By E. Knut. State University of New York College at Plattsburgh.

Amoebic liver abscess usually occurs several months after returning from travel to endemic areas discount clomiphene 25mg without prescription women's health kindle. The protozoan Entameba histolytica can cause diarrhea (amoebic colitis) and liver abscess (usually single generic 25mg clomiphene otc womens health quarterly exit christina diet secret articles, large, and loculated), although the two rarely present at the same time. Treatment is with metronidazole and patients without resolution of symptoms may need to undergo aspiration. Hemangioma Hemangiomas are the most common benign tumor of the liver and are seen in 5-20% of the general population. These vascular lesions are usually asymptomatic and are six times more common in women. Hemangiomas present at all ages but are most commonly seen in the third to fifth decades. Lesions larger than 4 cm are called giant cavernous hemangiomas, and rarely they can result in pain (from stretching the liver capsule) or a consumptive coagulopathy (Kasabach- Meritt syndrome) when they are very large. No treatment is need for these lesions as they have no malignant potential and the risk of hemorrhage is extremely rare. It is postulated that they form in response to micro-thrombosis of branches of the portal vein, with that area of the liver growing aberrantly because of it predominant arterial blood supply. Histologically, they are hypervascular, often with a central scar, and although they lack of normal venous anatomy they contain all of the normal cells of this liver (including Kuppfer cells). Technetium sulfur colloid scans will often show normal or increased uptake in the lesion due to the presence of the Kuppfer cells. Adenoma Hepatocellular adenoma is a rare mass lesion of the liver characterized by the benign proliferation of hepatocytes. Patients can present with multiple adenomas, with hepatic adenomatosis being associated with glycogen storage disease. Many patients are asymptomatic, but up to one quarter of patients may present with pain in the epigastrium. Although benign, it is estimated that approximately 10% of adenomas will undergo a malignant transformation, with the risk being highest for larger adenomas. Sulfur colloid studies may show the characteristic lack of uptake due to absence of Kuppfer cells in the adenoma. Each year there are more than 600,000 new cases, with more than half of them occurring in China alone. Furthermore, it has the advantage of linking these prognostic factors to recommended therapies. In carefully selected patients 5 year survival rates of 70% have been reported with all three modalities. Hepatoblastoma Primary liver tumours account for only about 1% of all childhood malignancies. Hepatoblastoma is a rare malignant tumor that develops in the liver of young children. Approximately one-third of patients will present at an early stage where surgical resection can be performed. In other patients, neoadjuvant chemotherapy with cisplatin, 5-fluorouracil and vincristine can be followed by liver transplantation. The five-year survival rate is less than 35% but improves to approximately 70% in patients undergoing transplantation. Biopsy will reveal adenocarcinoma; however, this pathology within the liver will usually be metastatic (see below) and therefore a workup to rule out another primary malignancy is necessary. Metastatic Tumors In North America, metastases from another malignancy are the most common malignant tumor to affect the liver. The diagnosis is usually confirmed by needle biopsy, and immunohistochemical staining may help identify the likely primary malignancy. Women should undergo breast and pelvic exams, as well as mammography and pelvic First Principles of Gastroenterology and Hepatology A. Endoscopy and colonoscopy should be performed to rule out gastrointestinal malignancy. For most cases, metastatic disease implies an advanced stage of cancer with a poor prognosis. Non-operative treatment options include radioactive labeled therapy with I- 111 metaiodobenzylguanidine or In-octreotide and chemotherapy. Introduction The importance of recognizing congenital hyperbilirubinemia lies mainly in distinguishing it from other, more serious hepatobiliary diseases. Except for Crigler-Najjar syndrome, congenital hyperbilirubinemias do not impair either the quality of life or the life expectancy of affected subjects. Persons with congenital (recessive) hyperbilirubinemia have normal standard liver tests (except of course for elevated serum bilirubin concentrations). The liver histology is also normal, (except for the black pigment accumulation in centrolobular hepatocytes Dubin-Johnson syndrome). With the exception of Gilberts syndrome, these syndromes are distinctly uncommon and are divided into two groups on the basis of the type of the serum hyperbilirubinemia (Table 1). Practice points: o Unconjugated hyperbilirubinemia in absence of hemolysis, is usually secondary to congenital defect in glucuronidation of bilirubin. Gilberts Syndrome Gilberts syndrome is the most common congenital hyperbilirubinemia syndrome. Approximately 9% of the general population in Western countries are homozygous for the variant promoter, and 30% are heterozygous. Other factors are probably involved in the clinical expression of the Gilberts phenotype since not all homozygous carriers develop hyperbilitubinemia. The syndrome manifests itself only in homozygous individuals; its inheritance is therefore consistent with an autosomal recessive trait.

