Internal Medicine potx

Callen, MD, FACP Professor of Medicine Dermatology Chief, Division of Dermatology University of Louisville School of Medicine Associate Chief of Staff for Research and Development VA Pal

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Internal medicine / [edited by] Bruce F Scharschmidt.

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ISBN-13: 978-0-521-70940-8 (pbk.)

ISBN-10: 0-521-70940-7 (pbk.)

1 Internal medicine – Handbooks, manuals, etc I Scharschmidt,

Bruce II Title.

[DNLM: 1 Internal Medicine – Handbooks WB 39 I5985 2007]

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ii

University of California, San Francisco

Associate Chief of Medicine for Research and Staff Cardiologist

VA Medical Center, San Francisco

dermatology

Jeffrey P Callen, MD, FACP

Professor of Medicine (Dermatology)

Chief, Division of Dermatology

University of Louisville School of Medicine

Associate Chief of Staff for Research and Development

VA Palo Alto Health Care System

Palo Alto, California

Professor of Medicine

Chief, Division of Endocrinology, Gerontology and Metabolism

Stanford University School of Medicine

Stanford, California

iii

Co-Director, Liver Transplant Program

Stanford University Medical Center

Stanford, California

head, eye, ear, nose and throat

Devron H Char, MD

President, Tumori Foundation

Clinical Professor, Department of Ophthalmology

Stanford University School of Medicine

Stanford, California

hematology

Edward J Benz, Jr., MD

Richard and Susan Smith Professor of Medicine

Harvard Medical School

Medical Director, San Francisco City Clinic

San Francisco Department of Public Health

Assistant Clinical Professor of Medicine

School of Medicine

University of California, San Francisco

kidney and urologic disease

Robert J Alpern, MD

Ensign Professor of Medicine

Dean, Yale School of Medicine

Yale University

New Haven, Connecticut

Affiliations v

Biff F Palmer, MD

Professor of Internal Medicine

Director of Renal Fellowship Program

Director, Fellowship Program in Pulmonary and Critical Care Medicine

Associate Director, Adult Pulmonary Laboratory

Senior Investigator, Cardiovascular Research Institute

School of Medicine

University of California, San Francisco

rheumatology, allergy and immunology

Shaun Ruddy, MD

Elam C Toone Professor Emeritus

Department of Internal Medicine

Medical College of Virginia

VCU Health Systems

Richmond, Virginia

vi

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vii

viii

Abdominal Aortic Aneurysm (AAA) 1

Abscesses and Fistulas 5

Acanthosis Nigricans 7

Acne 9

Acromegaly 12

Actinic Keratosis 15

Acute Acalculous Cholecystitis 16

Acute Bacterial Meningitis 18

Acute Fatty Liver of Pregnancy 21

