eMedicine.com

128. Oral Manifestations of Systemic Diseases (Follow-up)

for GERD in adults is proton pump inhibitors (PPIs), although H2-receptor antagonists are also beneficial. [ ] Patients may also benefit from decreased consumption of acidic foods and beverages. [ ] Patients with xerostomia should consider discontinuing medications that may exacerbate hyposalivation or use a salivary supplement. [ ] Also see . Chronic liver disease The liver has numerous synthetic, storage, and excretory functions. The liver synthesizes many of the coagulation factors necessary (...) , alcoholic liver disease, and nonalcoholic fatty liver disease, although countless other conditions can cause CLD. [ ] CLD is a leading cause of mortality and morbidity both in the United States and around the world. [ ] The systemic manifestations of CLD are numerous and beyond the scope of this article. They can be classified as those due to synthetic dysfunction (eg, coagulopathies, hypoalbuminemia), portal hypertension (eg, ascites, esophageal varices, hemorrhoids), bilirubin secretion (eg, jaundice

2014 eMedicine.com

129. Lower Gastrointestinal Bleeding (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.com

131. Therapeutic Injections for Pain Management (Follow-up)

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

132. 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

133. Deep Venous Thrombosis and Thrombophlebitis (Overview)

) 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

134. Anemia, Acute (Overview)

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

135. Anemia, Acute (Follow-up)

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

136. Normal and Abnormal Puerperium (Diagnosis)

ice applied to the perineum to reduce the swelling and to help with pain relief. Conventional treatment is to use ice for the first 24 hours after delivery and then switch to warm sitz baths. However, little evidence supports this method over other methods of postpartum perineum treatment. Pain medications are helpful both systemically as nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotics and as local anesthetic spray to the perineum. Hemorrhoids are another postpartum issue likely (...) to affect women who have vaginal deliveries. Symptomatic relief is the best treatment during this immediate postpartum period because hemorrhoids often resolve as the perineum recovers. This can be achieved by the use of corticosteroid creams, witch hazel compresses, and local anesthetics in addition to a bowel regimen that avoids constipation. Tampon use can be resumed when the patient is comfortable inserting the tampon and can maintain it without discomfort. This often takes longer for the woman who

2014 eMedicine.com

138. Oral Manifestations of Systemic Diseases (Diagnosis)

for GERD in adults is proton pump inhibitors (PPIs), although H2-receptor antagonists are also beneficial. [ ] Patients may also benefit from decreased consumption of acidic foods and beverages. [ ] Patients with xerostomia should consider discontinuing medications that may exacerbate hyposalivation or use a salivary supplement. [ ] Also see . Chronic liver disease The liver has numerous synthetic, storage, and excretory functions. The liver synthesizes many of the coagulation factors necessary (...) , alcoholic liver disease, and nonalcoholic fatty liver disease, although countless other conditions can cause CLD. [ ] CLD is a leading cause of mortality and morbidity both in the United States and around the world. [ ] The systemic manifestations of CLD are numerous and beyond the scope of this article. They can be classified as those due to synthetic dysfunction (eg, coagulopathies, hypoalbuminemia), portal hypertension (eg, ascites, esophageal varices, hemorrhoids), bilirubin secretion (eg, jaundice

2014 eMedicine.com

139. 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

140. 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

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