Poor prognostic indicators in acute pancreatitis First 24 hours Age >55 Leucocytosis >16 generic clomiphene 50 mg on line womens health virginia,000 Hyperglycemia cheap clomiphene 100mg otc menstrual reg by natures sunshine, serum glucose >11. It is commonly localized to the epigastric area and may radiate directly to the back. It improves on leaning forward and is frequently associated with nausea or vomiting. Depending on the location of the inflammation, the pain may be referred to either the left upper quadrant or the right upper quadrant. Classically the pain lasts between lines later in more detail, so I deleted it here. When the pancreatitis is severe, it may result in peripheral circulatory failure; under these conditions, the mortality rate approaches 60%. Recurrent nausea and vomiting may be due to a reflex mechanism secondary to pain and occurs in over 90% of the cases. Other causes include pseudo- obstruction secondary to ileus and distention or obstruction secondary to a pancreatic mass or pseudocyst. Since the common bile duct traverses the pancreatic head before entering the duodenum, jaundice may occur, often transiently. Jaundice may be caused by edema of the head of the pancreas or by an obstructing stone. Tachycardia could be secondary to pain, volume depletion or the inflammatory process. Low- grade fever could be secondary to the inflammation in the pancreas or result from such First Principles of Gastroenterology and Hepatology A. Shaffer 602 Abdominal examination may reveal epigastric and abdominal tenderness with guarding or rigidity. Bluish discoloration of the flanks (Grey Turners sign) or of the periumbilical area (Cullens sign) indicates that blood from hemorrhagic pancreatitis has entered the fascial planes. The signs are not specific and may occur in any condition that causes retroperitoneal hemorrhage. Tender red and painful nodules that mimic erythema nodosum may appear over the extremities. Although amylase values greater than 1,000 units have been said to occur principally in conditions requiring surgery (e. Local involvement of pancreatitis includes phlegmon (18%), pancreatic pseudocyst (10%), pancreatic abscess (3%) and thrombosis of the central portal system. Phlegmon is an area of edema, inflammation and necrosis without a definite structure (unlike an abscess). A phlegmon results from acute intrapancreatic inflammation with fat necrosis and pancreatic parenchymal and peri- pancreatic necrosis. This arises from the ischemic insult caused by decreased tissue perfusion and release of the digestive enzymes. When this damage is not cleared, further inflammation ensues, declaring itself by increased pain, fever and tenderness. In severe cases a secondary infection ensues, a process termed infected necrosis of the pancreas, which occurs within the first one to two weeks of the illness and carries a high mortality. In 3% of acute pancreatitis cases an abscess develops, usually several weeks into the illness. An abscess is a well-defined collection of pus occurring after the acute inflammation has subsided. A pseudocyst develops as a result of pancreatic necrosis and the escape of activated pancreatic secretions through pancreatic ducts. This fluid coalesces and becomes encapsulated by an inflammatory reaction and fibrosis. Systemic complications of acute pancreatitis are numerous (Table 6) and correlate well with the severity of the inflammatory process. They may be manifested by shock (circulatory collapse secondary to sequestration of retroperitoneal fluid or hemorrhage), respiratory and renal failure and profound metabolic disturbances. Complications of pancreatitis First Principles of Gastroenterology and Hepatology A. Shaffer 603 Local o Sterile necrosis o Infected necrosis o Abscess o Pseudocyst o Gastrointestinal bleeding Pancreatitis-related: o Splenic artery rupture or splenic artery pseudoaneurysm rupture o Splenic vein rupture o Portal vein rupture o Splenic/portal vein thrombosis, leading to gastroesophageal varices with rupture o Pseudocyst or abscess hemorrhage o Postnecrosectomy bleeding First Principles of Gastroenterology and Hepatology A. Shaffer 604 Non-pancreatitis-related: o Mallory-Weiss tear o Alcoholic gastropathy o Stress-related mucosal gastropathy Splenic injury o Infarction o Rupture o Hematoma Fistulization to or obstruction of small or large bowel Right-sided hydronephrosis