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C h a p T E r 4 Un d e r s t a n d i n g He p a t i t i s C di s e a s e Lorren Sandt S E C T I O N 1 Li v e r di s e a s e pr o g r e s s i o n Introduction Throughout this book purchase strattera 25 mg on-line medications you can take while breastfeeding, you will ofen read that chronic hepatts C and its treatments afect each person diferently generic strattera 10 mg without prescription medications 4 times a day. The broad range of variability observed between persons living with hepatts C is especially true of disease progression buy 18 mg strattera amex medications ending in pril. There is no accurate way to purchase 18 mg strattera mastercard medications you cannot crush predict the course of chronic hepatts C in an individual person. Remember, none of the situatons discussed in this chapter will necessarily happen to you. However, it is important to be aware of the possibilites so that if any of them do occur, you will be prepared and beter able to make good decisions. It measures approximately 7 inches (14 cm) across by 5fi inches (18 cm) along its diagonal. The right lobe is slightly larger than the lef and extends down the right side of the rib cage. Anatomy of the Liver* *Courtesy of Natonal Insttute of Diabetes and Digestve and Kidney Diseases Copyright � 2008, Caring Ambassadors Program, Inc. Placement of the Liver in the Body the liver is located on the right side of the abdominal cavity just below the lungs and diaphragm, the muscle that separates the chest cavity from the abdominal cavity (see Figure 2). The liver is packed so tghtly into the abdomen that the right kidney, parts of the large and small intestnes, and the stomach actually leave impressions on its surface. Even the ribs and muscle bands of the diaphragm make indentatons on the surface of the liver. Although there are no lymph nodes in the liver itself, it produces over fi of the body�s lymphatc fuid. It is carried by the blood to the liver where it infects hepatocytes (liver cells). Once diagnosed with hepatts C, you will have many tests to determine the status of your disease. For detailed informaton on the tests you may have and why, see Chapter 6, Laboratory Tests and Procedures. Therefore, it is important to look at the results of other test such as albumin, bilirubin, prothrombin tme, and platelet count to determine how well your liver is functoning. Cirrhosis can progress to end-stage liver disease and/or can give rise to liver cancer. When the liver is infamed, there is an overabundance of special cells called infammatory cells in the liver. Chronic infammaton can lead to changes in liver structure, slowed blood circulaton, and the death of liver cells (necrosis). Prolonged liver infammaton can eventually cause scarring, which is called fbrosis. By controlling liver infammaton, you can potentally control progression to fbrosis. Fibrosis is scar tssue that forms as a result of chronic infammaton and/or extensive liver cell death. Your healthcare provider uses the amount of fbrosis in your liver as one way of evaluatng how quickly your hepatts C appears to be progressing. The best way to accurately determine the amount of fbrosis in the liver is to have a liver biopsy. No other test can give you and your healthcare providers the important informaton that is learned from a liver biopsy. Cirrhosis When fbrosis becomes widespread and progresses to the point that the internal structure of the liver is abnormal, fbrosis has progressed to cirrhosis. Cirrhosis is the result of long-term liver damage caused by chronic infammaton and liver cell death. The most common causes of cirrhosis include viral hepatts, excessive intake of alcohol, inherited diseases, and hemochromatosis (abnormal handling of iron by the body). The loss of healthy liver tssue and reduced blood supply can lead to abnormalites in liver functon. Even when liver disease has progressed to cirrhosis, it may stll be possible for the damage to be at least partally reversed if the underlying cause can be eliminated. Cirrhosis progression can usually be slowed or even stopped with efectve treatment. People are ofen surprised to learn that you can have cirrhosis of the liver and not know it. The onset of cirrhosis is usually silent with few specifc symptoms to signal this development in the liver. Caring Ambassadors Hepatitis C Choices: 4th Edition As scarring (fbrosis) and liver cell destructon contnue, some of the following signs and symptoms may occur: y loss of appetite y nausea and/or vomiting y weight loss y change in liver size y gallstones y generalized, persistent itching (pruritus) y jaundice Despite the seriousness of cirrhosis, large numbers of people live many, many years with cirrhosis without symptoms and without progressing to liver failure. Once cirrhosis develops, it is very important to avoid further progression of the disease. Consumpton of alcohol in any form, including such things as certain mouthwashes and cough medicines, must be completely avoided by people with cirrhosis. However, liver cancer screening among people with chronic hepatts C is widely accepted and practced by most hepatologists and gastroenterologists. Liver cancer is life threatening, so do not delay telling your healthcare provider about any changes in your symptoms. If you have cirrhosis, you need to be followed closely by a healthcare provider who will monitor you with the appropriate liver cancer screening tests such as liver ultrasonography and/or alfa-fetoprotein levels. Liver Biopsy for Determining Disease Progression Scoring Infammaton and Fibrosis the most accurate way to check the severity of liver disease is with a biopsy. A liver biopsy is a test in which small pieces of liver tssue are removed and examined under a microscope. The three main things that will be looked for are infammaton, fbrosis, and cirrhosis.

