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Differentiated thyroid carcinoma does not patients with unfavorable histopathology (tall-cell cheap levitra oral jelly 20 mg on line erectile dysfunction medication otc, colum� behave more aggressively during pregnancy order 20mg levitra oral jelly overnight delivery erectile dysfunction causes depression. But there is a nar cell buy 20 mg levitra oral jelly with amex treatment of erectile dysfunction using platelet-rich plasma, insular cell buy levitra oral jelly 20 mg without a prescription erectile dysfunction heart disease, Hirthle cell, or diffuse sclerosing higher risk of complications in pregnant women undergo� subtypes). Nevertheless, assists with determining the activity of 131 I to be adminis� patients receiving thyroxine suppression therapy should tered. Patients patients with 1 1I after thyroidectomy: (1)thyroid remnant ablation and (2) treatment of known or suspected thyroid with asymptomatic, stable, radioiodine-resistant metastases cancer. However, the indications and optimal activity (dose) should be carefully monitored for tumor progression. If all scans are negative, the patient has a good prognosis and empiric therapy with 131 I is not useful. Radioiodine administration is contraindi� tritis, temporary oligospermia, sialadenitis, and xerosto� mia. Therapywith 131 I can cause neurologicdecompensation cated in women who are pregnant or nursing. Cumulative doses of 1 1I over residual normal thyroid tissues after surgeryfor differenti� 500 mCi (18. Pulmonary fibrosis can occur patients with no known lymph node involvement who are in patients with diffuse lung metastases after receiving at low risk for metastases. Thyrogen should not be administered to patients with Anaplastic thyroid carcinoma is treated with local resec� an intact thyroid gland because it can cause severe thyroid tion and radiation. Hyperthyroidism can also cause differentiation and apoptosis of anaplastic thyroid occur in patients with significant metastases or residual carcinoma cells in vitro, but clinical studies have not been normal thyroid. Anaplastic thyroid carcinoma does not respond to 1311 therapy and is resistant to most chemotherapy. Thyroxine roid lymphomas are best treated with external radiation is withdrawn for 14 days and the patient is allowed to become therapy; chemotherapy is added for extensive lymphoma. Medullary thyroid carcinoma age women to screen for pregnancy, serum thyroglobulin as does not respond to 131 I therapy and is relatively resistant to a tumor marker. Patients should be monitored closely, with therapy may be resumed at flreplacement dose. Vandetanib and cabo� thyroid cancer who received 1311 therapy have a 20% zantinib are approved for use against rapidly progressive increased risk of developing a second non-thyroid malig� metastatic medullary thyroid carcinoma; both require close nancy (especially leukemia and lymphoma). Vandetanib should usually not second cancers peaks about 5 years following 1311 therapy. Women are advised to administered to patients with gastrointestinal disease or avoid pregnancy for at least 4 months following 1311 ther� prior radiation to the neck or mediastinum, since it apy. Men have been found to have abnormal spermatozoa increases the risk for gastrointestinal perforation and tra� for up to 6 months following 1311 therapy and are advised to cheoesophageal fstula. Other Therapy for Differentiated Thyroid Cancer may stimulate the growth of medullary thyroid carcinoma. Local neck radiation nate, 4 mg intravenously every 6 months; those with symp� therapy may also be given to patients with anaplastic thy� tomatic osteolytic metastases, are treated with zoledronate, roid carcinoma. Brain metastases can be treated with 4 mg intravenously every 3 months for the first year and gamma knife radiosurgery. Recurrence in the neck may be treated with surgical deb� Most differentiated thyroid carcinoma recurs within the ulking and external beam radiation therapy. Patients at higher risk have traditionally thyroglobulin levels are inadequately sensitive and stimu� required at least two annual consecutively negative stimu� lated serum thyroglobulin measurements should be used lated serum thyroglobulin determinations less than 1 ng/ and always with neck ultrasound. Patients with differentiated thyroid carcinoma detected postoperatively and do not necessarily indicate must be monitored long-term for recurrent or metastatic metastatic disease, but follow-up is necessary. Thyrotoxicosis can be caused by body scanning should be performed for at least 30 minutes over-replacement with thyroxine or by the growth of func� for at least 140,000 counts and spot views of the neck tioning metastases. However, the presence of antithy� following characteristics imply a worse prognosis: age over roglobulin antibodies renders the serum thyroglobulin 45 years, male sex, bone or brain metastases, macronodular determination uninterpretable. Younger patients with pulmonary 2 ng/mL; such patients