Systemic (systemic cytokine response, aka cytokine storm) o Respiratory failure o Renal failure o Shock (circulatory failure) o Hyperglycemia o Hypoglycemia o Hypocalcemia o Hypomagnesemia o Disseminated intravascular coagulation o Subcutaneous nodules due to fat necrosis o Retinopathy o Psychosis o Malnutrition o Death Adapted from: Keller J, et al. Although acute pancreatitis may run a mild self-limiting course, severe pancreatitis occurs in up to 25% of acute attacks, with a mortality approaching 10%. The majority of deaths occur within the first week of hospital admission and are caused by local and systemic complications, including sepsis and respiratory failure. Most clinical studies in the adults cite pancreatic infection as the most common cause of death, accounting for 7080% of deaths. The diagnostic process is complicated by the fact that Formatted: Not Highlight Formatted: Not Highlight First Principles of Gastroenterology and Hepatology A. The diagnosis of acute pancreatitis is based on consideration of the above mentioned symptoms and signs,a combination of clinical find- ings and the use of laboratory and radiographic techniques. Amylase is rapidly cleared by the renal tubules and although it can stay elevated for several days, it may return to normal within 24 hours from the time of onset. Although amylase-to- creatinine clearance was used in the past to diagnose pancreatitis, it is now rarely used. Lipase levels appear to be a more sensitive and specific method of diagnosing acute pancreatitis and may remain elevated forlonger than serum amylase several days following the onset of pain. Immunologic assays for trypsinogen or immunolipase are experimental and do not add any more information than the serum lipase. Although not diagnostic, it is important to complete lab workup of a patient with pancreatitis.

Although there is insufficient head-to-head data discount clomiphene 50mg mastercard pregnancy 28 weeks, the gel formulation of testosterone may be a more effective treatment compared with other formulations of testosterone buy 100 mg clomiphene otc women's health past issues. Patients receiving testosterone patch had a higher rate of having application site skin reactions than those with placebo. The use of gel testosterone did not show a dose- related increase in adverse events. The use of combination cream containing testosterone, isosorbide dinitrate, and co-dergocrine was associated with an increased risk of mild headaches compared with placebo or cream testosterone alone. The short-term followup 317 precluded ascertainment of the incidence of prostate cancer. In one trial, two patients who had been treated with patch testosterone, developed prostate cancer. Other Treatments (Off-label use) For summary of trials refer to Evidence Table F-10 (Appendix F). The results indicated either numerical or statistically significant improvements in erectile function (i. With insufficient data, statistical test results, and a small number of studies, the trial results are inconclusive regarding the efficacy of phentolamine relative to placebo. Due to the lack of sufficient amount of harms data it is not clear if patients taking oral phentolamine are at higher risk of developing adverse events. Note 344 that in one trial, patients on trazodone experienced statistically significant improvement in erectile response (i. Since this trial was not double blind, it is hard to judge if the observed differences were truly due to the treatment administered or to other extraneous factors. Limited evidence suggests that the use of trazodone may be associated with an increased risk of adverse events (priapism, sedation, headache) and higher rates of withdrawal due to adverse events compared with placebo. Additional evidence from trials using different doses is needed to corroborate or disprove these findings. Nevertheless, there were higher frequencies of adverse events and withdrawals due to adverse events in the active treatment groups than in the placebo groups. Another trial demonstrated an increased number of successful coital episodes for the active treatment group of patients. However no formal statistical test results were presented to substantiate the findings. Given the above-mentioned limitations, more evidence is needed to draw more definitive conclusions regarding the relative efficacy of pentoxifylline. Some of