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Abnormal electromyographic activity (decelerating burst and complex repetitive discharges) in the striated muscle of the urethral sphincter in 5 women with persisting urinary retention 100mg kamagra effervescent. Abnormal electromyographic activity of the urethral sphincter kamagra effervescent 100 mg, voiding dysfunction 100 mg kamagra effervescent, and polycystic ovaries: A new syndrome? Urodynamic study of women in urinary retention treated with sacral neuromodulation kamagra effervescent 100mg. Pressure reflectometry: In vitro recordings with a new technique for simultaneous measurement of cross-sectional area and pressure in a collapsible tube . Urethral pressure reflectometry; a novel technique for simultaneous recording of pressure and cross-sectional area in the female urethra . Urethral pressure reflectometry during intra-abdominal pressure increase-an improved technique to characterize the urethral closure function in continent and stress urinary incontinent women . A faster urethral pressure reflectometry technique for evaluating the squeezing function . The test in most widespread use is cystometry , in which abdominal and bladder pressure are measured synchronously with urine flow during bladder filling (filling cystometry) and voiding (pressure flow studies) , as described in Chapter 32. This can make the ability to obtain extra information important for full insight into underlying pathophysiology and consequently for making safe treatment recommendations. Nevertheless, it is an essential measure for assessing complex cases by adding high-resolution anatomical details to the physiological (urodynamic) data. A clear indication for, and appropriate selection of, relevant test measurements and procedures 2. Some companies offer special equipment where computerized systems mix urodynamic signals with x-ray images in order to produce a combined superimposed image on a computer screen. Fluoroscopy is performed using either a fixed x-ray unit with a table that can be positioned in the supine and upright position or a C-arm image intensifier. In fixed units, a radiotranslucent commode seat attachment to the table facilitates fluoroscopic screening of voiding in the seated position, which is 492 ideal for women. While a C-arm image intensifier provides inferior image quality to fixed x-ray units, it enables patients to sit or stand in a natural position, ensuring the least inhibition to voiding. Provision of a suitable environment is crucial, stipulating that the walls of the screening room are not permeable to x-rays, to ensure radiation does not spread into the adjacent environment. Since the study is a radiological procedure, there are several key safety aspects, in addition to the preparation for conventional urodynamic tests: Steps should be taken to ensure radiation exposure of pregnant women is avoided. For protection of patients, it is necessary to ensure there is adequate justification for doing the test, checking of patient identity, and screening mechanisms for pregnancies and allergies. Within the unit, a specific person has to take responsibility for compliance with the required legislation and ensure equipment maintenance is undertaken according to the manufacturer recommendations. As the contrast medium is of different density from urine, adjustments may have to be made to the flowmeter, which would otherwise record falsely high readings because of the greater weight of the voided fluid [8]. The performance of fluoroscopy by trained urodynamicists allows tailoring of the examination to patient symptoms and past medical and surgical history and limiting parts of the examination that are not expected to offer valuable information, such as prolonged imaging during the voiding phase. Pulsed or low-dose setting continuous fluoroscopy with spectral beam filtration and optimal selection of the tube current and high voltage by an automatic brightness control system could further reduce the radiation exposure [10]. Minimization of the primary radiation field to include only the anatomical region of interest and an attempt to spare the ovaries also reduce the detrimental risks [11]. Staff also need to be protected, with x-ray-opaque (lead) aprons or shielding and body-worn dose monitoring detectors. During screening, all individuals present need to move to a location as far as practicable from the x-ray source and the source of scattered x-rays (notably the patient receiving the x- rays will scatter part of the dose). The patient’s symptom scores and bladder diary are reviewed, so that the crucial aspects are clearly understood. Thereby, the urodynamicist can ensure there is the best chance of understanding contributory mechanisms and potential adverse aspects, so that a treatment recommendation can factor in correction of causative factors and avoidance of complications. Positioning during filling and voiding has to be considered, in order to enable placement of the anatomical areas into the line of the imaging equipment. Fluoroscopy is performed at key points as deemed relevant by the urodynamicist and depending on the urodynamic question: After filling with about 50 mL of contrast. This serves as a “baseline” for comparison with x-ray screening performed at other times. This is used to assess whether the bladder neck has opened (since stimulation of urethral receptors can give a sensation of urgency) and whether the bladder has changed shape (suggesting the occurrence of bladder contraction). Pelvic floor support is assessed by noting the position of the base of the bladder at rest and during the cough series or straining. At rest, it should be level with the pubic symphysis, and when straining, only a low-amplitude transient downward movement should be observed. Activating the imaging equipment for a short time (<2 seconds) allows the urodynamicist to assess the state of pelvic floor support (Figure 34. Screening during voiding should reveal a urethra of 2–3 cm length and an even caliber. Screening is usually done in the anteroposterior and oblique plane, both during filling and voiding. Sometimes, other planes can be helpful in cases of suspected structural abnormalities. For example, a lateral viewpoint can be useful in mapping the location of a bladder diverticulum. At rest, the base of the bladder lies slightly above the lower border of the pubis (upper image, white arrow). When she coughed (lower image), the bladder base was only fractional lowered at maximum cough amplitude (yellow arrow). At rest, the base of the bladder lies below the lower border of the pubis (upper image, white arrow). When she coughed (middle image), the bladder base was further lowered at maximum cough amplitude (yellow arrow indicates base of pubis). With a series of coughs, urodynamic stress incontinence (bottom image, red arrow) was seen on the third cough. Only if refractory bothersome symptoms remain in a patient willing to undergo more interventional treatment would cystometry be undertaken. The specific urodynamic approach to understanding the patient’s problems has to be derived from the clinical context and potential treatment options. At rest, the base of the bladder lies level with the lower border of the pubis (white arrow). When she coughed, the bladder base did not move any lower and the urethra opened, i. Bladder hernias through the rectus sheath could be detected in women with multiple lower abdominal/pelvic surgery (Figure 34. Voiding with high detrusor pressure but only a low flow rate indicates that there is an obstruction impeding urine flow. However, inclusion of urodynamic testing does not necessarily lead to influence on clinical outcomes of treatment, if voiding symptoms or retention is the reason for intervention [21]. A similar picture of incoordination between detrusor and sphincter during voiding due to a neurological abnormality is suggestive of detrusor sphincter dyssynergia. Finally, video and sound recording allows review of complex cases during multidisciplinary meetings. The variety of examination protocols has led to a wide range of reported radiation doses. Among the organs, the bladder and uterus receive the highest absorbed doses with 1. A quality assurance protocol is also able to reduce the radiation exposure by decreasing the number of the spot films and fluoroscopy time [27]. Routine documentation of fluoroscopy time and dose area product by the urodynamicist is advisable as it raises radiation awareness and reduces the radiation dose [28]. Anaphylactic Reaction Anaphylactic reaction is a recognized complication of administration of radiographic contrast media. Immediate severe reactions can lead to laryngeal edema, hypotension, and very rarely even death. The selection of contrast agents might influence the anaphylactic risk as low-osmolality nonionic contrast medium is associated with lower rate of severe reactions than conventional high osmolar ionic agents (0. It also requires operators with specialized training and