Acute Heart Failure 23

Acute Lymphoblastic Leukemia 29

Acute Myeloblastic Leukemia 37

Acute Myocarditides 41

Acute Pancreatitis 45

Acute Pericarditis 48

Acute Renal Failure 50

Acute Respiratory Acidosis 55

Acute Respiratory Alkalosis 56

Acute Respiratory Failure/Monitoring 58

Adenocarcinoma of the Ampulla of Vater 62

Adenovirus 63

Adrenal Insufficiency 66

Adrenal Tumors 70

Adult Optic Neuropathies 74

Age Related Maculopathy 80

ix

x Contents

Air Embolus 83

Alcohol Abuse, Dependence, and Withdrawal 85

Alcoholic Liver Disease (ALD) 89

Allergic Rhinitis 93

Alopecia 96

Alpha-1-Antitrypsin 100

Alzheimer’s Disease 101

Amaurosis Fugax 103

Amblyopia 104

Amebiasis 106

Amebic Liver Abscess 109

Amyloidosis 111

Amyotrophic Lateral Sclerosis (ALS) 115

Analgesic Nephropathy And NSAID-induced ARF 117

Anaphylaxis 120

Anemias Secondary to Systemic Disease 122

Anisakiasis 125

Anorectal Tumors 126

Anorexia Nervosa 129

Antibiotic-Associated and Pseudomembranous Colitis 133

Antiphospholipid Antibodies 135

Aortic Coarctation 138

Aortic Dissection 140

Aortic Insufficiency (AI) 143

Aortitis 146

Aphasia 149

Aplastic Anemia 150

Apparent Mineralocorticoid Excess 153

Appendicitis 153

Arterial Embolus 156

Ascariasis 160

Ascites 162

Contents xi

Aspergillosis 166

Asthma 171

Atelectasis 176

Atherosclerotic Occlusive Disease 179

Atopic Dermatitis 187

Atrial Fibrillation (AF) 188

Atrial Flutter 191

Atrial Premature Complexes 194

Atrial Septal Defect (ASD) 195

Atrial Tachycardia (AT) 197

Atrioventricular Block 198

Autoimmune Hepatitis (AIH) 201

Autonomic Dysfunction 204

Autosomal Dominant Polycystic Renal Disease 206

Autosomal Recessive Polycystic Renal Disease 208

AV Reentrant Tachycardia (AVRT) 209

AV-Nodal Reentrant Tachycardia (AVNRT) 211

Back or Neck Pain 213

Bacterial Arthritis 214

Bacterial Pneumonia 218

Balanitis 220

Bartter’s Syndrome 223

Bell’s Palsy 224

Benign Disorders of the Rectum and Anus 225

Benign Prostatic Hyperplasia 228

Benign Tumors of the Liver 232

Biliary Tract Motility Disorders 235

Biotin Deficiency 238

Bladder Tumors 239

Blastocystis Hominis Infection 242

Blastomyces Dermatitidis 243

Blepharitis 246

xii Contents

Brain Abscess 248

Brain Death 249

Bronchiectasis 250

Bronchiolitis 253

Bronchitis, Acute 257

Budd-Chiari Syndrome 259

Buerger’s Disease 261

Bulimia Nervosa 263

Bullous Pemphigoid 266

Candidiasis 270

Candidiasis: Oral 272

Carcinoid 273

Cardiac Arrest 277

Cardiac Trauma 280

Cardiac Tumors 281

Cat Scratch Disease 286

Cecal Volvulus 288

Celiac Sprue and Malabsorption 289

Cellulitis 292

Cerebrovascular Disease & Stroke 294

Cervical Spine Disorders 297

Chediak Higashi Syndrome 298

Cheilitis 299