the reported treatment- 340 related adverse events in one trial were nausea and headache. Although moxonidine was shown to be more effective in increasing deep penile diameter and artery velocities compared with metoprolol, this result may have been biased because this trial did not employ double blind 347 techniques to adequately mask the treatment modality. The limited amount of evidence suggested that the number of patients with adverse events was greater in the treatment groups than in the placebo groups. However, these results were obtained from only a few trials, so the evidence warrants a cautious interpretation. Additional trials conducted in these subgroups using uniformly defined clinical outcomes would help to draw more definitive conclusions. Penile fibrosis and scarring can lead to abnormal penile 372 curvature with erections and subsequent discontinuation of therapy. Evidence regarding the relative incidence of penile fibrosis amongst patients treated with different types of injection therapies is inconclusive. Moreover, it is important to determine whether there is a medication-, dose- or frequency- response effect of injections. In many cases, the methodological and/or reporting quality of the primary studies was poor, as judged by the Jadad scale and the Schulz allocation concealment component. For example, the adequacy of methods used for randomization, treatment allocation concealment, or blinding could not be ascertained for majority of the reviewed studies. In turn, the absence of this information compromised the valid interpretation of the study results. There was substantial heterogeneity with respect to efficacy/harms outcomes, types of interventions, diverse concurrent clinical conditions, and reporting quality across the reviewed studies. Clinical and/or methodological heterogeneity limited the extent of statistical pooling of the efficacy- and harms-related data. In crossover trials, pre-crossover quantitative data was usually not reported making it difficult to incorporate the results into the meta-analyses. Due to limited resources and the timelines of this review, the authors of individual studies could not be contacted for additional information that was not provided in the reports. Empirical evidence has shown that harms occurring during a trial are generally underreported. Overall, the occurrence and details of adverse events was poorly reported in the primary studies. Many trial reports did not provide the data on the incidence of any all- cause adverse events and serious adverse events. Moreover, the types of adverse events across the trials, as well as the definition of adverse events and in particular serious adverse events were not reported consistently from study to study. The authors often did not provide statistical test results for the between-group differences in adverse events. The interpretation of the study results was complicated by the lack of well accepted guideline(s) regarding the magnitude of clinically important (or meaningful) difference for a given validated outcome.

However generic clomiphene 100 mg amex menstrual gas, multiple ney disease and related ndings in the Diabetes Control and Complications Trial/Epidemiology of formities (e discount clomiphene 25mg fast delivery breast cancer bras. Annual Data formities, including Charcot foot, who can- potential aws in study design (135). A Report: Epidemiology of Kidney Disease in the not be accommodated with commercial well-conducted randomized controlled United States. Control and Complications Trial and Epidemiology gression of renal function decline independently Renal insufciency in the absence of albuminuria of Diabetes Interventions and Complications of glycemic effects. Intensive diabetes therapy zin and cardiovascular and renal events in type 2 tions Study Group. N Engl J Med 2017;377:644657 of renal insufciency with and without albumin- Engl J Med 2011;365:23662376 41. Liraglutide and cardiovascular out- ology of Diabetes Interventions and Complica- with metformin on complications in overweight comes in type 2 diabetes. Intensive blood-glucose control with sul- dividual patient-level data from a large clinical meta-analysis. Diabetologia 2013;56:457466 phonylureas or insulin compared with conven- trials programof the dipeptidylpeptidase 4 inhib- 14. Lancet 2015;66:441449 practice guidelines for chronic kidney disease: 