adequate workload to maintain their competence [9]. Therefore, it is an investigation limited usually to large tertiary referral centers. The quality of imaging may also be poor with obese patients and those with anatomic limitations to their positioning. It could also be difficult for some patients to void in front of the camera, with catheters in the bladder and rectum and observers watching them in an unnatural laboratory environment. Two-dimensional and three- dimensional pelvic floor ultrasound offer supplementary information about bladder neck position and mobility, urethral sphincter volume, pelvic organ descent, morphology of the levator ani, diameters of the genital hiatus, and location and functional impact of a preimplanted tape [32]. Standardization of pelvic floor ultrasound imaging and well-designed and adequately powered multicenter studies are required before its introduction into routine clinical practice. Nonetheless, imaging can provide valuable anatomical and functional information relevant for decision making in individual cases. Urethral closure studied with cineroentgenography and simultaneous bladder- urethra pressure recording. Synchronous cine-press-flow-cystourethrography with special reference to stress and urge incontinence. Good urodynamic practices: Uroflowmetry, filling cystometry, and pressure-flow studies. Use of routine videocystourethrography in the evaluation of female lower urinary tract dysfunction. Urodynamics for clinically suspected obstruction after anti-incontinence surgery in women. The number of voiding radiographs during cystourethrography in women with stress incontinence or prolapse can be reduced to enhance safety without compromising study interpretation. Reduction of radiation during fluoroscopic urodynamics: Analysis of quality assurance protocol limiting fluoroscopic images during fluoroscopic urodynamic studies. Physician documentation of fluoroscopy in voiding cystourethrography reports correlates with lower fluoroscopy times: A surrogate marker of patient radiation exposure. A retrospective review of a series of videourodynamic procedures, with respect to the risk of anaphylactoid reactions. The urinary mucosal barrier in retrograde pyelography: Experimental findings and clinical implications. This is important as incontinence is a benign condition but can diminish quality of life significantly and can influence everyday life. Furthermore, the laboratory situation in which conventional urodynamics are performed can give psychological inhibition of the bladder [2]. Natural (orthograde) fill cystometry was described for the first time in 1957 by Comarr [3]. In 1959, Mackay [4] reported about bladder pressure measurement in an ambulant patient using radiotelemetry. The technique has evolved ever since, and many methods have been developed [1,7,8]. As time progressed, tape recording systems have been used, with the disadvantage of limited recording capacity [9]. This made transfer of data and review of the data at the end of the assessment possible. The technique is particularly valuable in recording bladder filling and voiding phases (Figure 35. However, studies comparing ambulatory urodynamics to the patients’ treatment outcomes have not been described yet. This paper covers the technical aspects and considerations of urodynamic equipment. Ambulatory urodynamic equipment consists of an abdominal (usually rectal) and bladder pressure 504 catheter (connected to a transducer system), a recording unit, and the analyzing system. The catheters generally used in conventional urodynamic measurements are water filled and connected to an external transducer. However, in ambulatory urodynamics, water-filled catheter systems are not recommended, as pressures measured are dependent on the patients’ positioning and are prone to movement artifact [20]. Air-filled catheter systems are also mounted to an external transducer, with the difference that the catheter is filled with air instead of water. Because of the low density of air, the measured pressure is transmitted directly from the catheter tip to the transducer, making it functionally more similar to a catheter-tip transducer. However, responses to rapidly changing pressures can be delayed and diminished in air-filled catheter systems [21]. However, based on the limited recording capacity available at that time, a recording threshold was determined. Consequently, small pressure differences were missed, and diagnosis based on the measurement could not reliably be provided. In this system, the transducers are mounted in the tip of the five to eight French catheters inserted in the bladder and rectum. The catheter inserted in the bladder contains a second transducer measuring pressure at the urethral level. The registered pressure signal is converted to a voltage, which is then amplified. Compared to water-filled catheter systems, microtip transducers are less prone to movement artifact, with the additional advantage of fast response to pressure differences. A major disadvantage of microtip catheters is the positioning of the catheter tip since, like the air-filled catheters, there is uncertainty of positioning of the microtip transducers [20]. Therefore, pressure values should be clearly displayed at the start of the assessment. Microtip transducer drifting during the measurement can be an issue; however, this is usually only within a small range [22].

Granulomatous Sialadenitis Granulomatous infammation can involve the salivary gland parenchyma or associ- ated lymph nodes kamagra effervescent 100 mg. It is commonly a response to extravasated ductal contents kamagra effervescent 100mg, particularly mucin 100 mg kamagra effervescent, second- ary to obstructive sialadenopathy 100mg kamagra effervescent, which can result from a variety of causes includ- ing specifc infections (e . In very rare cases , granulomatous infammation can be due to certain neoplastic conditions such as Hodgkin lymphoma , T-cell lymphoma , and a subset of metastatic carcinomas (e . Cytologic Criteria Hypocellular (scant acinar and ductal cells) Groups of epithelioid histiocytes Variable amounts of acute and chronic infammatory cells ± Multinucleated giant cells ± Necrotic background debris 30 W . Obstructive sialadenopathy with extravasation of ductal contents is the most common cause of a granulomatous reaction, which can result from calculi or less often tumors. In cases with more marked granulomas, care should be taken to avoid misinterpreting the epithelioid histiocytes with their mod- erate amounts of eosinophilic cytoplasm and curved nuclei as an epithelial neo- plasm. Cat-scratch fever and tularemia can be associated with suppurative granulomatous infammation, including peripherally palisading epithe- lioid histiocytes, centrally located neutrophils, and an associated mixed chronic infammation. When infectious etiologies are suspected, special stains can be per- formed using cell block material or using liquid based slides. Aspirates yield loose collections of epithelioid histiocytes, and usually lack background necrosis (noncaseating). Sarcoidosis is a diagnosis of exclu- sion, and requires clinical and microbiologic correlation as well as special stains to exclude an infectious cause. The etiology of parotid gland lymph node hyperplasia can be non- specifc, or it can be a response to clinical or subclinical bacterial or viral infection often involving the skin of the face or scalp. Mononucleosis, tuberculosis, and cat- scratch disease, among others, can also result in such a reaction. Cytologic Criteria Aspirates of reactive lymph node hyperplasia are usually cellular and contain (Figs. In most cases, the predominant cell population will consist of a mixture of small mature B- and T-lymphocytes. Clinical correlation is needed along with demonstration of polyclonality by fow cytometry or immunohistochemical studies. Caution is recom- mended, particularly when evaluating aspirates of lymph nodes in the elderly, lymph Table 3. These aspirates of reactive lymph node hyperplasia show (a) a cohe- sive group of lymphocytes and follicular dendritic cells representing a germinal center fragment. In addition, patients with autoimmune disease such as Sjögren’s syndrome are at increased risk of developing primary parotid gland lymphomas. Occasionally, reactive lymphoid hyperplasia can contain an increased proportion of larger cells, either lymphoid or histiocytic (Fig. It is also important to note that a subset of lymphomas can yield an aspirate with a heterogeneous appearance mimick- ing reactive lymphoid hyperplasia, namely extranodal marginal zone lymphoma as well as others such as Hodgkin lymphoma, some T-cell lymphomas, and T-cell rich B-cell lymphoma. For any case of a salivary gland lymph node aspirate where lym- phoma is in the differential diagnosis, fow cytometry using an aliquot of unfxed material is highly recommended. Clinical correlation and follow-up are important in patients with lymphadenopa- thy, and a note suggesting additional evaluation