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Opiate receptor antagonists such as naloxone may be helpful for treatment of pruritus gastritis diet generic 10 mg metoclopramide otc. Patients with chronic cholestasis and fat maldigestion also require dietary fat restriction gastritis diet salad metoclopramide 10 mg for sale, fat-soluble vitamin supplements gastritis diet order generic metoclopramide line, and calcium supplements gastritis bile trusted metoclopramide 10mg. In contrast to chenodeoxycholic acid, it is a poor detergent because its 7-hydroxyl group projects toward the hydrophobic surface of the molecule, impeding hydrophobic interactions with other lipids. It was originally used for dissolution of cholesterol gallstones but was serendipitously found to improve cholestasis and liver injury in a variety of chronic cholestatic liver diseases. It reduces serum bilirubin, transaminase, and alkaline phosphatase levels and can improve clinical symptoms and liver histology. It also may have direct protective effects on the liver and may alter immunologic function. Indications for transplantation include intractable symptoms, complications of cirrhosis, or deterioration of prognostic indicators. The healthier the patient at the time of transplantation, the better the outcome; conversely, patients with complications of liver disease frequently die while awaiting transplantation. Obliteration 826 Figure 157-5 Cholangiographic appearance of cholestatic disorders. The tumor is obstructing the common bile duct and the pancreatic duct, producing proximal dilatation of both (double duct sign). A cannula extending from the endoscope has been passed through the area of obstruction and its tip lies in the proximal common hepatic duct. A large cholesterol gallstone in the common bile duct appears as a radiolucent shadow outlined by radiodense contrast material. Multiple strictures are present in both the intrahepatic and extrahepatic biliary tree. Beadlike areas of dilatation can be noted between areas of stricture, but the fibrotic process in the liver prevents generalized dilatation of the proximal biliary ducts. Cholestasis of metabolic origin may be seen commonly in severely ill patients and is associated with trauma, surgery, sepsis, and parenteral hyperalimentation. Numerous drugs and estrogen also can produce cholestasis either as a direct effect or as an idiosyncratic reaction (see Chapter 148). Cholestasis of pregnancy appears to reflect sensitivity to the direct cholestatic effects of estrogen. In sarcoidosis (see Chapter 81), an idiopathic disease characterized by non-caseating granulomas in lung and other tissues, liver involvement is common. Usually these patients are symptom free with mild abnormalities of liver function tests. Granulomas in the portal tracts may produce fibrotic obliteration of small bile ducts. Rarely, bile duct obliteration may be sufficiently 827 severe to produce biliary cirrhosis. Although some experts consider hepatic involvement in sarcoidosis to be an indication for glucocorticoid therapy, glucocorticoids have not been proven to alter the natural history of sarcoidosis involving the liver. Primary biliary cirrhosis (see Chapter 153) is a progressive cholestatic disorder characterized by autoimmune destruction of small interlobular bile ducts. Injury is thought to occur as a result of cytotoxic T cell-mediated immune attack directed against bile ductular epithelial cells. Progressive familial intrahepatic cholestasis typically presents as mild to moderate cholestasis in infancy or childhood. Liver biopsy specimens appear generally unremarkable except that bile ductules can be identified in fewer than 50% of portal tracts. Severity and prognosis are variable: some patients develop biliary cirrhosis requiring transplantation in childhood, whereas others have an indolent course. A variety of genetic defects in pathways of bile acid synthesis or biliary lipid secretion have been implicated in the pathogenesis of this disorder. Chronic graft-versus-host disease occurs when T cells from an allogenic source are infused into an immunodeficient patient, most typically at the time of bone marrow transplantation (see Chapter 182). After hepatic transplantation (see Chapter 155), chronic hepatic allograft rejection is associated with immunologic injury to biliary ductules and hepatic arterioles. Arterial intimal injury leading to intimal hyperplasia may compromise hepatic circulation and accelerate the progression of liver injury. A benign intrahepatic cholestasis of metabolic origin is seen commonly in severely ill patients.