Syndromes

• Hemoglobin electrophoresis
• Blood accumulating under the skin (hematoma)
• Pain or swelling return after they went away
• Hoarseness has lasted for more than 1 week in a child, or 2-3 weeks in an adult
• Laparoscopic repair: Your surgeon will make 3 - 5 small cuts in your belly. Your surgeon will insert a laparoscope (a thin, hollow tube with a tiny camera on the end) through one of these cuts and other tools through the other cuts. The laparoscope is connected to a video monitor in the operating room that allows your surgeon to see inside your belly and do the repair. The surgeon may need to switch to an open procedure if there is bleeding, a lot of scar tissue from earlier surgeries, or you are very overweight.
• Undescended testicles
• Horizontal ridges
• Beclomethasone dipropionate
• Feeding intolerance

Chemotherapy has been shown to cheap strattera 10 mg medicine abbreviations improve overall survival and reduce the odds of death by 25% in selected patients strattera 18mg sale treatment quadriceps strain. Metastatic or Advanced Disease Although breast cancer is uncommonly found to order strattera 40mg amex symptoms 3 days after embryo transfer be metastatic at the time of presentation discount 18 mg strattera free shipping treatment water on the knee, approximately one third of patients subsequently develop distant metastatic disease. Median survival for patients with metastatic disease is 2 years, but fewer than 5% live beyond 5 years. However, unlike infiltrating or invasive cancer, the risk for nodal involvement is <1% and lymph node sampling is not routinely recommended. Evidence from four randomized controlled trials show that prophylactic tamoxifen reduces the risk for estrogen receptor-positive breast cancer in women without previous breast cancer. Raloxifene is a selective estrogen receptor modulator that has been demonstrated to reduce the incidence of breast cancer. These studies measured the effects of raloxifene on bone mineral density and. Surgical prevention includes contralateral mastectomy, prophylactic bilateral mastectomy, and bilateral salpingo-oophorectomy. Prophylactic bilateral mastectomies have been shown to reduce the risk of breast cancer by 90%. Breast cancer can be especially difficult to diagnose during pregnancy and lactation (secondary to increased glandular breast tissue), which may lead to a delay in diagnosis. Thus, cancers are often found at a later stage in pregnant women or immediately postpartum. Pregnant patients do as well as their nonpregnant counterparts at a similar disease stage. Treatment during pregnancy is generally the same as that for nonpregnant patients. The agents used to identify the sentinel lymph node are not approved in pregnancy and therefore axillary dissection is commonly performed. Initiation of chemotherapy is generally considered safe after the first trimester. No evidence has been reported that aborting the fetus or interrupting the pregnancy leads to improved outcome. Reducing the risk of distant metastases: a better end point in adjuvant aromatase inhibitor breast cancer trialsfi Patient evaluation after surgical procedures is determined by the severity of illness, comorbidities, and the type and degree of the procedure. A written night of surgery evaluation should document assessment of respiratory effort and adequacy, hemodynamic stability, pain control, and recovery from anesthesia. Pulse, blood pressure, and fluid intake and output (including intraoperative fluids) should be recorded in the evaluation of hemodynamic status. Intraoperative insensible fluid loss can be approximated as 5 to 15 mL/kg/hr, in addition to maintenance fluid, for the time that the abdomen is open. On our gynecology service, we approximate insensible losses as 250 mL/hr per quadrant of the incision. Whatever the method, the important point is to account for increased insensible loss in your total fluid calculations. Low