for patients with persistent lymph- adenopathy can be useful. This is particularly true in cases where immunophenotyping is not performed, as well as for certain unsuspected lymphomas such as Hodgkin lymphoma where fow cytometry can be negative. This aspirate demonstrates the lymphoepithelial lesion of lymphoepithelial sialadenitis, which consists of a bland sheet of ductal epithelial cells with admixed small lymphocytes (smear, Papanicolaou stain) often related to Sjögren’s syndrome; it is more common in women, and affects the parotid glands in about 90% of cases [19]. Bilateral disease is typical, although one gland may be more severely affected than the other. Patients experience recurrent, often progressive, parotid gland enlargement with varying degrees of discomfort or pain. Patients with Sjögren’s syndrome have an increased risk of developing lym- phoma, particularly extranodal marginal zone lymphoma. The ductal epithelial cells will exhibit a uniform atypia, including enlarged nuclei with variably distinct nucleoli that overall resembles reparative changes. In some cases, the lymphoepithelial lesions can raise a differential 3 Non-Neoplastic 35 Fig. In some cases, a glandular cyst lining component, which can be ciliated, may also be encountered. In middle-aged and older patients, care should be taken to exclude the possibility of metastatic squamous cell carcinoma, which will usually exhibit more marked squamous atypia than in a lymphoepithelial cyst. Clinical context is important to exclude a squamous cell carcinoma (smear, Papanicolaou stain) Entities Sometimes Classifed as “Non-Neoplastic” Sialadenosis Sialadenosis or sialosis is an uncommon persistent, non-infammatory, non-neoplas- tic enlargement of salivary glands [7]. Sialadenosis primarily affects the parotid glands, often bilaterally, although it can occasionally occur in the submandibular glands. Clinically, the salivary gland swelling develops gradually, without a defned mass, and is usually painless. Clinical and radiologic correlations are essen- tial in diagnosing sialadenosis, since the major differential diagnosis is a sampling error (i. Therefore, for aspi- rates containing only non-neoplastic salivary gland elements, the cytopathologist should usually classify the aspirate as “Non-Diagnostic” when a discrete mass is present (i. In either case, a comment describing the possibility of a sampling error is strongly recommended (see sample report). Because numerous acinar cells are present in sialadenosis, care must be taken not to confuse this entity with a well-differentiated acinic cell carcinoma (see Chap. Most importantly, the cells of sialadenosis maintain a normal cytologic and histo- logic cytoarchitectural arrangement, including a normal ductal component, while the neoplastic cells of acinic cell carcinoma do not. Other entities in the differential diagnosis of sialadenosis include accessory parotid gland, hamartoma, lipoma/lipo- matosis, and sialolithiasis. Accessory parotid gland tissue may present clinically as a mass, and can occur anywhere along the parotid (Stensen’s) duct overlying the masseter muscle. It is considered a hyperplastic change in which there are variable degrees of oncocytic metaplasia of acinar and ductal cells (Fig. Depending upon the extent of oncocytosis, distinction from oncocytoma (a true neoplasm) is often not possible since the two entities overlap clinically and histologically [20]. Cytologic Criteria Acinar and ductal cells with abundant, granular, eosinophilic cytoplasm Normal cytoarchitectural arrangement of acini and ductal cells is maintained Variable amounts of benign ductal cells and fbroadipose tissue Features suggestive of neoplasm, cyst, or infammatory lesion are absent Explanatory Notes Oncocytosis in the salivary gland is more common with increasing age. The differ- ential diagnosis includes oncocytoma as well as oncocytic changes that can occur in several primary salivary gland neoplasms, including pleomorphic adenoma and mucoepidermoid carcinoma. Recognizing the admixture of oncocytic acinar and ductal cells in a “normal” architectural pattern is the key to avoid misdiagnosing oncocytosis as an oncocytic neoplasm. Any change in either the clini- cal or radiologic features should prompt repeat sampling, especially given the risk of sampling error in this subset of salivary gland lesions. Note: Clinical and radiological correlations are recommended to ensure that the aspirate is representative of the lesion. Note: Non-necrotizing granulomas are present admixed with acute and chronic infammation. Diagnostic considerations include a non-specifc reac- tion secondary to obstructive sialadenopathy, infection, and sarcoidosis. Clinical follow-up is recommended, and if lymphadenopathy persists, addi- tional evaluation may be indicated. Note: Based on the clinical presentation of bilateral salivary gland enlarge- ment without a discrete mass and with enlarged acinar cells microscopically, the fndings are suggestive of sialadenosis. Cytological diagnosis of sialadenosis, sialadenitis, and parotid cysts by fne-needle aspiration biopsy. Sialadenosis of parotid gland: a cytomorphologic and morphometric study of four cases. Sialadenosis of the parotid gland: report of four cases diagnosed by fne-needle aspiration cytology. Fine needle aspiration cytology in diagnois of salivary gland lesions: a study with histological comparison. Preoperative assess- ment of salivary gland neoplasm with fne needle aspiration cytology and echography: a retro- spective analysis of 357 cases. Diagnosis of salivary gland tumors by fne needle aspiration cytol- ogy: A review of clinical utility and pitfalls. Nontyrosine crystalloids in salivery gland lesions: report of seven cases with fne-needle aspiration cytology and follow-up surgical pathology. Multinodular oncocytic hyperplasia: can cytomorphology allow preoperative diagnosis of a non-neoplastic salivary disease? Chapter 4 Atypia of Undetermined Signifcance Marc Pusztaszeri, Zubair Baloch, William C. Rossi Unita’ Operativa Istopatologia e Citodiagnostica, Fondazione Policlinico Universitario A. Sparsely cellular aspi- rates composed of basaloid cells can raise a differential diagnosis that includes chronic sialadenitis and a basaloid neoplasm (Fig. Most cases of chronic sialadenitis will be hypocellular with 4 Atypia of Undetermined Signifcance 45 Fig. These two images (a, b) show rare atypical cells in an infammatory background, indefnite for a neoplasm (smears, Papanicolaou stain) Fig. Group of epithelioid cells, indefnite for a neoplasm (smear, Papanicolaou stain) background chronic infammation and few small cohesive groups of ductal cells, often with a basaloid quality. In contrast, most aspirates of a basaloid neoplasm are cellular and composed of complex basaloid groups, often with associated matrix. Similarly, salivary gland aspirates with various metaplastic changes including squamous, oncocytic, and sebaceous features, can be challenging and raise the differential diagnosis of a poorly sampled 46 M. The aspirate shows occasional epithelial cells with oncocytic features in a background with numerous lymphocytes, indefnite for a neoplasm (smear, Papanicolaou stain). This aspirate contains occasional groups of bland epithelial cells with oncocytic features. The fndings are indefnite for an oncocytoma versus oncocytic metaplasia (smear, Papanicolaou stain) neoplasm including mucoepidermoid carcinoma, pleomorphic adenoma, and Warthin tumor [5–8]. The presence of a scant population of spindle cells can also suggest both reactive processes such as nodular fasciitis or granulomatous infam- mation and neoplastic conditions including myoepithelioma, schwannoma, and solitary fbrous tumor (Fig. For salivary gland aspirates containing a prominent lymphoid component, sev- eral lesions, both non-neoplastic and neoplastic, should be considered in the differ- ential diagnosis [10] (Table 4. When evaluating these lymphocyte-predominant aspirates, attention 4 Atypia of Undetermined Signifcance 47 Fig. This hypocellular aspirate shows a very rare group of mildly atypical epithelial cells with associated “lymphocytic tangles,” suggestive but not diagnostic of a neoplasm (smear, Papanicolaou stain) Fig. The epithelial cells in this aspirate are suggestive of a neoplastic process but abundant blood limits the evaluation (smear, Papanicolaou stain) should be given to the degree of cellular heterogeneity, the pattern of lymphocytes as dispersed or in aggregates, and the degree of atypia of the lymphoid population. Aspirates of enlarged reactive intraparotid and periparotid lymph nodes are common. Most reactive lymph node aspirates show a polymorphous population of lymphocytes, lymphohistiocytic aggregates, tingible body macrophages, plasma cells, and lymphoglandular bodies in the background (see Chap. The differential diagnosis includes a benign mucinous cyst; however, a low-grade mucoepidermoid carcinoma cannot be excluded (smear, Romanowsky stain) Fig. Mixed population of lymphocytes