Cholangiocarcinoma 299

Choledochal Cysts 302

Cholestasis 305

Cholestasis of Pregnancy 308

Chordae Tendineae Rupture 309

Chromium Deficiency 310

Chronic Acalculous Cholecystitis 311

Chronic Bundle Branch Block and Hemi-blocks 312

Chronic Coronary Artery Disease (CAD) 314

Contents xiii

Chronic Granulomatous Disease 317

Chronic Heart Failure 318

Chronic Kidney Disease 327

Chronic Lymphocytic Leukemia 333

Chronic Myelogenous Leukemia 336

Chronic Obstructive Pulmonary Disease 340

Chronic Pancreatitis 343

Chronic Renal Failure 346

Chronic Respiratory Acidosis 351

Chronic Respiratory Alkalosis 352

Chronic Respiratory Failure 353

Churg Strauss Disease 357

Clostridium Infections 360

Cluster Headache 362

Coccidioides Immitis 363

Colon Polyps and Tumors 367

Coma 370

Complications of Human Immunodeficiency Virus Type 1 (HIV-1) Infection 371

Condyloma Acuminata 388

Confusion & Delirium 389

Congenital Qualitative Platelet Disorders 390

Conjunctival Tumors 393

Constipation and Fecal Impaction 394

Constrictive Pericarditis 397

Contact Dermatitis 398

Contraception for the Internist 399

Corneal Ulcer 403

Coronary Artery Injury 406

Coronary Syndromes, Acute 407

Coronavirus/Common Cold 413

Cough 414

xiv Contents

Crigler-Najjer Syndrome Type 1 417

Crigler-Najjer Type 2 419

Crohn’s Disease 420

Croup 424

Cryptococcus Neoformans 426

Cryptosporidiosis 430

Crystal-Induced Arthritis 432

Cushing’s Syndrome 435

Cutaneous Larva Migrans 439

Cutaneous Lupus Erythematosus (LE) 441

Cutaneous Vasculitis 444

Cyclosporiasis 447

Cyst of Tunica Albuginea of Testis 449

Cystic Fibrosis 449

Cystic Fibrosis 452

Cysticercosis 455

Cystinuria 458

Cystitis and Pyelonephritis 458

Cytomegalovirus 461

Deep Venous Thrombosis 463

Dementia 467

Dent’s Disease 468

Dermatofibroma 469

Diabetes Insipidus 470

Diabetes Mellitus, Type 1 472

Treatment Goals 474

Diabetes Mellitus, Type 2 475

Diabetic Retinopathy 479

Diarrhea 482

Dientamoeba Fragilis Infection 485

Diphtheria 487

Disorders of Neutrophil Function 489

Contents xv

Disseminated Intravascular Coagulation, Thrombotic

Thrombocytopenic Purpura, Hemolytic Uremic Syndrome

(DIC/TTP/HUS) 490

Diverticulitis and Diverticular Disease 494

Drug Allergy 497

Drug and Toxin-induced Liver Diseases 500

Drug Eruptions 503

Dubin-Johnson Syndrome 508

Dyspepsia 509

Dysphagia 512

Dyspnea 514

Echinococcosis 517

Ehlers-Danlos Syndrome 520

Encephalitis 522

Enteral and Parenteral Nutrition 524

Enterobiasis (Pinworm) 530

Enteroviruses 532

Epididymitis and Orchitis 535

Epilepsies 536

Episcleritis and Scleritis 537

Erectile Dysfunction 539

Erysipelas and Cellulitis 543

Erythema Multiforme Major; Aka Stevens Johnson Syndrome (see also Drug Eruptions) 545

