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Hemorrhoid Coagulation

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161. Threatened 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

162. Therapeutic 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

163. Portal Hypertension (Overview)

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

165. Therapeutic Injections for Pain Management (Treatment)

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

166. Surgical Management of 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

167. 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

168. 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

169. Intestinal Fistulas (Overview)

The prognosis is based on the etiology of the fistula, as well as the comorbidities of the patient. Pain, wound management, abscess formation, local infection, nutritional deficiencies, and recurrent septic states are just a few of the physical consequences of intestinal fistulas. More recently, it appears that intestinal fistulas may also be associated with impaired coagulation status in patients with Crohn disease. [ ] Patients with fistulas most likely present with much more than physical discomfort (...) of Crohn's disease. Int Surg . 1992 Jan-Mar. 77 (1):19-27. . Lavery IC. Colonic fistulas. Surg Clin North Am . 1996 Oct. 76 (5):1183-90. . Donner CS. Pathophysiology and therapy of chronic radiation-induced injury to the colon. Dig Dis . 1998 Jul-Aug. 16 (4):253-61. . Li Y, Ren JA, Wang GF, et al. Impaired coagulation status in the Crohn's disease patients complicated with intestinal fistula [Chinese]. Chin Med J (Engl) . 2018 Mar 5. 131 (5):567-73. . Bottger TC, Junginger T. Factors influencing

2014 eMedicine.com

170. Dermatologic Aspects of Bioterrorism Agents (Overview)

the same as those for any gram-negative septicemia and include fever, chills, nausea, vomiting, and diarrhea; later, purpura, disseminated intravascular coagulation (DIC), and acrocyanosis and necrosis occur. The mortality rate is nearly 100% without treatment, but 30-50% with treatment. Pneumonic plague may occur primarily from inhalation of aerosols or secondarily from hematogenous dissemination. Humans contract this form from domestic cats in 28% of cases (25% of these patients are veterinarians

2014 eMedicine.com

171. 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

172. Intestinal Fistulas (Follow-up)

DJ, eds. Clinical Surgery International: Surgery of Inflammatory Bowel Disorders . Avon, CT: Churchill Livingston; 1987. Vol 14: 190-6. Annibali R, Pietri P. Fistulous complications of Crohn's disease. Int Surg . 1992 Jan-Mar. 77 (1):19-27. . Lavery IC. Colonic fistulas. Surg Clin North Am . 1996 Oct. 76 (5):1183-90. . Donner CS. Pathophysiology and therapy of chronic radiation-induced injury to the colon. Dig Dis . 1998 Jul-Aug. 16 (4):253-61. . Li Y, Ren JA, Wang GF, et al. Impaired coagulation (...) . 2018 Feb 15. . Rots WI, Mokoena T. Successful endoscopic closure of a benign gastrocolonic fistula using human fibrin sealant through gastroscopic approach: a case report and review of the literature. Eur J Gastroenterol Hepatol . 2003 Dec. 15 (12):1351-6. . Sirikurnpiboon S, Phadhana-anake O, Awapittaya B. Comparison of endoanal ultrasound with clinical diagnosis in anal fistula assessment. J Med Assoc Thai . 2016 Feb. 99 Suppl 2:S69-74. . Hancock BD. ABC of colorectal diseases. Haemorrhoids. BMJ

2014 eMedicine.com

173. 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

174. 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

176. Thrombophlebitis, Superficial (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 Emergency Medicine

177. Snake Envenomation, Mohave Rattle (Treatment)

clinical course. When considering the use of antivenom, weigh the risk of adverse reaction to antivenom against the benefits of reducing venom toxicity. Nonenvenomation, ie, dry bite (probably occurs in < 10% of rattlesnake bites), 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

2014 eMedicine Emergency Medicine

178. Snake Envenomation, Rattle (Treatment)

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

179. Snake Envenomation, Moccasins (Treatment)

to be dead. Do not reach or step into places outdoors that are not visible. At home, remove debris in which snakes might hide (eg, log piles). Remove items, such as bird feeders, that might attract snakes—seeds that fall from bird feeders attract rodents, which attract snakes. Heavy clothing (such as hiking boots) may retard some strikes. Young children should be closely supervised, and older children should be educated to avoid snakes. [ ] Previous Next: Long-Term Monitoring Discharge instructions (...) for 2 weeks after the snakebite. Drink plenty of liquids. Return if urine decreases in amount or becomes cola colored. Referral to a physical therapist or surgeon may be indicated. Patients who developed severe coagulopathy or thrombocytopenia should have these studies rechecked in 3 days, and as needed for signs of coagulation problems (eg, bleeding gums, easy bruising). Previous References Wingert WA, Pattabhiraman TR, Cleland R, Meyer P, Pattabhiraman R, Russell FE. Distribution and pathology

2014 eMedicine Emergency Medicine

180. Deep Venous Thrombosis (Diagnosis)

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

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