with background lymphoglandular bodies and increased numbers of larger lymphocytes. A lymphoma cannot be excluded, particularly in the absence of fow cytometry (smear, Romanowsky stain) A variety of neoplastic and non-neoplastic lesions of the salivary glands can present with a predominant cystic component, with at least one-third of cystic sali- vary gland lesions being neoplastic [11] (Table 4. Such aspirates may be obtained from non-neoplastic lesions including mucus retention cysts, mucoceles, ductal cysts, and lymphoepithelial cysts as well as cystic neoplasms such as Warthin tumor, cystic pleomorphic adenoma, low-grade mucoepidermoid carcinoma, and cystadenoma/cystadenocarcinoma. However, cases containing mucinous cyst contents only and/ or a sparse epithelial component can pose diagnostic diffculties. Aspirates of cystic salivary gland lesions can be generally divided into mucinous and non-mucinous types. Aspirates of non- mucinous cyst contents characterized by watery proteinaceous fuid containing scat- tered lymphocytes, histiocytes, and debris will be classifed as “Non-Diagnostic-cyst 4 Atypia of Undetermined Signifcance 49 Fig. These aspirates (a, b) show groups of basaloid- appearing epithelium that are indefnite for a neoplastic process versus reactive or metaplastic changes (smear, Papanicolaou stain). This hypocellular aspirate contains occasional epithelioid and spindled cells that are suggestive of a neoplasm (smear, Papanicolaou stain) contents. For aspirates of mucinous cyst contents or where signifcant amounts of background mucin are pres- ent, the possibility of a low-grade mucoepidermoid carcinoma should be consid- ered. Aspirates yield squamous cells, sometimes with reactive atypia, in a lymphoid background [7–11]. The differential diagnosis, particularly when signifcant squamous atypia is present, includes a cystic metastasis of squamous cell carcinoma (Fig. This aspirate shows a mixed lymphoid pattern with an atypical population of intermediate-size lymphocytes. This hypocellular cyst aspirate contains rare atypical epithelial groups that are suggestive of, but not diagnostic of, a cystic neoplasm (smear, Papanicolaou stain) cytopathologists should make every attempt to classify specimens using other more specifc categories whenever possible. This image showing a collection of cytologically bland keratinizing squamous cells raises a differential diagnosis of metastatic squamous cell carci- noma versus reactive squamous atypia in a benign squamous cyst. For cystic lesions, aspiration of any residual mass using ultrasound guidance can help to achieve a more specifc cytologic diagnosis. In aspirates with an atypical lymphoid population, fow cytom- etry, immunochemistry, or tissue biopsy should be considered to rule out a lympho- proliferative disorder. Note: The differential diagnosis of mucin-containing cysts includes muco- cele, mucus retention cysts, and low-grade mucoepidermoid carcinoma. Aspiration of a residual mass, if present, may help to achieve a more specifc diagnosis. Note: While the aspirate may represent chronic sialadenitis with metaplasia and reactive changes, a salivary gland neoplasm with basaloid features cannot be completely excluded. Recommend clinical and radiologic correlations and additional sampling if clinically indicated.

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Systematic review on the efficacy and safety of injectable bulking agents for passive fecal incontinence 100mg kamagra effervescent. Its incidence increases with age and is higher in those of lower socioeconomic class and with lower educational status [2] kamagra effervescent 100 mg. These include dietary factors 100 mg kamagra effervescent, toileting habits kamagra effervescent 100mg, medications , underlying medical conditions , psychological problems , organic diseases of the gastrointestinal tract (Table 63 . Accurate history and clinical examination and investigations are essential in identifying a cause for each patient’s symptoms . The primary function of the colon is the absorption of water from the small bowel effluent , leaving 100–150 mL of water in feces. A secondary function is to enable bacteria to ferment undigested fiber; the rectum stores feces until defecation takes place. The colon, rectum, and internal anal sphincter (continuation of the smooth muscle) are extrinsically innervated by the autonomic nervous system. The sympathetic innervation via the coeliac, superior, and inferior mesenteric plexus and hypogastric nerves (T11–L2) inhibits peristalsis and are sensitive to distension. The parasympathetic innervation by preganglionic vagal fibers and S2–4 splanchnic nerves increases peristalsis, contracts rectum, and relaxes internal anal sphincter to assist defecation. The intrinsic enteric nervous system (submucosal and myenteric plexuses) influences contractions and tone while the cells of Cajal are pacemakers. In order to be considered of medical significance, symptoms must be present for at least 3 months with onset of symptoms 6 months before diagnosis [5]. Subtypes of Constipation Constipation can be divided into the following subtypes: 1. Motility disorder: Decreased high-amplitude peristaltic contraction causing slow transit constipation. Patients with severe colonic inertia may have a more diffuse motility disorder [6]. An accurate history from the patient is important and should include size, consistency, and frequency of defecation and duration of symptoms. The presence of mucus or blood in or on stool and history of abdominal or perianal pain should be ascertained as well as any difficulty in evacuation, need for perineal pressure, or digitation vaginally or rectally. Patients with slow transit constipation may complain of infrequent bowel movements and lack of urge to defecate despite laxatives. Patients may have additional symptoms of urinary dysfunction or symptoms of uterine or vaginal prolapse, implying more global pelvic floor abnormality and dysfunction. A thorough obstetric history may reveal a history of obstetric trauma; high vaginal parity; prolonged labor, which may be associated with uterine prolapse; enteroceles; rectocele; and descending perineal syndrome. These conditions may present as symptoms of obstructive defecation such as prolonged defecation with sensation of anorectal obstruction and rectal fullness with tenesmus; as such these are also important screening parts of a urogynecological or urological history. Women sometimes use vaginal, anal digitation, or perineal pressure to aid evacuation. General Poor diet ± lack of exercise Poor fluid intake/dehydration Old age Postoperative pain Hospital environment (lack of privacy/use of bed pan) 2. Metabolic/endocrine conditions Amyloid Glucagonoma Hypercalcemia (hyperparathyroidism, milk alkali syndrome) 991 Hypothyroidism Hypokalemia Panhypopituitary syndrome Pheochromocytoma Pregnancy Porphyria Arsenic/mercury/lead/phosphorus poisoning Uremia 4. Bowel disorders Obstruction: colorectal cancer, Crohn’s stricture, diverticular disease, volvulus Pelvic mass (e. Neuromuscular conditions Central disorder: tumors, trauma, cerovascular Peripheral disorder: von Recklinghausen’s disease, multiple endocrine neoplasia Spinal or pelvic nerve injury (e. Pelvic floor dysfunction is often associated with depression and anxiety, so questioning about additional contributing factors such as psychiatric illness and any history of sexual abuse may yield important information that may modify treatment regimens [13,14]. Patients with constipation may also report an increased incidence of history of sexual and physical abuse and a poorer health status than the general population [15]. In a study of 118 constipated patients, 32% reported physical abuse and 22% sexual abuse [16]. It is important that the issue of abuse is explored with appropriate backup from a safeguarding team where required. Patients often report that their bowel problems have adversely affected their family life, their relationships, work, and social life [16]. Rectal examination is mandatory looking for skin tags, anal fissures, external hemorrhoids, and excoriation if present. Gaping of anal opening may suggest an underlying neurological problem or a full-thickness rectal prolapse. It is important to check for altered sensation around the perianal skin and perineum. A lack of reflex contraction of the external anal sphincter to perianal stimulation may indicate impaired pelvic innervation. Patients may demonstrate a full- thickness rectal prolapse, a bulge into the vaginal introitus indicating a rectocele, or bulging of the perineum below the ischial tuberosities indicating perineal descent. Digital rectal examination is performed systematically to assess resting anal tone; squeeze pressure by asking the patient to clench their anus on the examining finger. The finger is swept clockwise and anticlockwise to examine the entire circumference of the anal canal feeling for masses, ulceration, and tenderness. In patients with anismus or dyssynergia, the