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Genetic factors contribute to order reglan 10mg otc gastritis tylenol the onset of tobacco use discount 10mg reglan otc gastritis diet ������, the continuation of tobacco use buy reglan 10 mg mastercard gastritis food to eat, and the development of tobacco use disorder generic 10mg reglan with visa gastritis stories, with a degree of heritability equivalent to that observed with other substance use disorders. Some of this risk is specific to tobacco, and some is common with the vulnerability to developing any substance use disorder. Culture-Related Diagnostic Issues Cultures and subcultures vary widely in their acceptance of the use of tobacco. The prev� alence of tobacco use declined in the United States from the 1960s through the 1990s, but this decrease has been less evident in African American and Hispanic populations. Also, smoking in developing countries is more prevalent than in developed nations. The degree to which these cultural differences are due to income, education, and tobacco control ac� tivities in a country is unclear. Non-Hispanic white smokers appear to be more likely to develop tobacco use disorder than are smokers. African American males tend to have higher nicotine blood levels for a given number of cigarettes, and this might contribute to greater difficulty in quitting. Also, the speed of nicotine metabolism is significantly different for whites compared with African Americans and can vary by genotypes associated with ethnicities. Diagnostic M arkers Carbon monoxide in the breath, and nicotine and its metabolite cotinine in blood, saliva, or urine, can be used to measure the extent of current tobacco or nicotine use; however, these are only weakly related to tobacco use disorder. Functional Consequences of Tobacco Use Disorder Medical consequences of tobacco use often begin when tobacco users are in their 40s and usually become progressively more debilitating over time. One-half of smokers who do not stop using tobacco will die early from a tobacco-related illness, and smoking-related morbidity occurs in more than one-half of tobacco users. Most medical conditions result from exposure to carbon monoxide, tars, and other non-nicotine components of tobacco. Comorbidity the most common medical diseases from smoking are cardiovascular illnesses, chronic obstructive pulmonary disease, and cancers. Smoking also increases perinatal problems, such as low birth weight and miscarriage. The most common psychiatric comorbidities are alcohol/substance, depressive, bipolar, anxiety, personality, and attention-deficit/hyperactivity disorders. In individuals with current tobacco use disorder, the prevalence of cur� rent alcohol, drug, anxiety, depressive, bipolar, and personality disorders ranges from 22% to 32%. Tobacco Withdrawal ^ Diagnostic Criteria 292. Abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed within 24 hours by four (or more) of the following signs or symptoms: 1. The signs or symptoms are not attributed to another medical condition and are not bet� ter explained by another mental disorder, including intoxication or withdrawal from an� other substance. It is not permissible to code a comorbid mild tobacco use disorder with tobacco withdrawal. The symptoms after absti� nence from tobacco are in large part due to nicotine deprivation. Symptoms are much more intense among individuals who smoke cigarettes or use smokeless tobacco than among those who use nicotine medications. This difference in symptom intensity is likely due to the more rapid onset and higher levels of nicotine with cigarette smoking. Tobacco withdrawal is common among daily tobacco users who stop or reduce but can also occur among nondaily users. Typically, heart rate decreases by 5-12 beats per minute in the first few days after stopping smoking, and weight increases an average of 4-7 lb (2-3 kg) over the first year after stopping smoking. Tobacco withdrawal can produce clinically signifi� cant mood changes and functional impairment. Associated Features Supporting Diagnosis Craving for sweet or sugary foods and impaired performance on tasks requiring vigilance are associated with tobacco withdrawal. Abstinence can increase constipation, coughing, dizziness, dreaming/nightmares, nausea, and sore throat. Smoking increases the metab� olism of many medications used to treat mental disorders; thus, cessation of smoking can increase the blood levels of these medications, and this can produce clinically significant outcomes. This effect appears to be due not to nicotine but rather to other compounds in tobacco. Prevalence Approximately 50% of tobacco users who quit for 2 or more days will have symptoms that meet criteria for tobacco withdrawal. The most commonly endorsed signs and symptoms are anxiety, irritability, and difficulty concentrating. Development and Course Tobacco withdrawal usually begins within 24 hours of stopping or cutting down on to� bacco use, peaks at 2-3 days after abstinence, and lasts 2-3 weeks. Tobacco withdrawal symptoms can occur among adolescent tobacco users, even prior to daily tobacco use. Smokers with depressive disorders, bipolar disorders, anxiety disor� ders, attention-deficit/hyperactivity disorder, and other substance use disorders have more severe withdrawal. Diagnostic Markers Carbon monoxide in the breath, and nicotine and its metabolite cotinine in blood, saliva, or urine, can be used to measure the extent of tobacco or nicotine use but are only weakly re� lated to tobacco withdrawal. Functional Consequences of Tobacco W ithdrawal Abstinence from cigarettes can cause clinically significant distress.

