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Eyelid lacerations do not lacerations spasms with spinal cord injury order 100 mg voveran sr, may be due to: Phave to muscle relaxant homeopathy buy 100 mg voveran sr otc be repaired immediately muscle relaxant tmj cheap 100 mg voveran sr with mastercard. To perform an adequate repair yellow round muscle relaxant pill generic voveran sr 100mg online, proper equip of the levator muscle is not indicated unless an eyelid ment, lights, and support personnel must be present. Probing and irrigation of a potentially lacerated the anatomy of the upper and lower eyelids guides canalicular system is contraindicated in the young the techniques for repair. Silk sutures at the eyelid margin orbicularis muscle; and are preferred because they are soft, easy to work. There are normally three linear rows of lashes on the upper eyelid and two linear rows of lashes on the lower eyelid. The lower Proper alignment of the eyelashes and proper eyelid tarsus requires one to two deep sutures. Punopposed pull of the orbicularis muscle the gray line is the surface projection of the muscle is one reason why lid margin lacerations look of Riolan. The eyelid margin sutures, when properly placed, can be secured away from the conjunctiva. It is very unusual for a lid margin to be missing in with one additional skin suture. Careful reapproxima the typical surgical process is the following: tion and firm support by the sutures allow ade-. A 6-0 silk suture through the meibomian gland orifices will aA 5-0 Dexon suture with a D-1 needle is a good choice for eye align the eyelid margin. The needle is a spatulated, half-circle needle, suture will help with the placement of all subse and these characteristics allow precise lamellar placement through the lacerated tarsus. If it appears to be gaped, may be camouflaged with makeup or permanently the same 5-0 Dexon suture can be used to reapprox repaired with a bloc excision of the damaged eyelid imate the orbicularis muscle. The incidence of keloid formation increases in pigmented patients with severe trauma. Sutures of 6-0 silk can be used for eyelid margin As with so many problems in medicine, keloids tend and skin closure. The medical management of ations, the skin sutures are typically placed deeper keloids involves judicious use of steroid injections, and wider than they are when closing lacerations that 11,12 dermabrasions, and late wound revision. Deeper and wider bites help stabilize the lid laceration and counteract the pull of the orbicularis muscle. These sutures are carefully placed to requires the surgeon to be familiar with the canalicu prevent any imbrication of eyelashes. A lack of knowledge of these orientation because scarring and contraction may structures should prompt a referral to an oculoplas develop within the eyelid margin as it heals. It is very unusual to have upper canalicular systems do not need to be Pmissing tissue from an eyelid laceration. As mentioned previously, however, evidence shows that both the upper and lower canalicular systems are needed to carry Complications 1 away tears. If eyelid margin revision is necessary due to either notching or trichiasis, a bloc of eyelid tissue may be taken, which includes the abnormal eyelid margin. The proper repair of an eyelid margin defect requires the full-thickness bloc excision of the corresponding tarsus. Pentagonal excisions of Peyelid margins must include the full height of the tarsus. Eyelid alopecia can develop when scarring and trauma destroy the eyelash follicles. Very often, even relatively trivial eyelid applicator stick, patience, and gentle retracting lacerations involve the canalicular system. The naso exposure will often reward the surgeon with a cut lacrimal system can be gently probed and/or irri canalicular edge. A few facts that are help be found, the eyelid should be closed without fur ful to remember are the following. A stent passed through the lar system laceration have been identified, stents nasolacrimal duct will enter the nose beneath the infe can be passed through the canalicular system to rior turbinate. To retrieve this stent, its entry into the bridge the laceration with tubing (Fig. The probes have a small bulb proximated, there is no reason for a suture to be at the end, which facilitates their removal from the placed in the cut edge of the canalicular system. Monocanalicular systems the stent will keep the canalicular system in good also exist for surgeons who are less familiar with the alignment and approximation. A bicanalicular intubation is preferred because it is less likely to become dislodged. The repair of eyelid canalicular lacerations begins with adequate patient preparation. The stent typically will tubing can be tied with five or six knots and fall out through the nasal vestibule, either immedi