have a 23% risk oflocal neck metas� metastases tend to respond better to 1311 therapy than do tases and a 13% risk of distant metastases. Certain papillary histologic types are associ� stimulated radioiodine neck and whole-body scan detects ated with a higher risk of recurrence and reduced survival: only about half of these metastases because they are small tall cell, columnar cell, and diffuse sclerosing types. Patients with a follicular variant of require additional radioiodine therapy, especially if the papillary carcinoma have a prognosis somewhere between serum thyroglobulin level is very low. The Hirthle cell variant of follicular metastases in patients with a detectable serum thyroglobu� carcinoma is even more aggressive. It is also sensi� given stage, the different types of differentiated thyroid tive for detecting metastases from medullary thyroid carci� noma. Diabetic patients with serum glucose less than carcinoma have a similar prognosis. Patients who have not received 1311ablation have mortality rates that are increased is less sensitive for small brain metastases. False-positives can occur with benign hepatic tumors, sarcoidosis, radiation therapy, 5-year survival, while those having more than 10 metasta� ses have a 20% 5-year survival. Other scanning-Thallium-201 (2�1Tl) scans may be Patients with only local metastases have a 5-year survival of useful for detecting metastatic differentiated thyroid carci� 95%, while those with regional (supraclavicular, mediasti� noma when the 1311 scan is normal but serum thyroglobu� nal) metastases have a 5-year survival of 70%, and those lin is elevated. The overall 10-year survival rate is 90% when the tumor is confined to the thyroid, 70% for those with metastases to. Prognosis cervical lymph nodes, and 20% for those with distant In the United States in 2014, there were an estimated metastases. When postoperative serum calcitonin levels are 63,000 new diagnoses of thyroid cancer and about 1900 below 150 pg/mL (44 pmol/L), residual disease is likely deaths, yielding an overall mortality rate of 3%. However, confined to the neck, whereas when postoperative serum certain thyroid cancers behave aggressively.

The term should be restricted to order levitra oral jelly 20 mg without a prescription erectile dysfunction doctor philippines the form of the disorder that is related to 20mg levitra oral jelly amex erectile dysfunction pills buy 2 [height (m)] 139 anorexia nervosa by virtue of sharing the same psychopathology discount levitra oral jelly 20 mg visa impotence vacuum pump. The age and sex distribution is similar to discount 20 mg levitra oral jelly free shipping erectile dysfunction on coke that of anorexia nervosa, but the age of presentation tends to be slightly later. The disorder may be viewed as a sequel to persistent anorexia nervosa (although the reverse sequence may also occur). A previously anorexic patient may first appear to improve as a result of weight gain and possibly a return of menstruation, but a pernicious pattern of overeating and vomiting then becomes established. Repeated vomiting is likely to give rise to disturbances of body electrolytes, physical complications (tetany, epileptic seizures, cardiac arrhythmias, muscular weakness), and further severe loss of weight. Diagnostic guidelines For a definite diagnosis, all the following are required: (a)There is a persistent preoccupation with eating, and an irresistible craving for food; the patient succumbs to episodes of overeating in which large amounts of food are consumed in short periods of time. When bulimia occurs in diabetic patients they may choose to neglect their insulin treatment. There is often, but not always, a history of an earlier episode of anorexia nervosa, the interval between the two disorders ranging from a few months to several years. This earlier episode may have been fully expressed, or may have assumed a minor cryptic form with a moderate loss of weight and/or a transient phase of amenorrhoea. Bulimia nervosa must be differentiated from: (a)upper gastrointestinal disorders leading to repeated vomiting (the characteristic psychopathology is absent); (b)a more general abnormality of personality (the eating disorder may coexist with alcohol dependence and petty offenses such as shoplifting); (c)depressive disorder (bulimic patients often experience depressive symptoms). Most commonly this applies to people with normal or even excessive weight but with typical periods of overeating followed by vomiting or purging. Partial syndromes together with depressive symptoms are 140 also not uncommon, but if the depressive symptoms justify a separate diagnosis of a depressive disorder two separate diagnoses should be made. Bereavements, accidents, surgical operations, and emotionally distressing events may be followed by a "reactive obesity", especially in individuals predisposed to weight gain. Obesity may cause the individual to feel sensitive about his or her appearance and give rise to a lack of confidence in personal