When used as doses of 1 order reglan 10 mg online gastritis weight loss,500mg/day order reglan 10mg amex gastritis diet 22, no adverse impact on glucose metabolism is seen but significant prostaglandin D2-mediated flushing limits the clinical utility of this drug170 order 10mg reglan with visa gastritis diet �������. These results order 10mg reglan mastercard gastritis what to eat, while impressive, have yet to be reproduced and one must remain appropriately circumspect when interpreting this case report. Disclaimer the views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Armed Forces, Department of Defense, or the U. Severe acute pancreatitis: advances and insights in assessment of severity and management. Acute pancreatitis associated with hypertriglyceridemia: a life-threatening complication. Treatment of hyperlipidemic acute pancreatitis with plasma exchange: a single-center experience. The Causes and Outcome of Acute Pancreatitis Associated with Serum Lipase >10,000 U/L. A case of adolescent hyperlipoproteinemia with xanthoma and acute pancreatitis, associated with decreased activities of lipoprotein lipase and hepatic triglyceride lipase. Apolipoprotein B: a clinically important apolipoprotein which assembles atherogenic lipoproteins and promotes the development of atherosclerosis. The metabolism of triglyceride-rich lipoproteins revisited: new players, new insight. Lipoprotein lipase during continuous heparin infusion: tissue stores become partially depleted. Long-term follow-up of patients with acute hypertriglyceridemia-induced pancreatitis. Ethanol toxicity in pancreatic acinar cells: mediation by nonoxidative fatty acid metabolites. Prevention of recurrent acute pancreatitis in patients with severe hypertriglyceridemia: value of regular plasmapheresis. Role of hypertriglyceridemia in the pathogenesis of experimental acute pancreatitis in rats. Is Lipotoxicity presents in the early stages of an experimental model of autoimmune diabetesfl Exogenous and endogenous postprandial lipid abnormalities in type 2 diabetic patients with optimal blood glucose control and optimal fasting triglyceride levels. Drug-induced toxicity on mitochondria and lipid metabolism: mechanistic diversity and deleterious consequences for the liver. Hormonal and metabolic profiles in patients with alcohol-induced, mixed hypertriglyceridemia before and after abstinence from ethanol and before and after a lipid-lowering diet. State of the art review: Intravenous fat emulsions: Current applications, safety profile, and clinical implications. Hyperlipidemic acute pancreatitis: a possible role of antiretroviral therapy with entecavir. Gender factors affect fatty acids-induced insulin resistance in nonobese humans: effects of oral steroidal contraception. Severe hypertriglyceridemia and pancreatitis when estrogen replacement therapy is given to hypertriglyceridemic women. Oral estrogen replacement therapy in postmenopausal women selectively raises levels and production rates of lipoprotein A-I and lowers hepatic lipase activity without lowering the fractional catabolic rate. An observational study of severe hypertriglyceridemia, hypertriglyceridemic acute pancreatitis, and failure of triglyceride-lowering therapy when estrogens are given to women with and without familial hypertriglyceridemia. Comparative assessment of lipid effects of endocrine therapy for breast cancer: implications for cardiovascular disease prevention in postmenopausal women. Combination of apolipoprotein E2 and lipoprotein lipase heterozygosity causes severe hypertriglyceridemia during pregnancy. Successful outcome in severe pregnancy-associated hyperlipemia: a case report and literature review. Lipoprotein alterations, hepatic lipase activity, and insulin sensitivity in subclinical hypothyroidism: response to L-T(4) treatment. Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis. Exocrine pancreatic function during the early recovery phase of acute pancreatitis. Emergent therapy with therapeutic plasma exchange in acute recurrent pancreatitis due to severe hypertriglyceridemia. Chylomicronemia and the chylomicronemia syndrome: a practical approach to management. Safe and rapid resolution of severe hypertriglyceridaemia in two patients with intravenous insulin. A novel complex deletion-insertion mutation mediated by Alu repetitive elements leads to lipoprotein lipase deficiency. Dyslipidaemia in a boy with recurrent abdominal pain, hypersalivation and decreased lipoprotein lipase activity. A case of acute pancreatitis with hyperlipemia and hyperglycemia induced by alcohol abuse. Insulin infusion to treat severe hypertriglyceridemia associated with pegaspargase therapy: a case report.