allowed to retract back into the nose. In chronic tearing, which may require a reexploration of no case should a potentially viable tissue be the eyelid or a conjunctivo-dacryocysto-rhinostomy discarded. Spontaneous early dislocation of the stent is a relatively frequent complication of bicanalic ular silicone intubation. During the initial evaluation of the patient with an avulsive injury, the tissues must be handled with care. When evaluation of the eyelid has been Ideally, the stent should remain in place for 2 completed, the avulsed tissue may be protected months. It is needs to be examined and, if possible, primarily often possible simply to rethread the silicone tubing repaired. In the area of the avulsion injury, not at back through the canalicular system with a pair of for the eyelid margin, 6-0 nylon sutures can be used to ceps. A 0-00 choice because postoperative swelling and wound Bowman probe can be used to force the tube back tension can be expected. The stent can be re As a rule, absorbing sutures should not be moved by cutting the loop of tubing in the palpebral used for this type of trauma repair. One sile strength of an absorbing suture is simply edge of the cut tubing can be grasped with the forceps not adequate for the postoperative swelling. The conjunctiva will be in good approximation if the levator and tar Traumatic ptosis is not an uncommon consequence of sus are correctly reapproximated. Ptosis may be seen both sutures will lead to corneal abrasion and pain (see with lid lacerations and with contusion injuries. If ptosis is present after this may result in a restrictive ptosis or lagophthal meticulous lid closure, the treatment of choice is mos. Leaving the septum open also allows easy egress of orbital hemorrhage and Pimproves spontaneously for up to 6 months after injury. Do not repair the orbital tory of the accident; special attention needs to be paid to the mechanism of injury. In these patients, an eyelid exploration with When avulsion injuries are accompanied by tissue release of any scarring and special attention directed loss, reconstructive surgery is more complicated. Initial procedures, such as a tarsorrhaphy, poor after reconstructive surgery, due to neuromus may protect the eyeball until definitive reconstructive cular damage. A variety of techniques for In trauma patients in whom the levator function is reconstructing missing eyelids is available. An oculo normal, dehiscence of the levator aponeurosis is fre plastic surgeon who has experience in eyelid trauma quently found. Swelling caused by the accident can or eyelid cancer surgery should be consulted in these easily lead to a levator aponeurosis disinsertion. The retroauricular area is the second choice of skin tion is the most accurate predictor of surgical success. This skin is easily obtainable, and the donor site is readily hidden behind the ear. The third option for obtaining skin for eyelid Pfunction often require more extensive pto reconstruction is from the supraclavicular area. This skin, however, is slightly thicker and the donor site is not as easily hidden.

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The clots can become dislodged from the leg and travel to spasms of pain from stones in the kidney generic voveran sr 100mg overnight delivery the heart and lungs spasms left shoulder blade purchase voveran sr 100 mg mastercard, where they can block blood? What to spasms from colonoscopy order 100mg voveran sr visa do Measure the circumference of the thickest part of the two calves with a tape measure at the same height: a difference of more than 2 cm is abnormal spasms leg buy generic voveran sr 100mg online. There are many causes of bronchitis, but the commonest are infections, asthma, and cigarette smoking. Bronchitis due to infection Most cases of bronchitis in otherwise healthy people are caused by viruses. The only common bacterial infection causing bronchitis is whooping cough (pertussis) (see Chapter 23, Infectious diseases). Signs and symptoms Coughing every day, producing small amounts of clear, colourless or pale-yellow sputum; if a common cold or other minor viral infection is present:? Bronchiectasis in adults often results from an episode of severe pneumonia in childhood and can also be due to the inherited disorder cystic? Signs and symptoms A chronic cough producing large amounts of white or pale-yellow sputum (usually more than half a teacup a day). Signs and symptoms A sharp stabbing pain on one side of the chest, made worse by breathing move ments or coughing:? It is usually caused by the bacterium Streptococcus pneumoniae, also called the pneumococcus. What to do Since empyema cannot be diagnosed with confidence on board ship and requires a surgical operation to drain the infected fluid, seek medical advice with a view to early evacuation. In some