puborectalis muscle often fails to relax or may be felt to contract when they strain. The sensitivity and specificity of diagnosing dyssynergia on rectal examination are 75% and 87%, respectively, when two or more of the following are identified on rectal examination: impaired perineal descent, paradoxical anal contraction, or impaired push effort [18]. Rigid sigmoidoscopy or proctoscopy examination in clinic can be a useful adjunct in assessing any mucosal abnormality in the anus and rectum as well as assessing rectoanal intussusception; mucosal folds may be visible when prominent. If there is a history of vaginal prolapse or obstructed defecation, vaginal/pelvic examination should also be performed. So while screening for metabolic cause of constipation with full blood count and biochemistry including calcium and thyroid function test, this should be reserved for new patients presenting with constipation where there is a high index of suspicion or a relevant medical history. A meta-analysis of prospective cross-sectional surveys and cohort studies demonstrated no increase in prevalence of colorectal cancer in patients with constipation [21]. Additional investigations are reserved for patients who fail simple medical therapy. A modified algorithm of the management of constipation by the American Gastroenterological Association is shown in Figure 63. Diagnostic Studies to Evaluate Anorectal Function Balloon Expulsion Test This is a simple bedside test performed to assess the patient’s ability to expel an artificial stool. Although a failure to expel a 50 mL balloon suggests dyssynergia, a normal test does not exclude the diagnosis [20]. Maximum tolerated volume The three simple sensory thresholds described earlier cannot distinguish the factors influencing sensation including compliance and neural pathways [23]. Decreased sensation to distension is seen in obstructed defecation, but the evidence that this is due to parasympathetic nerve damage is debatable [24,25]. Damage to these nerves may be a factor in constipation following hysterectomy [26]. By using isobaric distension of a balloon, rectal compliance can be calculated as the steepest gradient of the curve plotting volume instilled divided by rectal pressure. Where compliance is high, greater volume needs to be instilled to achieve a given rise in pressure. Decreased compliance (reduced laxity, increased hypersensitivity) is often found in inflammatory bowel disease or after pelvic radiotherapy. Factors such as body position and consistency of “stool” play a role in one’s ability to expel stool. Up to 20% of asymptomatic healthy adults do not produce normal relaxation during attempted defecation [27]; hence, a finding of dyssynergia on anorectal manometry alone is not diagnostic. Defecating Proctography Defecating proctography is regarded as the gold standard investigation for evacuatory dysfunction. Contrast is inserted into the rectum, vagina, and small bowel to delineate each structure. The patient is asked to defecate on a commode under fluoroscopy to assess the process and effectiveness of defecation. Functional obstruction due to paradoxical contraction of puborectalis can be estimated by measuring the anorectal angle during defecation. Other causes of obstructive defecation such as rectocele, rectoanal intussusception, rectal prolapse, enterocele, sigmoidocele, vault prolapse, and excessive perineal descent can be identified. Ultrasound Scan Transperineal or translabial ultrasound scans allow multiplanar real-time imaging of the pelvis, providing important information on the dynamic functional anatomy of the pelvic floor. It is reported to have excellent tissue discrimination, allowing visualization of modern mesh implants that are difficult to see in other modalities [32]. Transperineal ultrasound scanning may compliment the aforementioned defecography by providing more information on rectal compliance and movement [33]. Diagnostic Studies to Evaluate Intestinal Transit Since patient recall of bowel habit is often inaccurate, it is helpful to have an objective measure of transit. In the general population, the colonic transit time is normally less than 72 hours [34]. Various modalities are now available to determine gastrointestinal transit time [35]. Transit Study Using Radiopaque Markers A capsule containing 24 radiopaque markers is swallowed and abdominal radiographs are taken at 12 and 120 hours. Normal colonic transit is defined as >20% markers at 12 hours and <80% at 120 hours [36]. Alternatively, different shaped radiopaque markers are ingested at 0, 24, and 48 hours and an abdominal x-ray is taken at 120 hours [37,38] (Figure 63. By counting the number of different shapes remaining, a special formula is used to estimate the transit time. Patients are asked to have high-fiber diet (20–30 g/day) and avoid laxatives, enemas, or medications that affect the bowel during the study. Excessive retention of markers in the rectum may infer outlet obstruction, rather than slow transit; 60% of patients with dyssynergic defecation have excessive retention of markers [39]. Evidence in favor of the test with some evidence on specificity, sensitivity, accuracy, and positive predictive values. Gastrointestinal Transit Scintigraphy Scintigraphy can be used to assess the whole gastrointestinal tract or colonic transit [35]. Liquid or solid 111 99m labeled with In or Tc is ingested and scanned sequentially over hours to assess gastric emptying and small bowel transit [40,41]. Colonic transit scintigraphy is used to measure regional colonic transit 111 by swallowing a pH-sensitive capsule containing In absorbed on activated charcoal that is released in the terminal ileum. Colonic Manometry Colonic manometry catheters are placed using a colonoscope or via guidewire. A 24 hour recording allows complete assessment of overall motor activity in the colon at rest, during sleep, while walking, and after meals and medication, which may be helpful in diagnosing underlying myopathy or neuropathy, especially in children [46]. There is minimal evidence to suggest that increasing fluid intake will increase transit times unless an individual is dehydrated, but fluid intake of 1. One controlled trial has shown that higher fluid intake in the presence of a high-fiber diet can improve symptoms of chronic constipation [50]. However, exercise is to be encouraged if only for its other proven health benefits. In addition, position when defecating is important and, in many societies, squatting is the normal posture used. The sitting position with a 90° posture is a relatively recent innovation used in Western 997 toilets. This sitting position causes a narrow anorectal angle that increases straining needed to empty the rectum. A study designed to compare the straining forces applied when sitting or squatting looked at normal volunteers defecating in three positions: sitting on a standard-sized toilet seat (41–42 cm high), sitting on a lower toilet seat (31–32 cm high), and squatting [54]. Both the net time needed for sensation of satisfactory bowel emptying and the degree of straining were significantly less in the squatting position compared with both sitting positions (p < 0. Thus, patients are advised to adopt a position where the knees are above the hips with feet flat on the floor. There are now several devices available to enable a squatting position to be adopted on a pedestal toilet. The mechanism of each type of laxative will help to determine the most appropriate type of laxative for the patient’s symptoms (Table 63. Bulk Laxatives/Fiber Undigestible fiber is an important part of our diet to provide stool bulk. Bulk-forming laxatives attract water, forming larger and softer stool, which in turn causes colonic distension, stimulating peristalsis and effective propulsion of stool along the colon to rectum. Systematic review has reported that bulking agents induce an average increase of 1. Lactulose (semisynthetic disaccharide, poorly absorbed sugar), macrogols (inert polymers of ethylene glycol), or magnesium salts retain fluid in the colonic lumen causing osmotic diarrhea. Absorption of magnesium is limited but caution must be exercised in patients with impaired renal function [58]. Lactulose is less effective than macrogols [59] and its use may be limited due to flatulence and bloating caused by bacterial fermentation. Stimulant Laxatives Diphenylmethane derivatives such as bisacodyl, sodium picosulphate and anthraquinone derivatives such as senna are stimulant laxatives, which act on the enteric nervous system to increase intestinal motility but may cause abdominal cramps as a consequence. Long-term use of anthraquinone-derived stimulants can generate brown discoloration of mucosa known as pseudomelanosis coli. Parasympathomimetics such as neostigmine enhance parasympathetic activity in the gut and increase intestinal activity. Neostigmine can be used in selected cases for the treatment of pseudoobstruction that has failed to settle with conservative management [60].