postoperative urine output deserves assessment for bleeding, inadequate intraoperative fluid resuscitation, inflammatory �third space� intravascular volume loss, and urinary tract injury. An isotonic fluid bolus of 10 mL/kg can be given to assess the volume status by monitoring changes in urine output. In addition to intake and output measures, daily weight should be recorded for patients at high risk of postoperative fluid imbalance. Perioperative beta adrenergic blockade has been shown in multiple large clinical trials to decrease cardiac events and overall mortality in high-risk noncardiac surgical patients. High risk factors include the following: age >55 years, diabetes, hypertension, hypercholesterolemia, and current tobacco use. Ideally, beta blockade is instituted preoperatively and continued for several weeks after surgery to reduce the deleterious effects of the stress-activated sympathetic response. Prophylactic antibiotics are indicated just before incision (<1 hr) and during surgery; their use postoperatively and especially beyond 24 hr after a procedure should be strongly discouraged. Infection control measures reduce the occurrence of multidrug-resistant organisms and prevent hospital-based transmission. Effective hand hygiene protocols produce a significant reduction in nosocomial infection rates. Standard precautions, protecting both patients and healthcare workers, should also be strictly employed. Chapter 14 describes management of critical care hypertensive disorders during and after pregnancy. Hypotension and Shock Shock is a clinical syndrome in which decreased perfusion leads to symptoms of vital organ dysfunction, including hypotension, oliguria, and altered mentation. Management starts with determination of the etiology and correction of the underlying disease process. Hemorrhagic shock is classified by the volume of blood loss and physiologic response (Table 3-1). It is important to replace both volume and erythrocytes, and perhaps coagulation factors, during massive hemorrhage. Restoring intravascular volume with crystalloid improves blood pressure, cardiac filling pressure, and organ perfusion. Ongoing myocardial ischemia or impaired oxygenation deserves transfusion with packed red cells to hemoglobin of 10 g/dL. Crystalloid is typically available on any unit, inexpensive, and carries less risk than colloid administration. Colloid therapy is more costly but may provide better short-term volume expansion.

Dur $$$$ ing pregnancy purchase strattera 25 mg overnight delivery treatment hyperthyroidism, estrogen levels order 40 mg strattera with mastercard medications and mothers milk 2014, including estradiol buy strattera 40mg without prescription medications in mothers milk, rise steadily toward term purchase 40 mg strattera free shipping medicine ball. Each 100 mg/dL of ethanol contributes about 0 mg/dL [mmol/L] 22 mosm/kg to serum osmolality (see Table 8�15). The factor inhibitor), liver disease (except and interfere with specific factor assays. Vitamin K-dependent coagulation factors $$$ a standard curve made from occur in rare patients with lupus defi ciency. Analytic validity of genetic tests to identify autosomal dominant disorder, factor V Leiden and prothrombin G20210A. Predictive value of factor V Leiden and prothrom rare, inheritance of two G20210A bin G20210A in adults with venous thromboembolism and in mutations would further increase family members of those with a mutation: a systematic review. Predictive value of factor V Leiden and prothrom up to half of the cases of unex bin G20210A in adults with venous thromboembolism and in plained venous thrombosis and family members of those with a mutation: a systematic review. Disease levels are defined as severe (< 1%), moderate Blue Clotting-based assay is commonly Decreased in: Hemophilia A, (1�5%), and mild (> 5%). Factor deficiency can be distinguished from factor Deliver immediately to nonparallelism. Laboratory