patients, bacterial infection leads to the formation of a collection of pus in the lungs (lung abscess). Aspiration pneumonia or lung abscess should be suspected if fever and cough develop in a patient after an alcoholic debauch or an epileptic? Distinguishing between simple aspiration pneumonia and lung abscess requires a chest X-ray, but the initial treatment is the same. Signs and symptoms Gradual onset, so that the patient often has difficulty knowing exactly when the i llness started. The larger sinuses in each cheek bone (maxillary sinuses) and in the forehead just over the eyes (frontal sinuses) are most commonly affected. Sinusitis can be due to viruses or bacteria but most cases with severe symptoms are due to bacteria. A diagnosis of sinusitis is highly likely in a patient with typical cold symptoms who continues to have nasal blockage and pain over a sinus seven to 10 days after the onset of the cold. Signs and symptoms Onset usually following a cold; blocked nose; pain and tenderness over the affected sinus; pain made worse by leaning forward; thick yellow discharge from the nose; fever; mainly headache, if the frontal sinus is affected; pain in the upper teeth, if the maxillary sinus is affected. What to do In mild cases, have the patient use a vasoconstrictor spray or drops (oxymetazoline, 0. In cooler climates the allergen is generally pollen, so symptoms are 144 International Medical Guide for Ships Respiratory diseases most troublesome in the spring. In warmer climates, moulds and perennial grasses are usually responsible, so symptoms can occur throughout most of the year. Attempting to avoid the allergen responsible for hay fever is usually impractical. Nasal congestion, the main symptom of hay fever, can lead to obstruction of the sinuses and bacterial or viral sinusitis (see above). This causes symptoms like wheezing (a whistling sound with each breath), cough, chest tightness, and dif? Signs and symptoms Coughing attacks, worse at night and after exercise, sometimes the only symptom; a feeling of tightness in the chest; wheezing; in severe cases, shortness of breath. What to do specifcally If the patient uses frequent doses of bronchodilator drugs, make sure that preventer? (or long-term control?) medication is also taken (this is usually a steroid, either inhaled or taken by mouth). Questions to ask the patient: How intense is the pain: slight, mild, moderate, or severe? Red fags in abdominal pain On board ship, the main aim in examining a patient is to determine whether or not the patient is seriously ill and needs evacuation. The swelling can block off the blood supply to the appendix, which dies (becomes necrotic) and bursts, leading to a life-threatening infection and inflammation of the peritoneum (peritonitis), the membrane that lines the wall of the abdomen. Note In a young man with the above symptoms, appendicitis is by far the most likely diagnosis. Pancreatitis can be acute (a single severe episode) or chronic (sustained but less intense in? What to do in a case of acute pancreatitis Seek medical advice with a view to evacuation. About 75% of cases are caused by adhesions scar tissue in the abdomen caused by surgery performed in the past. Bowel obstruction is dangerous because the gut swells and can become strangulated and then rupture, causing life-threatening infection of the abdominal cavity. The toxin causes nausea and vomiting within six hours of ingestion of the contaminated food. The bacteria are killed by cooking but the toxin is resistant to heat, so the contamination can occur either before or after cooking. Large amounts of food can be contaminated, and many people can be affected at once in enclosed communities, such as passengers and crew on a cruise ship who eat food served in a buffet. This bacterium produces a toxin that causes diarrhoea, but only after a large number of the bacteria have been ingested. Infection is, therefore, mainly associated with food kept at room temperature for a long time after cooking. This syndrome must be distinguished from dysentery (see below), in which the patient passes many small stools mixed with blood. People acquire infection by eating the food uncooked (including foods, such as mayonnaise, prepared with uncooked eggs) or under-cooked, or left to stand at room temperature after cooked food has been contaminated through contact with raw food residue. What to do in a case of foodborne illness If vomiting is the only or main symptom:? What to do to prevent foodborne illness Note that: nearly all raw food has some microorganisms on or in it: in many cases these are disease-causing organisms; adequate cooking destroys all disease-causing organisms; foodborne illness is, therefore, associated with:? To avoid foodborne illness on board: make sure all crew members, but especially food handlers, wash their hands