It detects only acid refux episodes Indications for surgery are Combined 24 hour multiple intraluminal Failure to respond to a 6 week course of intensive impedance and pH monitoring: It has an edge over medical treatment plain pH monitoring since it also detects nonacid Presence of a stricture refux epiosodes Recurrent aspirations and apnea 100 mg kamagra effervescent. By 2 years of age 100mg kamagra effervescent, 60% of the patients become Differential Diagnosis asymptomatic kamagra effervescent 100mg. Odophagia is defned as painful swallowing Conservative Measures Globus is defned as a sensation of a lump in throat kamagra effervescent 100 mg. Additional Gastrointestinal hemorrhage , a common childhood prob- measures include administration of thickened feeds . Understandably , it may present as hematemesis or Proton pump inhibitor such as omeprazole , lansapra- cofee-ground-colored emesis , or blood per rectum which zole and esmoprazole (Box 29 . Is he in shock due to excessive of the bleed and duration of contact with gastric secretions. Other Always look for evidence of portal hypertension, heman- causes include severe gastritis, bleeding or coagulation disorder gioma, purpura, telangiectasia, intestinal obstruction z Melena: Altered (denatured) blood in stools giving it a black-tarry and blood dyscrasia. Remember to thoroughly clean the bowel trauma from nasogastric tube, hemorrhagic gastritis, in suspected polyp. In intussusception or malrotation hiatal hernia, esophageal or duodenal atresia, foreign with volvulus, such cleaning is contraindicated body impaction, vascular malformations and idiopathic Sigmoidoscopy is necessary in the presence of Infancy and childhood: Swallowed blood after evidence favoring polyps or colitis epistaxis, tonsillectomy, bleeding from gums, esopha- Diagnostic laparotomy in cases of signifcant bleeding geal varices, portal hypertension, peptic ulcer, erosive in whom diagnosis has defed all the investigations. Management is mainly of the etiologic condition and the Lower Gastrointestinal Tract Bleeding blood loss. Ingestion of minimum of 8 g/dL iron or bismuth-containing preparations or eating earth or z Monitor hematocrit (target at 30%) and urine output z Short-term antibiotic prophylaxis. Management of persistent bleed from esophageal varices comprises: Clinical Features Administration of somatostatin or octeotide Most children with H. Endoscopic sclerotherapy/endoscopic variceal ligation In a proportion of cases, chronic gastritis may manifest Endoscopic injection of tissue adhesive glue in gastric with recurrent abdominal pain and vomiting. Invasive investigations include fexible upper Lower Gastrointestinal Bleeding gastrointestinal endoscopy to biopsy the gastric mucosa Supportive measures are virtually on the same lines as for histopathology, culture or rapid urease test. It is Prognosis corkscrew-shaped and is found at neck of pyloric glands in Te unfavorable prognostic factors include: gastric pits. Massive hematemesis Initial hematocrit of 20% Treatment Severe anemia with Hb under 7 g/dL Since H. Best results (100%) are obtained employing a combination of amoxicillin and bismuth Tis spiral-shaped Gram-negative bacteria with unipolar subsalicylate. A combination of amoxicillin and tinidazole fagella was frst discovered in 1983 by Barry Marshall too gives very good results (94%). In view of the likelihood of and Robin Warren and initially christened Campylobacter salicylism through use of bismuth subsalicylate in children pyloridis. Its characteristics include ability to produce under 10 years, this agent should be avoided in this age abundant urease and unique fatty acid composition. If dual therapy fails, pediatric Helicobacter pylori infection is truly an infection of H. Te Some experts do not favor routine pharmacotherapy for development of stomach and duodenal disease depends H. Feco-oral route appears to be the major route of acquiring infection with clustering in families and Te term denotes a group of disorders [both immuno- within institutions for mentally retarded and orphanages. Te organism is highly host and tissue specifc, invading Causative Foods predominantly the mucos layer overlying the gastric epithelium in the antrum and causing gastric infammation Te most common cause of food allergy in early infancy and epithelial changes. Te modus operandi of production is cow milk or soy protein allergy followed by allergy to 584 peanut or egg (white) either through the mother’s diet or Provocative/neutralizing methods of diagnosing allergy through direct feeding. In later infancy, and childhood, by intradermal injection or sublingual administration wheat emerges as the most important food allergy. Te so-called eosinophilic Common ofending coloring additives used in foods gastroenteritis is diagnosed by demonstrating the number and additives are tartrazine, sunset yellow, carmoisine of eosinophils in small intestinal or gastric biopsy. For an acute severe life-threatening IgE-mediated Operational Mechanisms reaction, injectable epinephrine and/or hydrocortisone Te possible mechanisms of such adverse reactions to may be needed. With passage of time, it becomes possible to (alpha-gliadin) or cell (lymphocyte)-mediated injury cautiously reintroduce the ofending food into the diet Biochemical enzyme defciency (lactase, etc. A number of adverse reactions to whole cow milk Te term denotes a group of conditions in which there is a ingestion may occur, e. Occult fecal blood loss with resultant anemia Te incidence is highest in females in second decade of Enteropathy with loss of protein and blood life, especially with disturbed personality. Accumulation Vomiting and diarrhea of hair is referred to as trichobezoars, plants and animal Heiner syndrome characterized by pulmonary material as phytobezoars, calcium or casein content as hemosiderosis, chronic rhinitis, recurrent otitis media, lactobezoars. Lump(s)—lymph nodes, ileocecal mass, loculated Association between food allergy and behavioral ascites. High index of suspicion is a real forerunner for Diagnosis is usually by critical testing of the ofending arriving at the diagnosis which needs to be established food by elimination and provocation (challenge) through investigations. Chest X-ray may show evidence of a employed to identify presence of lgE antibody to food. The term, recurrent abdominal pain, is now replaced with chronic abdominal pain D. Ampicillin is an important cause of antibiotic associated diarrhea which may take the shape of pseudomembranous colitis E. Celiac disease may be complicated by leukemia or lymphoma for months and even years following the diagnosis 3. Gastrointestinal hemorrhage, regardless of its magnitude and location, is an indication for blood transfusion E. Five days after stopping treatment, he develops abdominal cramps with bloody diarrhea and fever. No, Darrow solution which has high potassium is not appropriate for initial rehydration in severe diarrheal dehydration. Storage of vitamins A, D, E, K, B12, iron and copper T e biliary system consists of biliary canaliculi (which Detoxifcation of drugs, including alcohol join to form bile ductules), bile ducts and hepatic ducts Inactivation of hormones. Common symptoms Blood supply is 75% from portal vein and 25% from hepatic z Icterus (jaundice) artery. Venous drainage is by hepatic veins that drain z Pruritus directly into the inferior vena cava. Hepatic lobules form the z Abdominal pain/distention z Clay-colored stools basic architecture. In between the liver cells (hepatocytes) z Dark-colored urine and sinusoids are spaces containing tissue fuid. Additional manifestations z Endocrinal abnormalities z Renal dysfunction (hepatorenal syndrome). Endocrinal disorders Percutaneous liver biopsy detailed later in Chapter 49 z Diabetes mellitus: Fatty liver (Pediatric Practical Procedures) is of considerable help z Congenital hypothyroidism: Prolonged neonatal jaundice beyond in—Providing exact histologic diagnosis in diseases frst month of life. B and C from contaminated blood transfusion and cholecystitis Analysis of stored material such as iron, copper or (both acute and chronic) from pigment stones. IgG antibody which persists virtually forever, thereby Serum bilirubin and its fractions assist in distinguish- preventing reinfection. Note the icterus which followed a couple of days after nausea, vomiting, abdominal discomfort, malaise Fig. Liver was palpable 3 cm below the costal margin with a of hepatitis A, B and D viruses. It was formerly designated as eternal non-A, non-B z Hepatitis B: Extrahepatic manifestations such as hepatitis virus. During the early stages of the disease, either recover completely or develop chronic hepatitis or virus can be isolated in the blood as well as stools. Differential Diagnosis Hepatitis B: Transmission is almost always via the Malaria (falciparum) inapparent parenteral route, e. Leptospirosis Transplacental passage may afect the fetus causing Viral hemorrhagic fever neonatal hepatitis. Nonetheless, child to child infec- Drug-induced hepatitis tion, occurring during plays or bed-sharing via skin Infectious mononucleosis lesions like impetigo, scabies, cuts and infected insect Autoimmune hepatitis bites is the major cause of hepatitis in childhood. Hepatitis C: Mode of transmission is parenteral, trans- Wilson disease fusion or vertical (sexual). Hemolytic jaundice Hepatitis D:Transmission is virtually on the same lines