Initial cancer therapy often requires a multimodal approach to maximize the chance of cure while simultaneously reducing the extent of surgery required gastritis juicing recipes cheap metoclopramide 10mg free shipping. Multimodal approaches require close communication among the involved physicians before surgery collagenous gastritis definition buy discount metoclopramide line. Early communication is improved by obtaining histopathologic diagnosis by needle biopsy or local excision of the primary cancer before more extensive therapy gastritis diet discount metoclopramide 10 mg on line. Two examples are of note in this regard: (1) the management of osteogenic sarcoma with limb salvage surgery gastritis diet patient education cheap 10 mg metoclopramide with amex, irradiation, and adjuvant chemotherapy and (2) the management of early breast cancer with lumpectomy, axillary staging followed by primary irradiation, and adjuvant systemic administration of cytotoxic or endocrine agents. In both instances, the combined approach yields a better cosmetic and functional outcome. Screening mammography can establish a diagnosis of breast cancer when the tumor is less extensive and when likelihood of cure is greater. Improved plastic surgical techniques have also made breast reconstruction possible for women who either require or prefer mastectomy rather than lumpectomy followed by radiation therapy. In addition to its use in diagnosis, staging, and primary therapy, cancer surgery also plays an important role in the management of some patients with more extensive cancer. In ovarian cancer, when the gynecologic oncologist "debulks" peritoneal and omental spread and leaves the patient with minimal residual disease, patients become better candidates for systemic chemotherapy and have a better survival. Additionally, early resection of pulmonary metastases of soft tissue sarcomas or of solitary brain metastases in melanoma, colon, or breast cancer may provide marked palliation and improved survival, albeit with only occasional cures. Radiation Therapy Radiation therapy has made major strides in instrumentation, physics, radiobiology, treatment planning, and applications to curative and palliative cancer therapy. In general, the term radiation refers to ionizing radiation that is either electromagnetic or particulate. Compared with surgery, radiation therapy has distinct advantages in the locoregional treatment of cancer. Radiation causes less acute morbidity and can be curative for some specific sites while preserving organ or tissue structure and function. An example is the use of radiation for the curative treatment of early-stage laryngeal cancer wherein vocal function can be preserved. The basic unit of ionizing irradiation is the gray (Gy), which has superseded the rad (1 Gy = 100 rads = 100 cGy) (see Chapter 19). Large tumors frequently have poorly perfused, hypoxic zones in which radiation often fails to induce needed reactive intermediaries. For example, electron-beam irradiation deposits most of its energy in the skin and soft tissues and can be useful for superficial therapy of skin neoplasms such as mycosis fungoides. Low-energy (kilovoltage) x-rays expend most of their effects on the overlying tissues above a deep-seated tumor and therefore cause considerable normal tissue damage. By contrast, higher-energy x-rays (megavoltage) or x-irradiation from a cobalt-60 source spare the skin, deposit their energy at greater depth, and provide a better approach to treating deep-seated neoplasms. The use of multiple irradiation fields reduces the dose to normal tissue while increasing the dose to the tumor. The use of fractionated doses causes less cumulative damage to normal tissues than to the tumor, because the normal tissues are often able to repair sublethal damage more quickly. Additionally, as a tumor shrinks with therapy, its oxygenation can improve and render it more radiosensitive. The selection of treatment is based on the relative radiosensitivity of the tumor and of the normal organs and tissues within the radiation field (Table 198-1). Although the major uses of radiation therapy involve local irradiation of sites of tumor involvement, total-body irradiation or total lymphoid irradiation is a valuable part of a preparative regimen for allogeneic or autologous bone marrow transplantation for leukemia or lymphoma (see Chapter 182). Irradiation can also cause sufficient cytoreduction of tumor in bone to permit healing of osteolytic lesions and thereby prevent pathologic fractures of weight-bearing bones. Other examples include tumor shrinkage to relieve postobstructive infection in lung cancer and to suppress bronchial or gastric bleeding secondary to cancer. Although modern radiation therapy with megavoltage equipment has proved to be extremely useful, even higher energy radiation approaches are currently in development. Additionally, several classes of compounds are under study as radiosensitizers to enhance the cytotoxic effects of radiation on tumor cells. Other chemotherapeutic agents, including gemcitabine and taxol, are also under investigation as radiosensitizing agents. Although the term radiation normally refers to ionizing irradiation, several other forms of radiation are also used in cancer treatment.