identifi cation of factor inhibitors: the perspective of a large tertiary hemophilia center. Normal small (regional enteritis, celiac disease, not correlate well with quantitative measurements. A normal quantitative stool fat reliably rules out pan creatic insufficiency and most forms of generalized Quantitative: Dietary small intestine disease. Pancreatic exocrine insuffi ciency: diagnostic lected for 72 hours and evaluation and replacement therapy with pancreatic enzymes. Chronic pancreatitis: maldigestion, intestinal ecology and intestinal infi ammation. Hydrogen peroxide is bowel disease, vascular ectasias, tions in colon cancer mortality with yearly (33% Dietary (meat, fish, used as a developer solution. Test/Range/Collection Physiologic Basis Interpretation Comments Ferritin, serum or Ferritin is the body�s major iron Increased in: Iron overload Serum ferritin is clinically useful in distinguishing plasma storage protein. Test [mcg/L] the test is used to detect iron malignancies (eg, leukemia, of choice for diagnosis of iron deficiency anemia. A guide to diagnosis of iron defi ciency and iron defi ciency anemia in digestive diseases. Screening primary care patients for hereditary hemochromatosis with transferrin saturation and serum ferri tin level: systematic review for the American College of Physi cians. Clinical and molecular insights into the hepatocellular carcinoma tumor marker des-gamma carboxyprothrombin. National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for use of tumor markers in liver, bladder, cervical, and gastric cancers. Decreased in: Acquired defi Fibrinogen is generally measured by a clotting-based ciency: liver disease, consump functional (activity) assay. Blue tary deficiency, resulting in an Direct thrombin inhibitor therapy may interfere with abnormal (dysfibrinogenemia), the assay. Guidelines for the diagnosis and management of disseminated intravascular coagulation. Plasma fi brinogen and D-dimer concentra tions are associated with the presence of abdominal aortic aneurysm: a systematic review and meta-analysis. NovelTreponema pallidumserologic tests: a cence microscope) the patient�s paradigm shift in syphilis screening for the 21st century. Accelerating worldwide syphilis screening through rapid testing: a systematic review. Deficiency can result ciency (50�60%, since cellular folate testing) is indicated when the clinical and in megaloblastic anemia. However, the Lavender to monoglutamate forms possibility of vitamin B12 deficiency must always be before absorption by the small considered in the setting of megaloblastic anemia, $$$ intestine. In the liver, folate since folate therapy treats the hematologic, but not monoglutamates are converted the neurologic, sequelae of vitamin B12 deficiency. Drugs: corticosteroids, oral to menopausal status during the transition into Midcycle 5�22 contraceptives. Ovarian reserve screening in infertility: practical applications and theoretical directions for research. Enzyme ing), erythropoietic sidered a better screening test for mild lead toxicity. Test does not discriminate between uroporphyrin, deficiency or inhibition), lack of coproporphyrin, and protoporphyrin, but protopor Lavender iron, or presence of interfering phyrin is the predominant porphyrin measured. Fructosamine, serum Glycation of albumin produces Increased in: Diabetes mellitus, Fructosamine correlates well with fasting plasma or plasma fructosamine, a less expensive gestational diabetes. Fructosamine�an underutilized tool in diabe during pregnancy) or if red cell tes management: case report and literature review. When and how to evaluate mildly elevated liver enzyme induction): phenytoin, enzymes in apparently healthy patients. Elevated serum gamma-glutamyltransferase activity is associated with increased risk of mortality, incident type $ 2 diabetes, cardiovascular events, chronic kidney disease and cancer�a narrative review.