In case of a newborn, difuse hepatitis of herpes simplex, as in serum hepatitis. However, vertical transmission cytomegalic inclusion disease and toxoplasmosis must from mother to the infant is infrequent. Te following investigations Clinical Features are of value: Incubation period of hepatitis A varies from 28–42 days. Conjugate (direct) hyperbilirubinemia (serum bilirubin In case of hepatitis B, it is much longer, i. Occasion- produce temporary sense of well-being and improve- ally, monocytosis to the extent of 25% may be present. Hepatotoxic drugs like chlorpromazine, paracetamol, Electrophoretic analysis shows high gammaglobulins, etc. Serologic tests are mandatory for identifying the exact Hepatitis B type of viral hepatitis. Complications Hepatitis E Acute liver failure Interferon and ribavirin may be of value. Small, but frequent feeds of high carbohydrate diet; A vaccine (Havrix) for human use is now available. Fats, in any form are poorly tolerated and (formaline-killed) has emerged as a major step in the should be avoided. Gammaglobulins Hepatitis B Neomycin may be given in serious cases for sterilization Hepatitis B is transmitted via a parenteral route; of the gut. Screening of blood given as syrup, 10–50 ml/day (O), or its diluted form as donors is essential. It appears quite early in the infection (though during provides active protection which is long-lasting though a brief window period, it may not be detectable) and disappears not immediate. For delta hepatitis, preventive measures are on the same z False neurotransmitters (octopamine) replacing true neurotrans- lines as for hepatitis B. Only a small proportion of the cases die following development of fulminant hepatitis and hepatic coma. Spans of lethargy Finds difcult to Normal euphoria; reversal of draw fgures and (Hepatic Encephalopathy, Fulminant Liver Failure) day-night sleeping; perform mental could be alert tasks Defnition 2. Stupor, but arousable, Asterix, hyper- Remarkably confused, incoherent refexia, rigidity, abnormal Etiopathogenesis speech extensor refexes triphasic waves 4. Measures aimed at reducing cerebral edema include: With modern intensive care, survival is around 30–50%. All types of chronic For respiratory failure, oxygen and assisted ventila- hepatitis come under this category. Te presence of continuing hepatic infammation is confrmed by raised hepatic transaminase levels. Demonstration of antinuclear and antismooth muscle antibodies in serum and multisystem involvement Fig. Note the enlarged liver in this girl in the form of arthropathy, rashes, thyroiditis and Coombs- with chronic hepatitis. The liver was enlarged (5 cm below costal positive hemolytic anemia strongly hint at an autoimmune margin; span 13 cm) and unusually frm. Management Diagnosis Specifc therapy is possible in only a minority of the sub- Clinical Clues jects (Table 30. Supportive care should be in the form the clinical clues to the diagnosis of metabolic liver disease. Tough three types are known, classical galactosemia Psychiatric manifestations: Behavioral problems, clum- is caused by defciency of galactose 1 phosphate uridyl siness and deterioration in scholastic performance. A high index of suspicion paves the way for reaching the Prenatal diagnosis is available. It is defned as an autoimmune involvement of the liver Liver biopsy for hepatic copper content: More than that may manifest as acute autoimmune hepatitis, insid- 250 µg/g dry weight of liver is nearly diagnostic. Treatment Types Treatment options are: Dietary restriction of copper in the form of avoidance Type 1 (75% cases): It is characterized by presence of organ meat (liver), nuts, chocolates, etc. Type 2 (25% cases): It is characterized by anti-liver, Orthotopic liver transplantation. Etiopathogenesis Portal vein thrombosis is a relatively common cause of portal hypertension. Tis almost always follows umbil- Te crux of the vulnerable background is obesity as a result ical sepsis and repeated exchange transfusions using of diet that is rich in saturated fats and refned carbohy- the umbilical vein. Signs include: Budd-Chiari syndrome, involving main hepatic vein Generalized obesity from various causes like thrombosis, vasculitis, sepsis Satriae Hepatomegaly or tumor, is rare in childhood. Occasionally splenomegaly Congenital hepatic fbrosis, usually in association with Dark pigmentation in skinfolds and axillae (acanthosis renal anomalies, is a rare cause of portal hypertension. Hematological investigations are required to fnd out the adverse efects of repeated hemorrhages and the current hematological status of the patient. Liver biopsy is of great help to establish the diagnosis of the underlying disease process. If the patient is signifcantly anemic and/or having large hematemesis, blood transfusion is usually needed. To control persistent bleeding from esophageal varices, endoscopic sclerotherapy, intraesophageal balloon Fig. Propranolol therapy has been found to be of value particularly in a child who had otherwise been doing for prevention of recurrent gastrointestinal bleeding. Te benefcial efect of this therapy appears to be A respiratory infection may cause severe cough and from reduced portal pressure secondary to decreased thereby precipitate a bout of hematemesis due to cardiac output.

A flap of omentum is inserted between the freed urethra and symphysis pubis to try and prevent further scarring 100 mg kamagra effervescent. This procedure has a 66% cure rate at 14 months but in carefully selected and screened patients [66] 100mg kamagra effervescent. Simpler methods include merely vaginal mobilization of the urethra and bladder neck off from the pubic ramus and plication of the lower bladder kamagra effervescent 100mg, bladder neck kamagra effervescent 100 mg, and urethra in an attempt to elongate the urethra . Most patients who do return with ongoing incontinence problems have a short urethra of only 1 . A sling of levator muscle or scar tissue is used if there is no muscle complex remaining . This gives a 70% complete cure rate with no ongoing incontinence and 15% improved in their continence and 15% have no change [69] . This improvement is maintained in a 6-month follow-up but longer-term follow-up is not available . Those not improved or improved slightly but not satisfactorily can use the urethral plug as the urethra is now longer and narrower . Urinary Retention After removal of the catheter on day 10 or 14 after fistula repair, up to 8% of patients will have urinary retention with overflow. All patients should have a residual urine volume checked after their catheter is removed. It is usually treated with recatheterization with “bladder training,” that is, clamping the catheter and releasing every 2 hours. After 48 hours, 70% of patients are voiding normally and the remaining will need a time of self-catheterization. Frequency and Voiding Disorders It has been noticed that on removing the catheter patients often complain of frequency of micturition and some voiding problems. It was often thought that this may resolve with time and could have been secondary from a prolonged catheterization; however, recent evidence from Ethiopia shows this problem is ongoing in at least some women. Of the 35 women studied with persistent incontinence despite fistula closure, 77% had more than eight episodes of voiding in 24 hours and 51% voiding more than 15 times. A further 13 persistently incontinence women were studied and this revealed a significant number of voiding dysfunctions with low flow rates, prolonged voiding times, and the average voided volume of only 72 mL [71]. Sexual and Reproductive Complications Other ongoing problems include dyspareunia in 11% of those sexually active (only 35% were sexually active at 6 months follow-up), 30% of women will have ongoing amenorrhea at 6 months, and nearly half of whom do not have an obvious cause, such as being postmenopausal, had a cesarean hysterectomy at the time of delivery, being pregnant, or on a long-acting progesterone contraception [39]. Social and Mental Health Most patients return to their normal living arrangements once they are cured and start to attend social functions and return to work. Several recent studies have shown improvements in social, physical, and mental health once they are cured [33,34,36]. Some, however, do not and still suffer ongoing mental health problems and difficulties with reintegrating back into their communities. All of the 71 cases had a fistula described as complicated, meaning that they had one or more of the following: excessive scarring, total destruction of the urethra, ureteric orifices outside the bladder or at the edge of the fistula, a small bladder, both recto- and vesicovaginal fistulae in conjunction, or the presence of bladder stones. Patients were more likely to have a failed repair if they (1) had a ruptured uterus at the time of labor, (2) had a previous failed repair, (3) presented with limb contractures, (4) presented malnourished or in poor health, (5) had a fistula described as complicated, and (6) had blood transfusion [72]. If a patient’s repair has broken, it is important to counsel the patient appropriately as there are likely to be discouraged and tearful. It is usually recommended that you should wait for 3 months before attempting another repair. Provisions need to be made for the patient to return to the hospital or if the patient is suffering severely, they can stay within the