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In non-edematous patients gastritis diet 6 weeks metoclopramide 10mg for sale, safe paracentesis requires infusing 6 to 8 g of albumin per liter of ascites removed gastritis earth clinic buy metoclopramide overnight delivery. This option is quite costly; cost may be reduced by substituting for albumin with other plasma expanders such as dextran 70 gastritis diet list generic 10 mg metoclopramide visa, although experience with non-albumin expanders is less extensive gastritis symptoms in dogs purchase metoclopramide online from canada. Peritoneovenous shunting, performed by surgically placing a subcutaneous catheter between the superior vena cava and peritoneum, is as effective as therapeutic paracentesis in treating refractory ascites. However, low-grade disseminated intravascular coagulopathy, catheter infection, and shunt occlusion are frequent complications that reduce long-term efficacy substantially. Like other therapy for complications of portal hypertension, neither paracentesis nor peritoneovenous shunts prolong survival. Preliminary results are encouraging in small numbers of patients, but long-term follow-up in larger study groups is required. Liver transplantation remains the most definitive therapy for liver disease underlying ascites and should be considered first when ascites develops. The urgency for transplantation is increased if complications of ascites appear, particularly spontaneous bacterial peritonitis. The pathogenesis is uncertain but is believed to reflect altered gut wall permeability to bacteria, impaired capacity of hepatic and splenic macrophages to clear portal bacteremias, and/or the presence of a large volume of peritoneal fluid conducive to bacterial growth. The clinical presentation is subtle, and frank peritoneal pain or tenderness is uncommon. Typical findings include fever, signs of sepsis, or decompensation of previously stable liver function manifested by new encephalopathy or azotemia. Common causative organisms include Escherichia coli, Pneumococcus, Klebsiella, and anaerobes. Because ascites Gram stain is rarely positive, if ascites polymorphonuclear leukocyte count is greater than 250/mm3, a presumptive diagnosis should be made and empirical antibiotic therapy. Other complications of ascites include hepatic hydrothorax, abdominal wall hernias with rupture, and tense ascites with leakage (especially after paracentesis). Conservative management consists of appropriate initial therapy for most of these except hernia rupture, which requires surgical reduction. Hepatorenal syndrome, also known as functional renal failure, is defined as renal failure associated with severe liver disease without an intrinsic abnormality of the kidney. The cause is unknown, but reductions in renal blood flow, cortical perfusion, and glomerular filtration rate are consistent features. Elevated circulating levels of endothelin-1, a potent vasoconstrictor, may play an important role. The diagnosis is established in patients with cirrhosis by documenting very low urine sodium (<10 mEq/L) and oliguria in the absence of intravascular volume depletion. The syndrome must therefore be distinguished from prerenal azotemia by an empirical fluid challenge (1000 mL saline) or measurement of pulmonary wedge pressure. Other likely causes of renal failure must be excluded, such as acute tubular necrosis or renal impairment from aminoglycosides and contrast agents, although these typically lead to high sodium excretion. The prognosis of hepatorenal syndrome is very poor, in part because onset of the syndrome denotes end-stage liver disease. The most effective treatment for hepatorenal syndrome is to correct the underlying liver disease, by liver transplantation if appropriate. Treating any underlying infections and optimizing volume status are important adjunctive measures. Broad defects in protein synthesis and/or secretion characterize the cirrhotic liver. Clinically apparent defects include hypoalbuminemia, which can reduce oncotic pressure and accentuate edema formation, and reduced concentrations of plasma clotting factors. Thrombocytopenia can result from bone marrow hypoplasia induced by alcohol or due to hypersplenism associated with splenomegaly in portal hypertension. Platelet sequestration by the congested spleen often leads to significant thrombocytopenia, yet clinically significant bleeding almost never occurs; platelet transfusions are therefore not indicated in this setting unless there is an additional platelet defect. Similarly, portacaval decompression or splenectomy is usually curative but is not appropriate unless required to manage variceal hemorrhage. Hepatopulmonary syndrome refers to the triad of liver disease, pulmonary vascular dilation, and reduced arterial oxygenation.