Examples of these cancers include breast discount reglan 10 mg fast delivery gastritis on ct, colorectal generic reglan 10 mg with amex gastritis diet ��, cervical effective 10 mg reglan gastritis healing symptoms, endometrial effective 10mg reglan gastritis type a and b, testicular, skin, and oropharyngeal cancers. Patients with suspected cancer undergo extensive testing to � Determine the presence and extent of tumor. Tumor Staging and Grading Staging Staging determines the size of the tumor and the existence of local invasion and distant metastasis. Grading systems seek to deflne the type of tissue from which the tumor originated and the degree to which the tumor cells retain the functional and histologic characteristics of the tissue of origin (differentiation). Samples of cells to be used to establish the grade of a tumor may be obtained from tissue scrapings, body fluids, secretions, or washings, biopsy, or surgical excision. This information helps the health care team predict the behavior and prognosis of various tumors. The tumor is assigned a numeric value ranging from 1 (welldifferentiated) to 4 (poorly differentiated or undifferentiated). Medical Management the range of possible treatment goals may include complete eradication of malignant disease (cure), prolonged survival and containment of cancer cell growth (control), or relief of symptoms associated with the disease (palliation). A variety of therapies may be used, including the following: � Surgery (eg, excisions, video-assisted endoscopic surgery, salvage surgery, electrosurgery, cryosurgery, chemosurgery, or laser surgery). Surgery may be the primary method of treatment or 124 Cancer it may be prophylactic, palliative, or reconstructive. C � Radiation therapy and chemotherapy (may be used individually or in combination). Nursing Management Maintaining Tissue Integrity Some of the most frequently encountered disturbances of tissue integrity include stomatitis, skin and tissue reactions to radiation therapy, alopecia, and malignant skin lesions. Cancer 125 � Help patient minimize discomfort by using prescribed topical anesthetic, administering prescribed systemic analgesics, and performing appropriate mouth care. C Managing Radiation-Associated Skin Impairments � Provide careful skin care by avoiding the use of soaps, cosmetics, perfumes, powders, lotions and ointments, and deodorants. Use only lukewarm water to bathe the area, and avoid applying hot-water bottles, heating pads, ice, and adhesive tape to the area. If the area is without drainage, use moisture and vaporpermeable dressings such as hydrocolloids and hydrogels on noninfected areas. Addressing Alopecia � Discuss potential hair loss and regrowth with patient and family; advise that hair loss may occur on body parts other than the head. Managing Malignant Skin Lesions � Carefully assess and cleanse the skin, reducing superflcial bacteria, controlling bleeding, reducing odor, protecting skin from pain and further trauma, and relieving pain. Anorexia, malabsorption, and cachexia are common examples of nutritional problems. Relieving Pain � Use a multidisciplinary team approach to determine optimal management of pain for optimal quality of life. Cancer 127 � Encourage strategies of pain relief that patient has used successfully in previous pain experience. Decreasing Fatigue � Help patient and family to understand that fatigue is usually an expected and temporary side effect of the cancer process and treatments. A patient who is employed full time may need to reduce the number of hours worked each week. Improving Body Image and Self-Esteem A creative and positive approach is essential when caring for the patient with altered body image. Assisting in Grieving � Encourage verbalization of fears, concerns, negative feelings, and questions regarding disease, treatment, and future implications. Also report change in respiratory or mental status, urinary frequency or burning, malaise, myalgias, arthralgias, rash, or diarrhea. Cancer 129 � Instruct all personnel in careful hand hygiene before and after entering room. Avoid insertion of urinary catheters; if catheters are necessary, use strict aseptic technique. Managing Septic Shock � Assess frequently for infection and inflammation throughout the course of the disease. Managing Bleeding and Hemorrhage � Monitor platelet count and assess for bleeding (eg, petechiae or ecchymosis; decrease in hemoglobin or hematocrit; prolonged bleeding from invasive procedures, venipunctures, minor cuts, or scratches; frank or occult blood in any body excretion, emesis, or sputum; bleeding from any body oriflce; altered mental status). Promoting Homeand Community-Based Care Teaching Patients Self-Care � Provide information