often and meticulously; discourage consumption of raw or under-cooked food; insist that:? Dysentery Dysentery is an illness usually caused by bacteria of the Shigella group, although other bacteria can cause a similar illness and Shigella can cause an illness producing watery diarrhoea. Dysentery is spread by food or water contaminated with human faeces containing the Shigella organism. Only a few individual bacterial organisms are needed to cause disease, so that, unlike Salmonella, multiplication of the organism in food is not a causative factor and infection can be acquired from freshly prepared food. Signs and symptoms In most cases, about 10 (but sometimes many more) low-volume motions a day. Escherichia coli are the commonest bacterium found in the human colon and make up a substantial part of the weight of normal faeces, but not all Escherichia coli produce entero-toxin. Diarrhoea that begins more than a week after leaving a port is probably due to infection on board. Signs and symptoms Diarrhoea, with usually large, watery motions, but rarely more than six per day; loss of appetite; 158 International Medical Guide for Ships Gastrointestinal and liver diseases nausea; vomiting in moderate and severe cases; abdominal cramps in moderate and severe cases; fever only in severe cases. Signs and symptoms Onset a few hours after eating an affected fish; initially, vomiting and diarrhoea; soon afterwards, abnormal sensation (burning, pins-and-needles?) in the limbs and blurred vision lasting for a few weeks or, in a few cases, for months. The histamine, which is not destroyed by cooking, may cause symptoms that can be mistaken for a Signs and symptoms Onset within an hour of eating the fish; sudden flushing of the face, a feeling of warmth, and a blotchy rash on the chest and face; disappearance of symptoms within a few hours. What to do to prevent scombroid poisoning Refrigerate fish carefully: scombroid can be caused by canned tuna not refrigerated after opening. A third form of infectious colitis can follow a course of antibiotics, whatever the reason for the antibiotic use. It usually occurs in elderly individuals suffering from extensive coronary artery and cerebrovascular disease and will not be considered here. Most patients have a history of symptoms going back months or a few years, with one or more similar episodes that have come and gone without treatment. In a few patients ulcerative colitis begins as a sudden severe illness and these cases can easily be confused with infectious diarrhoea.

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Ocular instability is usual at birth muscle relaxant and painkiller voveran sr 100mg on line, due to muscle relaxant lorazepam generic voveran sr 100 mg without prescription poor visual fixation muscle relaxant drugs specifically relieve muscle order voveran sr 100mg without prescription, but this abates during the first few weeks of life infantile spasms 8 month old order voveran sr 100 mg with mastercard. Congenital impairment of vision or visual deprivation due to lesions in any part of the eye or optic nerve can result in nystagmus at birth or soon thereafter. Causes include corneal opacity, cataract, albinism, achromatopsia, bilateral macular disease, aniridia, and optic atrophy. By definition, congenital idiopathic motor nystagmus has no associated underlying sensory abnormality, although visual performance is limited by the ocular instability. Typically it is not present at birth but becomes apparent between 3 and 6 months of age. At one time it was thought that congenital pendular nystagmus was indicative of an underlying sensory abnormality whereas congenital jerk nystagmus was not. Eye movement recordings have shown this not to be true, with both 691 pendular and jerk waveforms being seen whether or not there is a sensory abnormality. Indeed, in many cases, a mixed pattern of alternating pendular and jerk waveforms is seen. Congenital nystagmus, particularly the idiopathic motor type with its potential for better visual fixation, generally undergoes a progressive change in its waveform during early childhood. There is development of periods of relative ocular stability, that is, relatively slow eye velocity, known as foveation periods since they are thought to be an adaptive response to maximize the potential for fixation, and hence to improve visual acuity. In addition, congenital nystagmus with a jerk nystagmus has a characteristic waveform in which the slow phases have an exponentially increasing velocity. This can be a particularly useful feature in determining that nystagmus noted in adulthood is not of recent onset. The direction of any jerk component often varies with the direction of gaze, but an important feature in comparison to many forms of acquired nystagmus is that there is no additional vertical component on