Spironolactone should be started at 50 to 100 mg/day and can be advanced up to 400 mg to achieve a daily weight loss of 0 gastritis diet buy 10 mg metoclopramide amex. Furosemide can be used instead of or in combination with spironolactone gastritis diet purchase 10 mg metoclopramide fast delivery, beginning at a dose of 40 mg/day gastritis bleeding generic metoclopramide 10 mg visa, although there is a greater incidence of azotemia than with spironolactone gastritis reddit discount metoclopramide 10 mg without prescription. Patients treated with two diuretics must be monitored carefully because weight loss may be rapid, even when one diuretic alone has been ineffective. In patients with alcoholic liver disease, abstinence may be effective therapy if cirrhosis has not yet developed. Ten per cent of patients with ascites fail to respond to standard therapy, either because fluid cannot be mobilized or there is associated prerenal azotemia. In these patients, therapeutic paracentesis is safe and can remove 4 to 6 L or more per visit in those with peripheral edema. Although marked manifestations of the syndrome are unusual in patients with chronic liver disease, more subtle abnormalities of oxygenation are common. The abnormalities have been attributed to right-to-left shunts through pulmonary arteriovenous fistulas and development of bronchial varices in association with pulmonary hypertension. The syndrome occurs in chronic liver disease of all types and is more common in those with severe liver disease. As a result, the prognosis is poor, on the basis of both the pulmonary and hepatic disease. Affected patients complain of exertional dyspnea, with pulmonary function tests demonstrating normal lung volumes but markedly reduced diffusing capacity. Resolution of the syndrome has been seen in many patients after liver transplantation. Feminization in men with end-stage cirrhosis is particularly common in alcoholics and has been associated with increased estrogen and diminished testosterone levels. Altered drug metabolism (see Chapter 148) is an important consideration in prescribing drugs to those with end-stage liver disease, either because of impaired clearance leading to enhanced activity or toxicity, reduced sulfoxidation, or decreased protein binding. Bone disease manifested as thinning and spontaneous fractures is a major complication of late-stage cholestatic or alcoholic liver disease, especially primary biliary cirrhosis. Hepatic osteodystrophy can be due to osteoporosis (see Chapter 257), osteomalacia (see Chapter 263), or both. Hepatocellular carcinoma (see Chapter 156) is often preceded by cirrhosis, which is usually but not always clinically apparent. Poynard T, Bedossa P, Opolon P: Natural history of liver fibrosis progression in patients with chronic hepatitis C. A thorough analysis of currently accepted criteria for diagnosis, clinical features, and therapy of alcoholic liver disease, including transplantation. The best long-term data to date showing a beneficial effect of ursodeoxycholic acid in primary biliary cirrhosis. Variceal Hemorrhage Rossle M, Haag K, Ochs A, et al: the transjugular intrahepatic portasystemic stent-shunt procedure for variceal bleeding. This conclusion remains controversial, as outlined in an accompanying editorial (p. A review of data implicating nitric oxide as a potential mediator of metabolic derangements associated with ascites formation. Hepatorenal Syndrome Bataller R, Gines P, Guevara M, Arroyo V: Hepatorenal syndrome. The fact that no machine has been developed to save patients with liver failure indicates either that its most important functions are not well understood or that the liver performs so many complex vital functions that no single machine can replace all of them. Failure to complete one or more of these vital tasks can occur either due to massive destruction of liver cells or because liver cells become functionally "paralyzed" or "stunned," although they are not dead. Acute liver failure can happen suddenly in patients without pre-existing liver disease. Chronic liver failure can also evolve gradually in individuals with various kinds of chronic liver problems.