needed by patient and family to address the most immediate care needs likely to be encountered at home. Continuing Care � Refer patient for home care (assessment of the home environment, suggestions for modiflcations to assist patient and family in addressing patient�s physical needs and physical care, and ongoing assessment of the psychological and emotional effects of the illness on patient and the family). C Nursing Management Related to Treatment Cancer Surgery � Complete a thorough preoperative assessment for all factors that may affect patients undergoing surgery. Radiation Therapy � Answer questions and allay fears of patient and family about the effects of radiation on others, on the tumor, and on normal tissues and organs. Describe the equipment; the duration of the procedure (often minutes); the possible need for immobilizing the patient during the procedure; and the absence of new sensations, including pain, during the procedure. C � Reassure the patient that systemic symptoms (eg, weakness, fatigue) are a result of the treatment and do not represent deterioration or progression of the disease. Use the log-roll maneuver when positioning patient to prevent displacing the intracavitary device. Provide a low-residue diet and antidiarrheal agents to prevent bowel movements during therapy to prevent the radioisotopes from being displaced. Prohibit visits by children or pregnant women and limit visits from others to 30 minutes daily. Instruct and monitor visitors to ensure they maintain a 6-ft distance from the radiation source. Chemotherapy � Assess patient�s nutritional and fluid and electrolyte status frequently.

Here is yet another example of a negative result in a pharmacoepidemiological study generic reglan 10 mg amex gastritis diet yogurt. Again discount 10mg reglan chronic gastritis gerd, the probable reason lies in an extremely small proportion of drug-induced cases in total numbers of acute pancreatitis purchase reglan 10 mg online gastritis diet �10, which of course cannot influence the overall risk in high-risk populations generic reglan 10 mg line gastritis symptoms in urdu. Available clinical case reports or series are usually too outdated to rely on the information contained (Bartholomew, 1970), but experimental studies on the effects of scorpion toxin are very interesting. Concurrent stimulation of pancreatic secretion and contraction of the sphincter of Oddi have been demonstrated in the late 1970s. Rare reports on pancreatitis caused by adder bite (venom containing neurotoxic phospholipase A2) or even blue-ringed octopus bite (venom containing tetrodotoxin) have been published. Aside from alcohol, another addictive substance often mentioned in association with acute pancreatitis is marijuana, abused by smoking. A smaller series of marijuana-induced pancreatitis cases was reported by Wargo et al. Interestingly, stimulation of cannabinoid receptors was found to be a protective mechanism during experimental pancreatitis. This is yet another example of ambivalent behavior of some xenobiotics towards the pancreatic tissue. Diagnostics, disease course and management Among the reasons why the real incidence of drug-induced acute pancreatitis is still not known, the difficulties in diagnosis are probably most important. Milder cases of pancreatic injury are often missed because serum amylase and lipase estimations are not part of the metabolic profile obtained during a routine health checkup and abdominal pain is often attributed to underlying diseases. The first criterion seems to be easy to achieve until we remember that monotherapy in our patients becomes more and more scarce. Use of the classification systems mentioned above may be very useful for that purpose. Excluding all other causes of the disease is also not so straightforward in many cases of acute pancreatitis. The validity of diagnosis may depend on the equipment available and even more on the experience of the medical staff. Discontinuation of oral therapy is a natural part of any management of acute pancreatitis. In patients treated by multiple pharmacotherapy, it is impossible to decide which medication withdrawal led to a resolution of the symptoms and laboratory findings. In these cases, acute pancreatitis is usually diagnosed within several days from drug administration. Due to the character of the disease and ethical considerations, deliberate, repeated administration of suspect drug to induce a new episode of acute pancreatitis is not possible. An exception is the use of essential drugs in cases where the benefits outweigh the risks. A simplified algorithm for diagnosing drug-induced pancreatitis is given in Figure 1. The suspected drug etiology should be considered after the exclusion