vertical gaze. In most patients with congenital nystagmus, there is a direction of gaze (null zone) in which the nystagmus is relatively quiet. If this null zone is away from primary position, a head turn may be adopted to place the eccentric position straight ahead. In a few cases, the position of the null zone varies to produce the congenital type of periodic alternating nystagmus. Congenital nystagmus is usually decreased in intensity by convergence, and some patients will adopt an esotropia (nystagmus blockage). Anxiety and increased effort to see? will often increase the intensity of congenital nystagmus and thus reduce visual acuity. Once congenital nystagmus has been noted, it is important to identify any underlying sensory abnormality, if only to determine the visual potential. Extraocular muscle surgery is predominantly indicated for patients with a marked head turn. Supramaximal recessions of the horizontal rectus muscles reduce the intensity of congenital nystagmus, but the effect is only temporary. Nystagmus with a latent component means that it increases in intensity when one eye is covered, which is a characteristic feature of congenital nystagmus. This may be because of loss of sight in one eye or even from the development of a divergent squint. Acquired Pendular Nystagmus Any child who develops bilateral visual loss before 6 years of age may also develop a pendular nystagmus, and indeed the acquisition of a pendular nystagmus during infancy necessitates further investigation. A specific syndrome of acquired pendular nystagmus in childhood is spasmus nutans. This is a bilateral, generally horizontal (occasionally vertical), fine, dissociated pendular nystagmus, associated with head nodding and an abnormal head posture. There is a benign form, which may be familial, with onset before age 2 and spontaneous improvement during the third or fourth year. Spasmus nutans may also rarely be the first manifestation of an anterior visual pathway glioma. In adults, acquired pendular nystagmus is a feature of brainstem disease, usually multiple sclerosis or brainstem stroke. There may be horizontal, vertical, or torsional components or even a combination of components to produce oblique or elliptical trajectories. The syndrome of oculopalatal myoclonus characteristically develops several months after a brainstem stroke. There is pendular nystagmus with synchronous movements variably involving the soft palate, larynx, and diaphragm as well as producing head titubation. Various drug treatments have been tried for adult acquired pendular nystagmus, of which gabapentin, memantine, and baclofen have produced the best, although still limited, results. Vestibular Nystagmus Abnormalities of vestibular tone result in abnormal activation of the vestibulo ocular pathways and abnormal neural drive to the extraocular muscles. Loss of function in the left horizontal semicircular canal is equivalent to activation of the right horizontal semicircular canal, as would normally be produced by a rightward head turn. The corrective fast-phase response is rightward in direction, and a right-beating horizontal nystagmus is thus generated. The pattern of response to dysfunction of one or more semicircular canals can be similarly derived to give the full possible range of peripheral vestibular nystagmus, although in clinical practice, it is the effect of dysfunction of the horizontal canals that usually predominates. As a general rule, peripheral vestibular lesions are destructive, and the fast phase of the resulting nystagmus is away from the side of the lesion. Since the neural signal of the vestibulo-ocular pathways is a velocity signal, the slow phase of peripheral vestibular nystagmus has a constant velocity. This gives rise to the characteristic saw-tooth waveform on eye movement recordings. Peripheral vestibular nystagmus is not dependent on visual stimuli and thus is still present in the dark or with the eyes closed, as well as in blind individuals. It is, however, inhibited by visual fixation or, conversely, accentuated by wearing Frenzel spectacles, and this is an important factor in the normal dampening over 2?3 weeks of peripheral vestibular nystagmus. Head position does not usually influence peripheral vestibular nystagmus except in benign paroxysmal positional vertigo, in which elicitation of the characteristic pattern of nystagmus with the Hallpike maneuver is a specific diagnostic feature. Other clinical features associated with peripheral vestibular disease are vertigo, tinnitus, and deafness, the latter two reflecting the close association between the vestibular and auditory systems. Central vestibular nystagmus is an acquired jerk nystagmus due to disease in the central vestibular pathways of the brainstem and cerebellum. It has a variety of forms, but characteristic types are a purely