1998;352:837853 43. Semaglutide and cardiovascular tes mellitus, and hypertension with acute kidney 30. Lancet 2010;376:419430 cardiovascular outcomes, and mortality in type 2 Care 2017;40:14791485 31. N Engl J Med 2014;371:1392 zin and clinical outcomes in patients with type 2 betes. N Engl J Med 2016;375:323334 1406 diabetes, established cardiovascular disease and 18. Lancet Di- garding use of the diabetes medicine metformin cardiovascular events and mortality in community- abetes Endocrinol 2017;5:431437 in certain patients with reduced kidney function living individuals. Hyper- characteristics, glycaemia treatment approach, cessed 14 October 2016 kalemia after initiating renin-angiotensin system and glycated haemoglobin concentration on 48. Blood pressure lowering in Cardiol 2017;245:277284 risk in patients with type 2 diabetes. Albuminuria changes and controlimproveskidneyoutcomesinpatientswith pressure control in type 2 diabetes mellitus. Diabetes Care 2011;34:13181319 renal and cardiovascular outcomes in patients failure and diabetes mellitus and/or chronic kid- 82. Arch Ophthalmol 1462 retinopathy: a position statement by the Ameri- 2011;129:435444 55. Renoprotective effect of 412418 Evaluation of automated teleretinal screening the angiotensin-receptor antagonist irbesartan in 70. Diabetes mol 2016;134:204209 N Engl J Med 2001;345:851860 Care 1995;18:258268 85. Overt albuminuria specicity of nonmydriatic digital stereoscopic and microvascular outcomes in people with diabe- predicts diabetic retinopathy in Hispanics with retinal imaging in detecting diabetic retinopathy. Hyperglycemia, blood pressure, dian Ophthalmological Society evidence-based Exposed to Telmisartanand Enalapril Study Group. Can J Ophthalmol 2012; enzyme inhibition in type 2 diabetes and ne- 112:799805 47(2 Suppl. Compara- Control Cardiovascular Risk in Diabetes Eye Study abetic retinopathy during pregnancy. Diabetic retinopa- blockers for major renal outcomes in patients in persons with type 2 diabetes: the Action to thy in pregnancy. The effect of intensive treatment of dia- for glycemia before conception: the Coronary Ar- nuriaStudyGroup. Early Treatment Diabetic Retinopathy Study Engl J Med 2011;364:907917 factors on patient-reported visual function out- Research Group. Early Treatment Diabetic Reti- and retinal effects of enalapril and losartan in Trial/Epidemiology of Diabetes Interventions and nopathy Study report number 1. Effect of nerenone on albuminuria in pa- lar complications in the Diabetes Control and 95. Curr Diab Rep eral neuropathy among adults seeking treatment neuropathicpainimpact glycemic control? Phar- with painful diabetic peripheral neuropathy: re- tions Trial/Epidemiology of Diabetes Interven- macotherapy for diabetic peripheral neuropathy sults of a randomized-withdrawal, placebo- tions and Complications study. A Diabetic neuropathy: a position statement by the Pharmacotherapy for neuropathic pain in adults: randomizedwithdrawal,placebo-controlledstudy American Diabetes Association. Lancet evaluating the efcacy and tolerability of tapen- 2017;40:136154 Neurol 2015;14:162173 tadol extended release in patients with chronic 100. Diabetes of diabetic etiology: differential diagnosis of diabetic icanAcademyofNeurology;AmericanAssociation Care 2014;37:23022309 neuropathy. Effects of cardiac autonomic dys- treatment of painful diabetic neuropathy: report Am J Gastroenterol 2013;108:1837; quiz 38 function on mortality risk in the Action to Control of the American Academy of Neurology, the 128. Pharmacologic interventions for painful di- report of the task force of the foot care interest of Diabetes Interventions and Complications).

Moxisylyte: A review of its pharmacodynamic and pharmacokinetic properties discount clomiphene 50mg women's health clinic yonkers, and its McMahon C G discount 50mg clomiphene breast cancer license plate. Priapism associated with concurrent of verapamil gel to the penile shaft fails to infiltrate the tunica use of phosphodiesterase inhibitor drugs and albuginea. Visual erotic stimulation test for initial screening of psychogenic erectile dysfunction: a reliable McMahon C G, Stuckey B G A, Andersen M et al. Sexual 2004;29(6):640 dysfunction after radical prostatectomy: Prevalence, treatments, restricted use of treatments and distress. Relapse prevention strategies and 2004;29(6):631 techniques with erectile