relationships; the subjective appraisal of body size may be exaggerated. Obesity as a cause of psychological disturbance should be coded in a category such as F38. Obesity as an undesirable effect of long-term treatment with neuroleptic antidepressants or other type of medication should not be coded here, but under E66. Obesity may be the motivation for dieting, which in turn results in minor affective symptoms (anxiety, restlessness, weakness, and irritability) or, more rarely, severe depressive symptoms ("dieting depression"). The appropriate code from F30-F39 or F40-F49 should be used to cover the symptoms as above, plus F50. This section includes only those sleep disorders in which emotional causes are considered to be a primary factor. In many cases, a disturbance of sleep is one of the symptoms of another disorder, either mental or physical. Even when a specific sleep disorder appears to be clinically independent, a number of associated psychiatric and/or physical factors may contribute to its occurrence. In any event, whenever the disturbance of sleep is among the predominant complaints, a sleep disorder should be diagnosed. Generally, however, it is preferable to list the diagnosis of the specific sleep disorder along with as many other pertinent diagnoses as are necessary to describe adequately the psychopathology and/or pathophysiology involved in a given case. The actual degree of deviation from what is generally considered as a normal amount of sleep should not be the primary consideration in the diagnosis of insomnia, because some individuals (the so-called short sleepers) obtain a minimal amount of sleep and yet do not consider themselves as insomniacs. Conversely, there are people who suffer immensely from the poor quality of their sleep, while sleep quantity is judged subjectively and/or objectively as within normal limits. Among insomniacs, difficulty falling asleep is the most prevalent complaint, followed by difficulty staying asleep and early final wakening. Typically, insomnia develops at a time of increased life-stress and tends to be more prevalent among women, older individuals and psychologically disturbed and socioeconomically disadvantaged people. When insomnia is repeatedly experienced, it can lead to an increased fear of sleeplessness and a preoccupation with its consequences. Individuals with insomnia describe themselves as feeling tense, anxious, worried, or depressed at bedtime, and as though their thoughts are racing. They frequently ruminate over getting enough sleep, personal problems, health status, and even death. In the morning, they frequently report feeling physically and mentally tired; during the day, they characteristically feel depressed, worried, tense, irritable, and preoccupied with themselves. Diagnostic guidelines the following are essential clinical features for a definite diagnosis: (a)the complaint is either of difficulty falling asleep or maintaining sleep, or of poor quality of sleep; (b)the sleep disturbance has occurred at least three times per week for at least 1 month; (c)there is preoccupation with the sleeplessness and excessive concern over its consequences at night and during the day; (d)the unsatisfactory quantity and/or quality of sleep either causes marked distress or interferes with ordinary activities in daily living. The presence of other psychiatric symptoms such as depression, anxiety or obsessions does not invalidate the diagnosis of insomnia, provided that insomnia is the primary complaint or the chronicity and severity of insomnia cause the patient to perceive it as the primary 143 disorder. Other coexisting disorders should be coded if they are sufficiently marked and persistent to justify treatment in their own right. It should be noted that most chronic insomniacs are usually preoccupied with their sleep disturbance and deny the existence of any emotional problems. Thus, careful clinical assessment is necessary before ruling out a psychological basis for the complaint. Insomnia is a common symptom of other mental disorders, such as affective, neurotic, organic, and eating disorders, substance use, and schizophrenia, and of other sleep disorders such as nightmares. Insomnia may also be associated with physical disorders in which there is pain and discomfort or with taking certain medications. If insomnia occurs only as one of the multiple symptoms of a mental disorder or a physical condition, i. Moreover, the diagnosis of another sleep disorder, such as nightmare, disorder of the sleep-wake schedule, sleep apnoea and nocturnal myoclonus, should be made only when these disorders lead to a reduction in the quantity or quality of sleep. However, in all of the above instances, if insomnia is one of the major complaints and is perceived as a condition in itself, the present code should be added after that of the principal diagnosis. Thus, a few nights of sleeplessness related to a psychosocial stressor would not be coded here, but could be considered as part of an acute stress reaction (F43.