torsional or vertical jerk nystagmus and the syndromes of downbeat and upbeat nystagmus, which result from imbalance in vestibular tone from the vertical semicircular canals. Central vestibular nystagmus is frequently elicited or enhanced by specific head positions, presumably as a result of modulation by input from the peripheral 694 vestibular apparatus. It is not dampened by visual fixation and does not spontaneously abate in intensity with time. Other clinical features reflect the associated brainstem and cerebellar dysfunction and include abnormalities of smooth pursuit eye movements other than those due to the nystagmus itself. Downbeat nystagmus is a downward-beating nystagmus, usually present in primary position. It is often most obvious on gaze down and to the side, when the nystagmus becomes oblique, with the horizontal component in the direction of lateral gaze. Other causes are cerebellar degeneration, demyelinating disease, hydrocephalus, anticonvulsants, and lithium. Upbeat nystagmus is characterized by an upward-beating nystagmus in primary position, which usually increases, although it may reduce in intensity on upgaze. It is virtually always the result of brainstem disease but occasionally reflects cerebellar disease. It is seen in brainstem encephalitis, demyelination, and tumor and also as a toxic side effect of barbiturates, alcohol, and anticonvulsants. Gaze-Evoked & Gaze-Paretic Nystagmus Maintenance of steady eccentric gaze is dependent on the neural integrator system, which produces the tonic extraocular muscle activity necessary to overcome the viscous and elastic orbital forces acting to return the globe to primary position. Reduction in activity of the neural integrator results in eccentric gaze being negated by a slow drift of the globe toward primary position. Since the force acting to produce this central drift reduces with decreasing eccentricity, this slow drift has an exponentially decreasing velocity. Additional corrective fast eye movements, returning the eye to the desired eccentric position, result in nystagmus beating in the direction of gaze, whether it is horizontal, vertical, or oblique.

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Which one of the following is the best assessment been experiencing a stressful work environment lately of B back spasms 34 weeks pregnant voveran sr 100 mg low price. Which one one of the following risk categories is he most of the following is best to xanax muscle relaxant qualities cheap 100 mg voveran sr overnight delivery recommend for F muscle relaxant blood pressure generic voveran sr 100 mg without prescription. Which one of the following is the best treatment smoking cessation for preventing peptic ulcer strategy for B spasms 1983 imdb generic 100mg voveran sr overnight delivery. Which one of the following is the most appropri morning, she has developed bacteremia requiring ate initial management of J. Endoscopic sclerotherapy and vasopressin an episode of cardiac arrest with successful resus continuous infusion. Which one of the following is the most appropri is in place, and she is being fed enterally. She is tol ate approach to secondary prevention of esopha erating the tube feedings well without residuals geal hemorrhage for J. Transjugular intrahepatic portosystemic mg once daily at bedtime, and subcutaneous hepa shunts. Intermitent endoscopic variceal ligation and includes atrial fbrillation, hyperlipidemia, and ero propranolol 20 mg twice daily. Esomeprazole 20 mg intravenously every 24 ents to the emergency department of a tertiary care hours. Dexlansoprazole 60 mg once daily by nasogas is signifcant only for hypertension, for which he is tric tube. He is admited to the following is the most appropriate initial man the hospital with abdominal pain, nausea, hematemesis, agement of this patient? Pre-endoscopic intravenous pantoprazole con times/day, furosemide 40 mg once daily, spironolactone tinuous infusion. Pantoprazole 8-mg/hour intravenous continu metoprolol 25 mg twice daily, lisinopril 10 mg once ous infusion. Endoscopy reveals a 2-cm gastric ulcer with nonbleeding visible vessel; the biopsy results are 16. Which one of the following is the best medi cal management of the acute bleeding in N. Subcutaneous octreotide 100-mcg injection Questions 17 and 18 pertain to the following case. Intravenous pantoprazole 40 mg twice-daily department by his wife, who says he passed out in the bath intermitent infusion. Which one of the following is the best history includes atrial fbrillation, hypercholesterolemia, recommendation for N. Both naproxen and aspirin should be discon include lisinopril 10 mg once daily, amlodipine 10 mg/ tinued until bleeding has ceased and ulcers day, omeprazole 20 mg/day, simvastatin 20 mg/day at bed have healed. Reinitiate aspirin as soon as possible and ini mg twice