dysfunction. Clinical trials of sildenafil citrate (Viagra) demonstrate no increase Melman A, Bar-Chama N, McCullough A et al. The first human in risk of myocardial infarction and cardiovascular trial for gene transfer therapy for the treatment of erectile death compared with placebo. Ann Clin design results and analysis of drug treatments for Psychiatry 1990;2(2):93-101. Intracavernous sulfate, and growth hormone levels in ambulatory papaverine/phentolamine-induced priapism can be accurately men. The effect of changes in adiposity on testosterone levels in older Meyhoff H H, Rosenkilde P, Bodker A. Non-invasive men: longitudinal results from the Massachusetts Male management of impotence with transcutaneous nitroglycerin. Effect of Casodex on sleep- of sexual dysfunction associated with antidepressant related erections in patients with advanced prostate cancer. Current and Future Strategies for Preventing and Managing Erectile Dysfunction Mulhall J P, bdel-Moneim A, Abobakr R et al. Improving the accuracy of vascular testing in impotent men: correcting hemodynamic alterations using a Montorsi F, Briganti A, Salonia A et al. Improved Intracavernosal forskolin: Role in management of minimally-invasive assessment of penile haemodynamics: the vasculogenic impotence resistant to standard 3-agent combination of colour Doppler sonography and injection- pharmacotherapy. Brain activation patterns hardness: a unifying factor for defining response in the during video sexual stimulation following the administration of treatment of erectile dysfunction. Effect of yohimbine trazodone on psychogenic impotence: a randomized, double- Muneer A, Ralph D J, Minhas S. Sildenafil (Viagra) for male erectile dysfunction: a meta-analysis of clinical trial Munoz M, Bancroft J, Beard M. Rev Endocr Metab Disord relation to age and in comparison with normal 2005;6(2):85-92. Int J Impot Res dysfunction in men 40 to 69 years old: results from a 2005;17(3):291-292. Flutamide administration at 500 mg daily has similar effects on Moreira E D, Lisboa Lobo C F, Villa M et al. J Androl correlates of erectile dysfunction in Salvador, northeastern 2004;25(4):630-634. Intracavernous injection of prostaglandin E1 is effective in patients Morley John E, Kaiser Fran E. Journal of Vascular & in the treatment of sexual dysfunction induced by Interventional Radiology 2000;11(8):1053-1057. Lancet 1999;353(9155):840 testosterone after 3-month luteinizing hormone- releasing hormone agonist administered in the Narayan P, Trachtenberg J, Lepor H et al. A dose-response neoadjuvant setting: implications for dosing schedule study of the effect of flutamide on benign prostatic hyperplasia: and neoadjuvant study consideration. Transdermal and topical help for sexual problems after prostate cancer treatment: A pharmacotherapy for male sexual dysfunction. Epidemiology of external vacuum device in the management of erectile erectile dysfunction in four countries: cross-national study of the dysfunction. Drugs Aging treatment and monitoring of late-onset hypogonadism in males: 2002;19(3):217-227. The role of of sildenafil citrate (Viagra) in treated and untreated patients adrenomedullin in varicocele and impotence. Erectile Dysfunction and Comorbid Depression: Prevalence, Treatment Strategies, and Associated Medical Conditions. J Indian Med Assoc study of male sexual disorders: The neurophysiological 2000;98(12): assessments, anxiety-depression levels, and response to fluoxetine treatment [10]. The role of endothelial dysfunction in the pathophysiology of Pagani E, Glina S, Puech-Leao P et al. Anxiety and high plasma erectile dysfunction in diabetes and in determining catecholamines do not impair pharmaco-induced erection of response to treatment. Altered sexual treatment in 52 patients with chronic function and decreased testosterone in patients receiving myeloproliferative diseases. General quality dysfunction in married impotent patients: interrelationship with of life 2 years following treatment for prostate cancer: anthropometry, hormones, metabolic profiles and lifestyle. The role of prolactin levels in the sexual activity of married men with erectile dysfunction. Sexuality and intimacy following radical prostatectomy: Patient and partner perspectives. Comparison of effect on erection between vacuum constriction devices and intra- Pescatori E S, Silingardi V, Galeazzi G M et al.