Erythema Nodosum 548

Esophageal Cancer 550

Esophageal Infections and Inflammation 551

Esophageal Motor Disorders 556

Essential Tremor 559

Excessive Daytime Sleepiness 560

Exfoliative Dermatitis 561

Eyelid Lesions 562

Fanconi Syndrome 563

xvi Contents

Fever of Unknown Origin 564

Fibromas 568

Fibromyalgia 568

Filariasis 571

Folic Acid/Cobalamin (Vitamin B12) Deficiency 575

Folliculitis and Furunculosis 580

Food Allergies 582

Food Poisoning 586

Foreign Bodies and Bezoars 589

Fulminant Hepatic Failure 592

Galactosemia 596

Gallbladder Cancers 599

Gallstone Disease 600

Gastric Adenocarcinoma 604

Gastric Carcinoids 605

Gastric Lymphoma 606

Gastric Stromal Tumor 607

Gastroenteritis 608

Gastroesophageal Reflux Disease 610

Gastrointestinal Bleeding 613

Gastropathy 617

Geographic Tongue 621

Giant Cell Arteritis 622

Giardiasis 623

Gilbert’s Syndrome 625

Gitelman’s Syndrome 626

Glaucoma 626

Glomerular Diseases 630

Glucocorticoid-Remediable Aldosteronism 634

Glycogen Storage Disease 635

Goiter 638

Gonorrhea 640

Contents xvii

Gordon Syndrome (Pseudohypoaldosteronism Type 2) 644

Granuloma Annulare 645

Granulomatous Liver Disease 646

Granulomatous Vasculitis 647

Haemophilus Infections 651

Hairy Cell Leukemia 653

Hantavirus Pulmonary Syndrome 654

Hartnup’s Disease 656

Head and Neck Cancer 657

Head Trauma 662

Hearing Loss 663

Helicobacter Pylori 665

Hemiballismus 669

Hemochromatosis 670

Hemophilia A and B 673

Hepatic Encephalopathy 677

Hepatic Veno-occlusive Disease 680

Hepatitis A and E 682

Hepatitis B 685

Hepatitis C 688

Hepatitis Delta Virus 693

Hepatorenal Syndrome 694

Hereditary Elliptocytosis (HE) and Hereditary Pyropoikilocytosis (HPP) 696

Hereditary Spherocytosis 698

Hernia 700

Herpes Labialis 701

Herpes Simplex 702

Herpes Type 1/Type 2 703

Herpes Zoster 707

Hidradenitis Suppurativa 708

High-Oxygen-Affinity Hemoglobins 710

xviii Contents

Hirsutism (Dermatology) 711

Hirsutism (Endocrinology) 714

Histoplasma Capsulatum 718

Homocystinuria 722

Hookworm 725

Horner’s Syndrome 727

Human Herpes 6 728

Human Immunodeficiency Virus Type 1 (HIV-1) 729

Huntington’s Disease 735

Hydatid Cyst Disease 736

Hydrocele 738

Hypercalcemia 738

Hypercholesterolemia 742

Hyperemesis Gravidarum 746

Hyperkalemia 747

Hypermagnesemia 750

Hypernatremia 751

Hyperoxaluria 754

Hyperphosphatemia 757

Hypersensitive Carotid Syndrome and Syncope 759

Hypertension 760

Hyperthermia 767

Hyperthyroidism 770

Hypertriglyceridemia 773

Hypocalcemia 777

Hypoglycemia 780

Hypogonadism in Men 783

Hypokalemia 786

Hypomagnesemia 789

Hyponatremia 791

Hypophosphatemia 794

Hypopituitarism 796

Contents xix

Hypothermia 799

Hypothyroidism 802

Ichthyosis 804

Idiopathic (Immune) Thrombocytopenic Purpura (ITP) 808

Immune Hemolytic Anemia 810

Immunodeficiency Disorders, Congenital 818

Impetigo 822

Infectious Diarrheas 825

Infective Endocarditis 829

Influenza 833

Influenza, Avian 834

Inguinofemoral Hernia 836

Inner Ear Disorders Producing Vertigo 837

Insomnia 840

Interstitial Lung Diseases 841

Intertrigo 845

Intervertebral Disc Disease 847

Intestinal Flukes 848

Intestinal Motor Disorders 850

Intracranial Hypertension 853

Intracranial Hypotension 854

Intraocular Infection 855

Intraocular Tumors 859

Intravascular, Non-immune Hemolytic Anemia – Microangiopathic Hemolytic Anemias 860