daily, metoprolol 50 mg twice daily, naproxen tiate combination therapy with a lansoprazole 500 mg twice daily, warfarin 2. Discontinue naproxen and aspirin; initiate ibu daily without adequate relief of arthritic pain. Omeprazole 20 mg twice daily, amoxicillin nifcantly reduces mortality compared with 1000 mg twice daily, and clarithromycin 500 histamine-2 receptor antagonists. Pantoprazole 40 mg twice daily, amoxicillin nifcantly reduces further bleeding compared 1000 mg twice daily, and clarithromycin 500 with histamine-2 receptor antagonists. Esomeprazole 40 mg twice daily, metronidazole nifcantly reduces further bleeding compared 500 mg twice daily, and clarithromycin 500 mg with placebo. Omeprazole 20 mg twice daily, bismuth subsalicy nifcantly reduces mortality compared with late 262. She has a medical history of rheumatoid osteoarthritis, hypertension, hyperlipidemia, and myocardial infarc tion. Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 2 Welcome Welcome to the Cirrhosis Management Program at the University of Michigan. As your healthcare team, we take pride in doing everything possible to maximize your health. You, the patient, can make an enormous difference in your health by eating right, taking your medications properly, and taking control of your disease management. To schedule an appointment, call: 888-229-7408 To speak with a nurse, call: 800-395-6431 What is the liver? Storing vitamins, minerals, fats, and sugars for use by the body Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 3 What is liver cirrhosis? When something attacks and damages the liver, liver cells are killed and scar tissue is formed. This scarring process is called fibrosis (pronounced fi-bro-sis?), and it happens slowly over many years. Any illness that affects the liver over a long period of time may lead to fibrosis and, eventually, cirrhosis. Heavy drinking and viruses (like hepatitis C or B) are common causes of cirrhosis. Cirrhosis may be caused by a buildup of fat in the liver of people who are overweight or have diabetes. This prevents blood from flowing through the liver easily and causes the build-up of pressure in the portal vein, the vein that brings blood to the liver. To relieve this pressure, the blood goes around the portal vein, through other veins. Some of these veins, called varices, can be found in the pipe that carries food from your mouth to your stomach (the esophagus) or in your stomach itself. Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 4 Portal hypertension also causes blood to back up into another organ called the spleen. With cirrhosis, blood is blocked from entering the liver and toxic substances that the liver normally filters escapes into general blood circulation. Aside from the problems with liver blood flow, when cirrhosis is advanced, there aren?t enough healthy liver cells to make good substances, such as albumin (a protein) and clotting factors that the liver normally makes. This cancer can occur if some of the sick liver cells start to multiply out of control. There may be no signs of liver cancer until the cancer has grown very large and causes pain. In fact, a person may live many years with cirrhosis without being aware that her liver is scarred. But if nothing is done about the cause of cirrhosis (for example, if the person continues to drink alcohol, or if hepatitis or other causes of cirrhosis are not treated), the pressure in the portal vein gets higher and the few remaining healthy liver cells are not able to do all the work for the entire liver. At that point, you may notice symptoms like low energy, poor appetite, weight loss, or loss of muscle mass. As the disease progresses symptoms become more severe and may be life threatening. At this stage you can also develop the following Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 5 serious problems:? Jaundice yellowing of the eyes and skin, Sometimes, if the damaging agent (such as alcohol) is removed, the liver can slowly heal. Other times, the only way to cure cirrhosis is to replace the sick liver with a healthy liver this is called liver transplantation. Backup of blood from the scarred liver may cause the veins in the wall of the esophagus to enlarge. The pressure inside the enlarged veins, called esophageal varices, is higher than normal. The increased pressure can cause the Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 6 veins to burst, leading to sudden and severe bleeding. Signs of bleeding varices include vomiting of large amounts of fresh blood or clots. People who have signs of bleeding varices should go to an emergency room immediately. If you vomit blood or your stool turns black and tarry, you must Unless the varices break and go to the emergency room bleed, patients have no symptoms immediately.


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