Commonly cheap 18mg strattera overnight delivery symptoms xylene poisoning, radiation doses for brachytherapy are reported as the total dose delivered to buy 18mg strattera amex medicine man lyrics point A (defined as 2 cm above the lateral vaginal fornix and 2 cm lateral to cheap strattera 10mg mastercard symptoms prostate cancer the endocervical canal) and point B (3 cm lateral to buy 40mg strattera otc treatment plant point A). Vaginal, endometrial, and cervical cancers may be treated by either high or low-dose-rate intracavitary implants. Replacing low-dose-rate (usually cesium) with high-dose-rate intracavitary brachytherapy treatments (usually iridium-192) is becoming increasingly common in the United States and Europe. Among the advantages of high-dose-rate applications are that placement does not require anesthesia or operating room time, and radiation exposure is 10 to 20 minutes for each outpatient visit (usually four to six visits are. Interstitial implants are another form of brachytherapy configured as radioactive wires or seeds and placed directly within tissues. Hollow guide needles are inserted in a geometric pattern to deliver a relatively uniform dose of radiation to a target tumor volume. After the position of the guide needles is confirmed radiologically, they can be threaded with the radioactive sources (loaded) and the hollow guides removed. Interstitial implants are sometimes used in the treatment of locally advanced cervical cancer, or for women with pelvic recurrences of endometrial or cervical cancer. Common Side Effects of Radiation Therapy Skin reaction severity depends upon the total dose of radiation, dose fraction, treatment volume, and radiation energy. The reaction is characterized by erythema, desquamation, and pruritus and should resolve completely within 3 weeks of the end of treatment. Topical corticosteroids or moisturizing creams may be applied several times a day for symptomatic palliation and to promote healing. If the skin reaction worsens, it may be necessary to stop treatment and apply zinc oxide or silver sulfadiazine to the affected area until it improves enough to continue treatment. The perineum is at greater risk for skin breakdown because of its increased warmth, moisture, and lack of ventilation. The patient should be taught to keep the perineal area clean and dry in an effort to prevent skin breakdown. In addition, late subcutaneous fibrosis can develop, especially with doses higher than 6,500 cGy. Myelosuppression is dependent upon the volume of marrow irradiated and the total radiation dose. In adults, 40% of active marrow is in the pelvis, 25% is in the vertebral column, and 20% is in the ribs and skull. Nausea, vomiting, and diarrhea commonly occur 2 to 6 hr after abdominal or pelvic irradiation. Supportive therapy with hydration and administration of antiemetics and antidiarrheals such as Loperamide hydrochloride (Imodium) are generally used for first-line therapy. If the patient is having severe diarrhea, opiates such as opium tincture, paregoric elixir, or codeine may be used to decrease peristalsis. Finally, octreotide acetate (Sandostatin) may be given to reduce the volume of persistent high-output diarrhea. Chronic diarrhea, obstruction caused by bowel adhesions, and fistula formation are serious complications of irradiation that occur in fewer than 1% of cases. Small bowel and rectovaginal fistulas can be caused by radiation effects or by recurrent disease. Fistulas are often associated with a foul odor, and good hygiene, charcoal-impregnated dressings, skin cleansers, and air deodorizers help to eliminate the odor. After recurrent disease is ruled out as a cause of the fistula, the patient may require a temporary or permanent colostomy to allow healing of the affected bowel. Cystitis is characterized by inflammation of the bladder, with associated symptoms of pain. The bladder is relatively tolerant of radiation, but doses higher than 6,000 to 7,000 cGy over a 6 to 7-week period can result in cystitis. A diagnosis of radiation cystitis may be made after a normal urine culture result has been obtained. Hydration, frequent sitz baths, and, possibly, the use of antibiotics and antispasmodic agents may be necessary for treatment. Hemorrhagic cystitis may lead to symptomatic anemia that requires blood transfusions and hospitalization. Clot evacuation of the bladder with continuous bladder irrigation is often necessary. Persistent bleeding on continuous bladder irrigation or significant gross hematuria in the unstable patient requires immediate cystoscopic evaluation to localize and control the bleeding. Vesicovaginal fistulas and ureteral strictures are possible long-term complications of radiation therapy. Placement of nephrostomies, insertion of ureteral stents, and, less commonly, surgical intervention may be necessary. Vulvovaginitis occurs secondary to erythema, inflammation, mucosal atrophy, inelasticity, and ulceration of the vaginal tissue. Adhesions and stenosis of the vagina are common and can result in pain on pelvic examination and/or intercourse. Treatment involves vaginal dilation, either by frequent sexual intercourse or by the use of a vaginal dilator. Vaginal dilation should be performed at least two to three times per week for up to 2 years. In addition, the use of estrogen creams is useful in promoting epithelial regeneration. Infections, including candidiasis, trichomoniasis, and bacterial vaginosis, may be associated with radiation-induced vaginitis.

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