Iron Deficiency 866

Irritable Bowel Syndrome 870

Ischemic Bowel Disease 874

Isosporiasis 877

Jaw Swelling and Masses 878

Keloids 882

Laceration or Myocardial Perforation 883

xx Contents

Laryngotracheitis 884

Laxative Abuse 885

Legionella Infections 887

Leishmaniasis, Cutaneous 889

Leishmaniasis, Visceral 891

Leptospirosis, Relapsing Fever and Rat-bite Fever 893

Leukocytosis: Neutrophil 896

Leukopenia 900

Leukoplakia 904

Lichen Planus 905

Liddle’s Syndrome 907

Liver Fluke Infections 907

Liver Flukes 909

Liver Transplantation 911

Localized Scleroderma 915

Low-Oxygen-Affinity Hemoglobins 917

Lung Abscess 918

Lung Cancer 921

Lung Fluke 925

Lyme Disease 927

Lymphadenitis and Lymphangitis 930

Lymphomas 932

Lysosomal Diseases 937

Magnesium Deficiency 940

Malaria 942

Malignant Tumors of The Liver 947

Marasmus 949

Marfan’s Syndrome 952

Measles 954

Mediastinal Masses 957

Megacolon 960

Melanoma 964

Multifocal Atrial Tachycardia (MAT) 1007

Multiple Endocrine Neoplasia 1 1008

Multiple Endocrine Neoplasia 2 1012

xxii Contents

Nevi and Pigmented Lesions 1047

Niacin Deficiency 1050

Nocardiosis 1051

Nonalcoholic Fatty Liver Disease 1053

Nongranulomatous Systemic Vasculitis 1056

Nonmelanoma Skin Cancers: Basal Cell Carcinoma 1060

Nonmelanoma Skin Cancers: Squamous Cell Carcinoma 1063

Non-steroidal Anti-Inflammatory Drugs 1066

Nontuberculous Mycobacterial Infections 1069

Obesity 1071

Obstructive Sleep Apnea 1075

Occupational Pulmonary Disease 1078

Onychomycosis – Tinea Unguium 1083

Pelvic Inflammatory Disease 1145

Pemphigus Vulgaris and Pemphigus Foliaceus 1149

Peptic Ulcer Disease 1151

Portal Hypertensive Bleeding 1195

Postconcussion Syndrome or Postconcussive Syndrome 1198

xxiv Contents

Preeclamptic Liver Disease/HELLP 1199

Pregnancy Complications for the Internist 1201

Pressure Ulcers 1204

Priapism 1205

Primary Biliary Cirrhosis 1209

Primary Hyperparathyroidism 1211

Primary Sclerosing Cholangitis 1214

Prion Disorders (Creutzfeldt-Jakob Disease) 1217

Prolactinoma and Galactorrhea 1219

Pulmonary Valve Insufficiency (PI) 1250

Purine and Pyrimidine Metabolic Disorders 1252

Recurrent Aphthous Stomatitis 1269

Red Cell Enzymes 1270

Refractive Disorders (Ametropias) 1272

Renal Artery Stenosis 1277

Renal Vein Thrombosis 1292

Repaired Congenital Heart Disease 1294

Restless Legs Syndrome 1295

Rhegmatogenous Retinal Detachment 1296

Severe Acute Respiratory Syndrome 1333

Sex Differentiation Disorders 1335

Shock 1339

Short Bowel Syndrome 1343

Sickle Cell Syndromes 1345

Sigmoid Volvulus 1348

Sinoatrial Block 1349

Contents xxvii

Tinea Cruris/Corporis/Pedis 1431

Torsion of Appendix Testis 1433

Torsion Of Testis And Spermatic Cord 1434

Tricuspid Valve Insufficiency (TR) 1448

Tricuspid Valve Stenosis (TS) 1450

Trousseau Syndrome 1452

Trypanosomiasis, African 1454

Trypanosomiasis, American (Chagas’ Disease) 1457

Tuberculosis 1459

Tubulointerstitial Renal Disease 1462

Tumors of Paratesticular and Spermatic Cord Structures 1470

Urticaria and Angioedema (Dermatology) 1495

Urticaria and Angioedema (Rheumatology) 1498

Uveitis 1502

Vaginitis 1506

Valvular Heart Disease Aortic Stenosis (AS) 1510

Valvular Injury 1513

xxviii Contents

Varicella-Zoster 1514

Varicocele 1516

Varicose Veins 1517

Vascular Disease of Spinal Cord 1519

Ventilator Management in the ICU 1520

Ventricular Fibrillation (VF) and Sudden Death 1524

Ventricular Premature Complexes 1526

Ventricular Septal Defect (VSD) 1527

Volume Depletion and Edema 1542

Von Willebrand Disease 1546

Internal Medicine is designed to provide the busy clinician

with precisely the information needed where and when it is

needed The Associate Editors and contributors are

interna-tionally recognized authorities, and they have organized the

content specifically so as to convey the essentials necessary for

diagnosis, differential diagnosis, management, treatment and

follow-up Many topics start with a “What To Do First”

head-ing which brhead-ings the collective experience and guidance of top

experts to bear on the “up front” considerations the clinician

must face We are excited about Internal Medicine and hope

you share our view that it is an essential resource, particularly

in our current era of shortened physician-patient encounters

and the need for rapid clinical decision-making.