of more common causes of illness. A detailed medication history documentation is obvious as well as the determination of suspicious substances. There is no evidence for preferring one of these systems, so it is possible to use both, mainly if there is a difference between them in classifying a specific suspicious agent. Using these classification systems may improve the quality of information for further patient treatment and further processing of the event for scientific or pharmacovigilance purposes. Level of Characteristics probability Certain A clinical event, including a laboratory test abnormality, that occurs in a plausible time relation to drug administration, and which cannot be explained by concurrent disease or other drugs or chemicals the response to withdrawal of the drug (dechallenge) should be clinically plausible the event must be definitive pharmacologically or phenomenologically using a satisfactory rechallenge procedure if necessary Probable A clinical event, including a laboratory test abnormality, with a reasonable time relation to administration of the drug, unlikely to be attributed to concurrent disease or other drugs or chemicals, and which follows a clinically reasonable response on withdrawal (dechallenge) Rechallenge information is not required to fulfill this definition Possible A clinical event, including a laboratory test abnormality, with a reasonable time relation to administration of the drug, but which could also be explained by concurrent disease or other drugs or chemicals Information on drug withdrawal may be lacking or unclear Unlikely A clinical event, including a laboratory test abnormality, with a temporal relation to administration of the drug, which makes a causal relation improbable, and in which other drugs, chemicals, or underlying disease provide plausible explanations Conditional / A clinical event, including a laboratory test abnormality, reported as an unclassified adverse reaction, about which more data are essential for a proper assessment or the additional data are being examined Unassessable / A report suggesting an adverse reaction that cannot be judged, because unclassifiable information is insufficient or contradictory and cannot be supplemented or verified Table 3. Of course, severe cases tend to be more often 30 Acute Pancreatitis reported both in the literature and in spontaneous pharmacovigilance reports. In the disease management, there are no specific issues concerning drug-induced pancreatitis, with an exception of an immediate withdrawal of the suspected drug. A difficult question is how to reintroduce medication if the causative agent is not unambiguously identified. We recommend not introducing all withdrawn drugs at the same time to distinguish the cause of a possible flare-up. The most suspected drugs should be substituted by their analogs with a different chemical structure. Secondary prevention consists of avoiding the drug which caused the episode of acute pancreatitis. Rechallenge of such an agent is justified only if its benefits outweigh the risks, as discussed above. Future research Given how inadequate the current state of knowledge on drug-induced pancreatic injury is, the area for further research in this field is remarkably wide. The majority of the knowledge on the topic has been obtained from case reports or their series. These will remain a major source of information, so it is necessary to improve their informative value substantially. Provide the age and sex of the patient, along with the indication for treatment with a drug; provide the dose and frequency of medication; b. Document a definite case of pancreatitis based on current diagnostic guidelines; c. Provide information on the time course between initiation of drug and onset of pancreatitis; d. Exclude the most common causes of pancreatitis; document a positive response to withdrawal of medication;. Higher level of knowledge may be obtained by performing multicenter studies targeted at the etiology of non-alcoholic, non-biliary pancreatitis.