hospital and wait for their second repair. The only option for these women to have any quality of life is either to have a bladder augmentation or a urinary diversion operation. Patients who have such severe injuries often have their urethra affected, so even with a good reservoir, they are still unable to hold their urine. If the urethra is intact, then self-catheterization may be needed to effect full drainage of the bladder as the augmented bladder cannot contract, or mucous secreted from the bowel lining may block the urethra. This may be unmanageable for a woman living in the developing world, far from a supply of catheters and clean equipment. The former two options require an intact anal sphincter and the woman to agree to pass urine through the anus. The ileal conduit restricts a patient to living near a service that can supply the conduit bags, which are often rare in the developing world. The patient also needs to be close to a health center that knows how to deal with any complications. The ureters and kidneys in these women are often dilated and compromised and ascending infections can be common. There are anecdotal cases of ileal conduits being performed on patients, and then the patient has been unable to access bags, leaving her in a worse state than she was to start with. This should be an attainable dream in the twenty-first century and this suffering is placed in medical texts of yesteryear. The task, however, is immense with up to many thousands of new obstetric units being required for Africa alone to supply adequate maternity care [76]. In tandem with this, roads need to be built, transport systems put in place, and, most importantly, men and women educated. Until all this is achieved, the obstetric fistula patient will still need our caring attention. International Society of Obstetric Fistula Surgeon Meeting, December 10–12, 2009, Nairobi, Kenya. The obstetric vesicovaginal fistula: Characteristics of 899 patients from Jos, Nigeria. Obstetric fistula: A study of women managed at the Monze Mission Hospital, Zambia. Childbearing, health and social priorities: A survey of 22,774 consecutive hospital births in Zaria, Northern Nigeria. Dead mothers and injured wives: The social context of maternal morbidity and mortality among the Hausa of Northern Nigeria. Estimating the prevalence of obstetric fistula: A systematic review and meta-analysis. Obstructed labour injury complex: Obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world. Risk factors for developing residual incontinence after vesicovaginal fistula repair. Reduction in the incidence of stress urinary incontinence complicating a fistula repair. Five years experience of ureterovaginal fistula following obstetric or gynaecological intervention. Urinary and faecal incontinence following delayed primary repair of obstetric genital fistula. The obstetric fistula and peroneal nerve injury: An analysis of 974 consecutive patients. Bilateral common peroneal nerve palsy secondary to prolonged squatting in natural childbirth. The impact of surgical treatment on the mental health of women with obstetric fistula. Urinary changes in obstetric vesico-vaginal fistulae: A report of 216 cases studied by intravenous urography. Pituitary and ovarian function in women with vesicovaginal fistula after obstructed and prolonged labour. Predicting the risk of failure of closure of obstetric fistula and residual urinary incontinence using a classification system. Factors influencing urinary fistula repair outcomes in developing countries: A systematic review. Classification of female genitourinary fistula: Inter- and intra-observer correlations. The immediate management of fresh obstetric fistulas with catheter and/or early closure. Spontaneous closure of vesicovaginal fistulas after bladder drainage alone: Review of the evidence. Factors influencing choice of surgical route of repair of genito-urinary fistula, and the influence of route of repair on surgical outcomes: Findings from a prospective cohort study. Transvaginal mobilization and utilization of the anterior bladder wall to repair the vesicovaginal fistulas involving the urethra. Prevention of residual urinary stress incontinence following successful repair of obstetric vesico-vaginal fistula using a fibro-muscular sling. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: A preliminary report. Outcome of obstetric fistula repair after 10-day versus 14-day Foley catheterisation. Stress urinary incontinence after delayed primary closure of genitourinary fistula: A technique for surgical management. Sling procedures after repair of obstetric vesicovaginal fistula in Niamey, Niger. A new method to manage residual incontinence after successful obstetric vesicovaginal fistula repair. Assessment of 24-hour frequency in patients with persistent urinary incontinence following successful closure of obstetric vesicovaginal fistula. Uroflowmetry in patients with persistent urinary incontinence following successful closure of obstetric vesicovaginal fistula. Continent urinary diversion using the Mainz-type ureterosigmoidostomy—A valuable salvage procedure. They may be anatomically simple or complex and are associated with a range of conditions that may need to be addressed concomitantly. However, it is believed that this represents an underestimate and, with increased clinical suspicion and improved diagnostic techniques, the true incidence may prove to be higher [6] at least in symptomatic women. In 1953, Novak was quoted as saying, “This is a relatively rare condition and no gynecologist will see more than a few in a lifetime” [7]. However, the frequency of diagnosis has increased with more sensitive imaging modalities. In 1938, Hunner reported three cases associated with calculi and commented on the rarity of the condition [9]. In 1956, Davis and Cian reported 50 cases; more than had been reported previously in the entire history of the Johns Hopkins Hospital [10]. A racial predilection has been suggested, with diagnosis in African-American women being 2–6 times that in white women [14]; however, Ganabathi et al. Periurethral glands are tubuloalveolar structures located posterolaterally beneath the periurethral fascia in the proximal two-thirds of the urethra. Infection leads to obstruction of the glands, local abscess formation, and eventual rupture into the urethral lumen, as first described by Routh [18]. However, with current obstetric technology, traumatic delivery is no longer a prevalent factor in developed nations. Although there has been some evidence supporting a congenital etiology, this theory seems less likely to be the principle etiology given that two large series included no patients younger than 10 years of age [14,20]. The discovery of mesonephric adenoma and adenocarcinoma has implicated Gartner’s duct remnants. There have also been reports of nephrogenic adenoma, a benign metaplastic condition [32,38–44]. More than 80% of the diverticular cancers seen are either adenocarcinoma (61%) or transitional cell carcinoma (27%) [45–47]. One case of a high-grade serous carcinoma, a histopathology that typically arises in the uterine corpus or in the Fallopian tubes/ovaries has recently been reported [49]. Treatment of diverticular carcinoma includes wide local excision for localized disease (Seballos et al. Adjuvant radiation therapy or chemotherapy may also be indicated for extensive malignancy or for nonsurgical candidates [50,51]. Squamous cell carcinomas are typically diagnosed at an advanced stage, with all reported cases 1618 presenting at stage T2 or higher, and require a more aggressive treatment approach [50,52–55]. Among 79 patients reviewed by one center with follow-up ranging from 6 months to 10 years, anterior pelvic exenteration appeared to offer the highest likelihood of prolonged disease-free survival [48]. Frequently, patients receive an initial, erroneous diagnosis for which a variety of treatments are considered or attempted (Table 110. Rarely, some patients are without any pertinent physical findings, and workup is pursued only on clinical suspicion based on the patient’s history. This acronym represents location, number, size, configuration, communication, and continence. The anterior vaginal wall is compressed with a finger in the vagina, and the urethral lumen is inspected for any expression of effluent from the floor or the roof of the urethra (Figure 110. Cystoscopy is the only diagnostic tool that allows direct inspection of the urethra and bladder and, in some cases, may facilitate diagnosis of a diverticular neoplasm or calculus; however, the value of cystoscopy as a diagnostic tool has been questioned [66]. The ostium of the diverticular neck can be difficult to visualize between collapsed urethral folds, and noncommunicating diverticula (periurethral cysts) will not have a visible orifice [67,68]. Cystoscopy does not provide any information regarding size, shape, or appearance of the diverticulum or the diverticular wall [69]. These symptoms may include urinary leakage with increased intra-abdominal pressure, urgency incontinence, or spontaneous loss of urine that may represent intrinsic sphincter deficiency, paradoxical incontinence (i. The urodynamic findings in 55 women studied by Leach and Ganabathi [70] are noted in Table 110. Numerous imaging modalities are available and each has its own strengths and weaknesses [73].

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