Bruce F Scharschmidt

xxix

xxx

ABDOMINAL AORTIC ANEURYSM (AAA)

RAJABRATA SARKAR, MD

history & physical

■ Male:female ratio is 4:1

■ 5–10% of males over 65 years of age have AAA

■ High incidence in patients with peripheral arterial aneurysm

(popliteal, femoral)

■ Ruptured AAA – clinical suspicion

➣ elderly male with severe back or abdominal pain

➣ may radiate to groin

Signs & Symptoms

■ Most are asymptomatic and found on other imaging studies

■ pulsatile abdominal mass in less than 30% of patients with significant

AAA

■ Tender abdominal mass is suggestive of symptomatic aneurysm

■ examine for associated peripheral aneurysms (femoral, popliteal)

■ Unusual presentations:

➣ atheroembolism to lower extremities

➣ thrombosis (sudden severe ischemia of legs)

➣ high output CHF from aortocaval fistula

➣ GI bleeding from primary aorto-enteric fistula

■ Ruptured AAA

➣ Pulsatile mass+ hypotension

➣ abdominal/back/groin pain+ hypotension

tests

Laboratory

■ None

Imaging

■ Ultrasound for screening

■ CT scan is best test for aneurysms being considered for repair

■ Defines : associated iliac aneurysms, eligibility for endovascular

repair, possible suprarenal extension

■ Conventional MRI has no advantage over CT for AAA

■ Angiography is not used for diagnosis (can miss AAA due to normal

lumen)

1

2 Abdominal Aortic Aneurysm (AAA)

■ Angiography (contrast or MR) indicated preoperatively in patients

with:

➣ clinical suspicion of concurrent renal artery stenosis (severe

hypertension, elevated creatinine)

➣ mesenteric occlusive disease (post-prandial pain)

➣ significant lower extremity occlusive disease (claudication+ ankle/

brachial index<0.7)

■ Ruptured AAA: if diagnosis is unclear (no mass):

➣ Emergency ultrasound

r helpful only if aorta is clearly seen and completely normal

r often not helpful due to bowel gas and patient discomfort

r cannot rule out a leak from AAA

➣ CT scan

r Best test when diagnosis of AAA is unclear

r Emergency non-contrast scan of abdomen

r Intravenous contrast increases post-op renal failure and is notneeded to see AAA or leak

r Oral contrast not required

differential diagnosis

Ruptured AAA

■ most common misdiagnosis is kidney stone

■ second most common is musculoskeletal back pain; high suspicion

of AAA with new onset or change in chronic back pain

■ other:

➣ appendicitis (associated GI symptoms)

➣ diverticulitis (fevers, GI symptoms, focal left sided tenderness)

➣ aortic dissection (ripping pain, extends into chest and upper

■ Emergent (immediate) operation in patients with abdominal pain

and hypotension due to ruptured AAA

■ Emergent non-contrast CT scan in patients with symptoms

sugges-tive of ruptured AAA

General Measures

■ Rule out ruptured AAA first in all patients with suggestive symptoms,

as it is the most rapidly lethal diagnosis if missed

Abdominal Aortic Aneurysm (AAA) 3

■ Risk/benefit ratio of elective repair is contingent upon low operative

mortality (less than 5%)

specific therapy

Indications

■ Most patients

➣ Elective repair if diameter in any orientation is 5 to 5.5 cm

➣ Repair if serial scans (either ultrasound or CT) demonstrate rapidgrowth (> 1 cm/year) or saccular growth

➣ Urgent repair in patients with symptoms (tenderness)

➣ Repair associated lesions (renal, visceral or peripheral occlusivedisease) concurrently if indicated

■ Poor-risk patients

➣ consider endovascular repair

➣ discuss with patient/family outcome if not repaired

➣ (Risk of rupture is 2–3% per year at 5 cm, and may not be cant relative to other co-morbidities)

signifi-Treatment Options

■ Operative repair

➣ Most durable treatment

➣ Little difference between transperitoneal and retroperitonealrepairs

➣ Intraoperative pulmonary artery catheters in patients with poorejection fraction or CHF