Echocardiography reveals prolapsing mitral valve in 5% r Echocardiography shows the mid-systolic bulging of of the normal population clomiphene 100 mg overnight delivery women's health clinic elmendorf afb; however order 25mg clomiphene otc pregnancy hotline, not all are clinically signicant, especially in the absence of any mitral in- the valve leaets. There is an Denition opening snap after S2 caused by the stiff mitral valve, An abnormal narrowing of the mitral valve. If the Incidence patient is in sinus rhythm there is a pre-systolic increase Declining in the Western world due to the decline of in the volume of the murmur due to increased ow dur- rheumatic fever. Pulmonary hypertension may re- sult in pulmonary regurgitation with an early-diastolic Sex murmur (GrahamSteell murmur). The pathological process of rheumatic fever results in brous scarring and fusion of the valve cusps with cal- Investigations cium deposition. The valve becomes stiff, failing to open r Chest X-ray shows selective enlargement of the left fully. When the normal opening of 5 cm2 is reduced to1 atrium (bulge on the left heart border). The pressure within the within the mitral valve may be visible and there may left atrium rises and left atrial hypertrophy occurs. Signs of right ventricular hyper- falls with little increase possible on exertion. The condition is asymptomatic until the valve is nar- r Echocardiography is diagnostic showing the narrow- rowedbyaround 50%. Doppler studies can to pulmonary venous hypertension and the resultant assess the degree of stenosis and any concomitant mi- oedema, with dyspnoea, orthopnoea and paroxysmal tral regurgitation. A cough productive of r Cardiac catheterisation is used if Doppler is inconclu- frothy,blood-tingedsputummayoccur(frankhaemopt- sive and to assess for coronary artery disease if valve ysisisrare). On examination the patient may have mitral facies (bi- Management lateral, dusky cyanotic discoloration of the face). In se- The course of mitral stenosis is gradual with interven- vere mitral stenosis atrial brillation is very common. Associatedatrialbrilla- The apex beat is tapping in nature due to a palpable rst tion is treated with digoxin and anticoagulation. Patients with refrac- On auscultation there is a high pitched early diastolic tory pulmonary venous congestion or pulmonary hy- murmur running from the aortic component of the sec- pertension are treated surgically by conservative surgery ond heart sound. This is a mid- diastolic rumbling murmur due to back ow of blood Aortic regurgitation during diastole causing a partial closure of the mitral valve. Denition Retrograde blood ow through the aortic valve from the aorta into the left ventricle during diastole. Investigations r Chest X-ray shows an enlarged left ventricle and pos- Aetiology/pathophysiology sibly dilation of the ascending aorta. This may result from: r Inability of the valve cusps to close properly due to mal valve movement. Doppler studies demonstrate thickening, shrinkage, perforation or a tear in the and quantify the regurgitation. Causes include rheumatic heart disease (now itor the clinical effect of the valve lesion is to measure rare in the United Kingdom), infective endocarditis the left ventricular dimension. An end systolic dimen- occurring on a previously damaged or bicuspid aor- sion of over 5 cm indicates decompensation. Causes include se- infective endocarditis should be administered when vere hypertension, dissecting aneurysm and Marfans appropriate. It is only when volume overload is heart size or diminishing left ventricular function are excessive and chronic that the left ventricle fails. The indications for surgical intervention usually by valve rst sign of this decompensation is a reduction in the replacement. There is also reduced coronary artery perfusion with associated increased risk of myocardial ischaemia. Prognosis Mild or moderate aortic regurgitation has a relatively good prognosis and thus surgical intervention is not Clinical features required. However, it is important to perform surgical Aortic regurgitation is asymptomatic until left ventricu- correction before irreversible left ventricular failure lar failure develops. Onexamination there is a large volume pulse, which is collapsing in char- acter (see page 27). The blood pressure has a wide pulse Aortic stenosis pressure (high systolic and low diastolic pressure). Various signs of the high-velocity blood ow Aortic stenosis is a pathological narrowing of the aortic have been described but are rare. There is however turbulent r Echocardiography is diagnostic, often showing cusp ow across these valves, which become thickened and thickening and calcication. Severe stenosis may develop over a period of the degree of stenosis and can measure left ventricular 2030 years. It may lead to thicken- r Treatment includes management of angina and car- ing and calcication of the aortic valve, which is often diac failure. This pres- r Severe stenosis (pressure gradient over 60 mmHg) or sure overload results in left ventricular hypertrophy and symptomatic stenosis are indications for surgery (see arelative ischaemia of the myocardium with associ- page 30). As the stenosis becomes more severe, re- but this is increased if coronary artery bypass is also duced coronary artery perfusion exacerbates myocardial required. Balloon valvuloplasty may be used in pa- ischaemia even if the coronary arteries are normal. Im- tients unt for surgery or to improve cardiac function paired left ventricular emptying is most apparent dur- prior to surgery. Ischaemia and hypertrophy of the left ventricle may lead Prognosis to arrhythmias and left ventricular failure. Clinical features Patients are asymptomatic until there is severe steno- sis when they present with exercise-induced syncope, Pulmonary stenosis angina or dyspnoea.

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