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In particular purchase levitra oral jelly 20 mg without a prescription erectile dysfunction essential oil, no effect has been established between chocolate order levitra oral jelly 20mg without prescription impotence pills for men, Four ounces of shrimp provides about 325 -375 milligrams of omega-3 dairy products generic levitra oral jelly 20mg amex erectile dysfunction brands, shellfsh generic 20 mg levitra oral jelly fast delivery erectile dysfunction medications side effects, or fatty foods [79]. Isotretinoin, Retinol (Vitamin A), carotenoids (provitamin A) and retinoids (Vitamin A metabolites) are absorbed better with parallel intake of vegetable oils [13]. After adjustment for sex and age, the presence of acne remained pale eyes and forehead acne [85]. The dark color of blackheads has nothing to do with dirt: They look open comedones or blackheads are full of dirt [88]. Although squeezing pimples may make skin look better in the short term, it might force the pus even deeper into skin, which can make it One should pop pimples at frst sight. However, clinicians should Sitting in the Sun to Clear Pimples not be didactic in their recommendations regarding diet, hygiene and face-washing, and sunlight to patients with acne. During compared to healthy controls, which may provide prognostic puberty, alteration of the sebaceous lipid profile, called value for the disease [102]. Sebum is particularly abundant dysmenorrhea, stress, irritation, cosmetics and potential at anatomic sites with high concentration of P. Sphingolipids is generally considered mild but represents a high economical are a class of lipids composed of a backbone of spingoid and psychological burden for the society. The common China, the demand for facial beauty has been surprisingly differential diagnosis of acne includes folliculitis, keratosis increased. In the general esthetic pursuit of fairer skin in East pilaris, perioral dermatitis, seborrheic dermatitis and Asia, Chinese people increasingly pay attention to post-acne rosacea. The most common drug class utilized was excess include seborrhea, hirsutism and androgenetic J Clin Pharm 2019 22 Endocrinologic testing is not ordered routinely Acne Scars for women with regular menstrual cycles. Grade Severity Clinical fndings Open and closed comedones (blackheads or whiteheads) with few infammatory papules and pustules. Acne is also considered to be �mild acne� if someone only has a few pimples, or only has small ones. Often seen in black patients; lesions localized to the posterior neck; initially papules and pustules that may progress Acne keloidalis nuchae to confuent keloids Secondary to systemic medications, topical corticosteroid medications, contrast dye, and cosmetic products; may Acneiform eruptions be abrupt in onset and correlation with exposure; improvement with cessation of exposure. Other drugs that can also induce acneiform eruptions include nystatin, Drug-induced acne isoniazid, corticotropin, naproxen, hydroxychloroquine, cyclosporin A, antimycotics, gold salts, isotretinoin, clofazimine, epidermal growth factor receptor inhibitors (cetuximab, geftinib, and erlotinib), and interferon-beta. These lesions most commonly occur in intertriginous areas and areas rich in apocrine glands. Among the most common are axillary, groin, perianal, perineal, and inframammary locations. Small waxy papules over the medial cheeks, nose, and forehead; multiple lesions associated with tuberous sclerosis; skin biopsy test results show dermal fbrosis and vascular proliferation and dilatation (angiofbromas). Adenoma sebaceum Facial angiofbromas are also a feature of multiple endocrine neoplasia type I and, rarely, Birt-Hogg-Dube syndrome. Affects curly-haired persons who regularly shave closely, with a high prevalence in men of subequatorial African ancestry and, to a much lesser extent, Indo-Europeans. Seborrheic dermatitis presents as ill-defned erythematous patches with greasy scale distributed on the eyebrows, glabella, paranasal skin, nasolabial folds, Seborrheic dermatitis beard, scalp, and chest. Minimal to modest elevations of <200 ng/dL are suggestive of a benign cause of ovarian or adrenal cause while Testosterone above this level; neoplasia of ovarian or adrenal origin should be suspected. Secreted equally by ovaries and adrenals and follows a circadian rhythm making early morning samples, the best Androstenedione to analyze. Elevated (>200 ng/dl) in congenital adrenal hyperplasia or non-classic congenital adrenal hyperplasia due to 17-Hydroxy progesterone defciency or absence of 21fi-hydroxylase. Psychological issues Rather than fading with time, the appearance of scars often such as social dysfunction such as reduced/avoidance of worsens with