Nos intervalos da colica purchase 10 mg reglan gastritis symptoms and diet, o doente pode apresentar dor de fraca intensidade no hipocondrio direito generic reglan 10 mg without a prescription gastritis migraine, sensacao de plenitude pos-prandial generic reglan 10mg with amex gastritis sweating, duas a tres horas depois da ingestao de alimentos order 10mg reglan free shipping gastritis symptoms vs gallbladder. Durante a crise dolorosa o doente pode apresentar elevacao de temperatura, nauseas ou vomitos. Mesmo nao havendo migracoes de calculos para o coledoco ela pode estar presente e decorre geralmente do edema pericoledociano. Havendo ictericia ha coluria, apresentando-se a urina com a cor escura caracteristica. A palpacao do abdome revela presenca do ponto cistico doloroso, manobra de Murphy positiva, resistencia da parede abdominal na parte direita do epigastrio. Nos raros casos de mucocele da vesicula, ela e palpavel sob a borda inferior do figado. A migracao de calculos pode causar colecistite aguda, colangite, pancreatite aguda ou ictericia. Os exames laboratoriais podem apresentar alteracoes importantes que estao diretamente relacionadas ao tipo de complicacao decorrente que serao estudadas em outros capitulos. Os pigmentos e sais biliares sao gradualmente absorvidos, enquanto a mucosa continua a secretar muco que fica retido dentro da vesicula. Dependendo dos orgaos que constituem a fistula, podemos ter dois tipos de fistula: biliodigestivas e bilio-biliares. Na nossa casuistica, a incidencia de fistulas bilio-digestivas foi de 0,84% e de 23 fistulas bilio-biliares foi de 0,37% dos pacientes portadores de colelitiase. A presenca de processo inflamatorio exerce papel importante na etiopatogenia, promovendo a aderencia de estruturas vizinhas, mais comumente o duodeno e o colon, a vesicula biliar. Esta fistula e mais frequentemente causada por erosao de calculos atraves da parede da vesicula biliar e dos orgaos adjacentes. A passagem de calculo para a luz intestinal pode causar obstrucao, geralmente na porcao distal do ileo. Essas lesoes inflamatorias cronicas da papila duodenal podem estar associadas a presenca de coledocolitiase. Embora nao se tenha prova concreta, reconhece-se que a grande maioria das neoplasias da vesicula biliar estao associadas a calculos biliares. Apesar de existirem drogas com esse potencial, o seu emprego nao tem sido eficiente ate o presente 39 momento. No entanto, existem algumas situacoes clinicas em que a indicacao cirurgica e formal, e embora eletiva deva ser realizada sem delongas: a. Pacientes diabeticos estao mais propensos a quadro de colecistite aguda grave e complicacoes infecciosas no pos-operatorio c. Pacientes com microcalculos maior probabilidade de apresentar coledocolitiase, colangite, papilite e pancreatite aguda d. Convencional ou laparotomica E realizada atraves de laparotomia e com utilizacao de instrumentos convencionais. Alguns cirurgioes preferem a incisao mediana em pacientes magros e com angulo costal fechado. A incisao paramediana direita esta em desuso por ser trabalhosa, ter alto indice de eventracao e por apresentar pior resultado estetico. Esse procedimento impede que microcalculos migrem acidentalmente durante 11 manobras para apresentacao. O hilo vesicular e dissecado, o cistico e identificado e lacado com fio para evitar o deslocamento de calculos para o coledoco. A arteria cistica e localizada, em geral, no triangulo de Calot (formado pela face inferior do figado, vesicula biliar e ductos cistico e hepatico) dissecada e ligada junto a vesicula apos identificacao da arteria hepatica direita. A seguir prossegue-se com o descolamento da vesicula biliar do leito hepatico atraves de ligaduras ou do uso de eletrocauterio com o cuidado na identificacao de canais ou vasos aberrantes. Essa tecnica vem sendo substituida gradualmente pela colecistectomia videolaparoscopica mas o seu conhecimento e fundamental pois esta indicada em casos onde ha suspeita de neoplasia e em situacoes onde nao e possivel ou esta contra-indicada a via videolaparoscopica. Colecistectomia videolaparoscopica 24,26,34,37 Atualmente e a tecnica mais empregada no tratamento da colelitiase. Prossegue-se com uma sutura em bolsa com fio nao 25 absorvivel e abertura em cruz da aponeurose. A seguir introduz-se um trocarte de 11 mm sem mandril sob visao direta da cavidade. A otica de 30 graus e entao introduzida e outros tres portos sao instalados (Figura 7). Inicia-se a disseccao do pediculo vesicular com identificacao do ducto cistico (Figura 8). Se a radiografia for normal aplica-se clipe metalico no cistico e o mesmo e seccionado (Figura 10). Prossegue-se a intervencao com identificacao da arteria cistica e ligadura e seccao da mesma entre clipes metalicos. A seguir a vesicula e descolada do seu leito hepatico de modo retrogrado (Figuras 11 e 12). Com a evolucao da tecnica e do instrumental e com a maior experiencia dos cirurgioes pode ser realizada com seguranca na maioria dos casos, mesmo na 24,26 presenca de complicacoes da doenca. Atualmente, com a miniaturizacao dos instrumentos, e possivel a realizacao, com seguranca, de colecistectomia por microlaparoscopia, ou seja, com o emprego de trocartes de 2 mm e aplicacao de clipes de 5 mm. A presenca de bile pode ser devida a lesoes de canais aberrantes no leito vesicular, lesoes de ductos maiores ou escape da ligadura do ducto cistico.

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