normal aging or photo damage [129] (Figure social interactions with peers and opposite gender also 2) (Table 6). Boxcar scars are round-to-oval depressions with sharply demarcated vertical edges. Papular scars, unlike the depressed morphology of ice pick, rolling, and boxcar scars, are exophytic in nature and produce a cobblestone-like appearance. It is most likely related to infammatory mediators and enzymatic Atrophic scars degradation of collagen fbers and subcutaneous fat. The most basic, practical, system divides atrophic acne scars into the following three main types: a) icepick, b) rolling, and c) boxcar scars Icepick scars are narrow (<2 mm), deep, sharply margined epithelial tracts that extend vertically to the deep (a) Icepack dermis or subcutaneous tissue. Rolling scars occur from dermal tethering of otherwise relatively normal-appearing skin and are usually wider (b) Rolling than 4 to 5 mm. They Hypertrophic scars develop if too much connective tissue is produced while the wound is healing. Papular scars can clinically mimic closed comedones, acne, and granulomas, leading to an unnecessary delay in appropriate treatment. Active acneiform lesions causing any type of scars should be treated aggressively with systemic therapy to prevent further progression of scarring. Papular scars are 3 to 4mm skin-colored Papular Scars cobblestone-like papules distributed anywhere on the body but, in our clinical experience, most commonly on the chin, nose, and back. Keloids result from abnormal wound healing in response to skin trauma or infammation. Higher incidences are seen in darker skinned individuals of African, Asian, and Hispanic descent. In keloids, the fbroblastic phase continues, unchecked, resulting in the clinical and histopathological fndings. Consequentially, sexual minorities with therapy has shown the most favorable results and typically acne may be a group at high risk for development of mental consists of a regimen including benzoyl peroxide, topical health problems [139]. Oral antibiotics may be tried is the most debated aspect of isotretinoin therapy [141]. Milk and dairy products: High intakes (fi 2 glasses per are the mainstay of treatment; can be given in combinations.

Etiology doses range from 50 meg to purchase levitra oral jelly 20 mg on-line erectile dysfunction doctors in el paso tx 250 meg subcutaneously three Acute upper gastrointestinal bleeding may originate from a times daily cheap 20 mg levitra oral jelly with amex experimental erectile dysfunction drugs. These are listed in order of their fre� Bile salt binders: Cholestyramine or colestipol (2-4 g quency and discussed in detail below generic levitra oral jelly 20mg impotence when trying for a baby. Peptic Ulcer Disease bile salt-induced diarrhea discount levitra oral jelly 20 mg on line erectile dysfunction nofap, which may be idiopathic or secondary to intestinal resection or ileal disease. Peptic ulcers account for 40% of major upper gastrointesti� nal bleeding with an overall mortality rate of less than 5%. Best Pract Res Clin declining due to eradication of H pylori and prophylaxis Gastroenterol. Definitions, pathophysiology, and evaluation of Portal hypertension accounts for 10-20% of upper gastro� chronic diarrhoea. Initial Evaluation & Treatment patients with cirrhosis have medium to large esophageal varices, of whom 30% experience acute variceal bleeding A. Due to improved care, the hospital Theinitial step is assessment of the hemodynamic status. A mortality rate has declined over the past 20 years from 40% systolic blood pressure lower than 100 mm Hg identifies a to 15%. Nevertheless, a mortality rate of60-80% is expected high-risk patient with severe acute bleeding. A heart rate at 1-4 years due to recurrent bleeding or other complica� over 100 beats/min with a systolic blood pressure over tions of chronic liver disease. Postural hypotension and tachycardia are useful when present but may be due to causes other Lacerations of the gastroesophageal junction cause 5-10% than blood loss. Many patients 24-72 hours to equilibrate with the extravascular fuid, it report a history ofheavy alcohol use or retching. In patients with signifcant bleeding, two 18-gauge or larger intravenous lines should be started prior to frther D. They account for 7% of cases of screening (in anticipation of the possible need for transfu� acute upper tract bleeding. In patients without hemodynamic compromise or ectasias (angiodysplasias) which are 1-10 mm distorted, overt active bleeding, aggressive fuidrepletion can be delayed aberrant submucosal vessels caused by chronic, intermit� until the extent of the bleeding is frther clarifed. It is rarely necessary to angiectasias are small, cherry red lesions caused by administer type-specifc or 0-negative blood. The Dieulafoy lesion is an Placement of a nasogastric tube is not routinely needed aberrant, large-caliber submucosal artery, most commonly but may be helpful in the initial assessment and triage of in the proximal stomach that causes recurrent, intermit� selected patients with suspected active upper tract bleed� tent bleeding. The aspiration of red blood or "coffee grounds" con� firms an upper gastrointestinal source of bleeding, though E. Gastric Neoplasms up to 18% of patients with confirmed upper tract sources of bleeding have nonbloody aspirates-especially when Gastric neoplasms result in 1% of upper gastrointestinal bleeding originates in the duodenum. Erosive Gastritis while a clear aspirate identifies patients at lower initial Because this process is superfcial, it is a relatively unusual risk. Erythromycin (250 mg) administered intravenously cause of severe gastrointestinal bleeding (less than 5% of cases) 30 minutes prior to upper endoscopy promotes gastric and more commonly results in chronic blood loss. Efforts to stop or slow bleeding by gastric lavage with large volumes of fuid are of no benefit G. Severe erosive esophagitis due to chronic gastroesophageal refux may rarely cause signifcant upper gastrointestinal B. The amount of fuid and blood products required is based on assessment of vital signs, evidence of active bleeding from nasogastric aspirate, and laboratory tests. In the absence of continued gastrointestinal bleeding include hemobilia (from hepatic bleeding, the hemoglobin should rise approximately 1 g/dL tumor, angioma, penetrating trauma), pancreatic malig� for each unit of transfused packed red cells. The benefits of endoscopy in desirable to transfse blood in anticipation of the nadir this setting are threefold. To identify the source of bleeding-The appropriate fsed if the platelet count is under 50,000/mcL and consid� acute and long-term medical therapy is determined by the ered if there is impaired platelet fnction due to aspirin or cause ofbleeding. Patients with portal hypertension will be clopidogrel use (regardless of the platelet count). In Patients with a nonbleeding Mallory-Weiss tear, esophagi� the face of massive bleeding, administration of four factor tis, gastritis, and ulcers that have a clean, white base have a prothrombin complex concentrates is preferred (rather than very low risk (less than 5%) ofrebleeding. Initial Triage support may be discharged from the emergency depart� A preliminary assessment of risk based on several clinical ment or medical ward after endoscopy with outpatient factors aids in the resuscitation as well as the rational triage follow-up. Clinical predictors of increased risk of should be observed on a medical ward for 24-48 hours. To render endoscopic therapy-Hemostasis can be hematemesis or bright red blood on nasogastric aspirate, achieved in actively bleeding lesions with endoscopic shock, persistent hemodynamic derangement despite fuid modalities such as cautery, injection, or endoclips. Similarly, 90% of endoscopy should be performed within 2-24 hours in most bleeding ulcers, angiomas, or Mallory-Weiss tears can be patients but may be delayed in selected patients with seri� controlled with either injection of epinephrine, direct cau� ous comorbidities (eg, acute coronary syndrome) who do terization of the vessel by a heater probe or multipolar not have signs of continued bleeding. Low to moderate risk-All other patients are admitted sels, and angioectasias are also treated with these therapies. Acid inhibitory therapy-Intravenous proton pump inhibitors (esomeprazole or pantoprazole, 80 mg bolus, Specifc treatment of the various causes of upper gastroin� followed by 8 mg/h continuous infusion for 72 hours) testinal bleeding is discussed elsewhere in this chapter. The reduce the risk of rebleeding in patients with peptic ulcers following general comments apply to most patients with with high-risk features (active bleeding, visible vessel, or bleeding. Signs of chronic liver disease zole 40 mg; lansoprazole or dexlansoprazole 30-60 mg) once implicate bleeding due to portal hypertension, but a differ� or twice daily are sufficient for lesions at low-risk for ent lesion is identifed in 25% of patients with cirrhosis. Acute bleeding preceded by heavy Administration of continuous intravenous proton alcohol ingestion or retching suggests a Mallory-Weiss tear, pump inhibitor before endoscopy results in a decreased though most of these patients have neither. Upper Endoscopy institutions to administer either an intravenous or a high� Virtually all patients with upper tract bleeding should dose oral proton pump inhibitor prior to endoscopy in undergo upper endoscopy within 24 hours of arriving in patients with significant upper gastrointestinal bleeding.