Side Effects and Contraindications

of risk, but persantine thallium scanning is not

r MI after elective repair is rarely fatal

4 Abdominal Aortic Aneurysm (AAA)

■ Lower mortality and morbidity than open repair

■ Less durable than standard repair

■ Absolute Contraindications

➣ Bilateral common iliac artery aneurysms

➣ Pararenal or suprarenal aneurysm

➣ Angulation, thrombus or dilation of infrarenal neck

➣ Iliac occlusion or stenosis precluding transfemoral access

■ Relative contraindications

➣ Long term anticoagulation (higher risk of endoleak [see below])

➣ Associated occlusive disease requiring treatment

Specific Complications

■ Endoleak

➣ Persistent arterial flow in aneurysm sac due to: failure of device to

seal to arterial wall (Type I), back flow from branch vessel (TypeIII) or leak through graft material (Type III)

■ Post-implant fever

➣ Occurs 12–48 hours after implant; not due to infection

follow-up

During Treatment

■ Follow AAA less than 5 cm with serial ultrasound or CT scans q6–12

months, or more frequently if there is rapid change in size

Routine

■ Patients undergoing endovascular repair require lifelong yearly CT

scan to monitor position and seal of device

complications and prognosis

➣ Diagnose by bedside sigmoidoscopy Colectomy for

full-thickness ischemia; serial endoscopy for mucosal ischemiawhich often resolves May cause late ischemic strictures

■ Endoleak (seen only after endovascular repair)

➣ Diagnosed on post-op CT scan or angiogram Treatment is

usu-ally endovascular

■ Graft Infection

Abdominal Aortic Aneurysm (AAA) Abscesses and Fistulas 5

➣ Can occur after either open or endovascular repair Symptoms:

persistent fever or aorto-enteric fistula (upper GI bleeding)

Diagnosis: CT scan Treatment: graft excision and extra-anatomicbypass Mortality: 50%

Prognosis

■ Ruptured AAA

➣ Most die en route to hospital or on arrival

➣ 50% of those undergoing surgery survive

➣ Preoperative predictors of poor survival:

➣ Requires life-long follow-up for late complications

r Late onset endoleak:

r Graft migration or disruption

➣ Late complications

r Graft infection (1%)

r Secondary aorto-enteric fistula

ABSCESSES AND FISTULAS

EMMET B KEEFFE, MD

history & physical

Risk Factors

■ Recent abdominal surgery

■ Penetrating or blunt abdominal trauma

■ Perforation of appendix or colonic diverticulum

■ Perforation associated w/ intraabdominal malignancy

■ Crohn disease

■ Chronic diseases, eg, cirrhosis, renal failure

■ Drugs, eg, corticosteroids, chemotherapy

■ Prior radiotherapy

History

■ High spiking fevers w/ chills

■ Abdominal pain

6 Abscesses and Fistulas

■ Nausea & vomiting

Basic Blood Tests

■ Leukocytosis w/ left shift

■ Anemia

■ Nonspecific elevation of bilirubin & liver enzymes

Specific Diagnostic Tests

■ Positive blood cultures

■ Positive cultures from aspiration of abscess

■ Most common aerobes: E coli & Enterococcus

■ Most common anaerobes: Bacteroides

Imaging

■ Plain abdominal & chest films: air-fluid levels in area of abscess;

elevation of right diaphragm in subphrenic abscess

■ Gallium scan: useful for smaller abscess not well seen on imaging

■ CT: imaging modality of choice for identification of abscess; also

allows aspiration for culture

■ US: less sensitive for abdominal abscesses

■ Charcoal or methylene blue: oral administration with detection in

drainage from fistula

Abscesses and Fistulas Acanthosis Nigricans 7

General Measures

■ Initiate general supportive care: fluid & electrolyte replacement,

establish feeding (TPN if fistula present), oxygenation if needed

■ Swan-Ganz catheter, mechanical ventilation &/or vasopressors if

unstable

specific therapy

■ Adequate drainage of abscess either percutaneously or by surgery

■ Surgery indicated if pt fails to respond to percutaneous drainage in

1–2 d

■ Establish adequate drainage of enterocutaneous fistulas, eg, open

recent surgical excision, use of percutaneous catheters

■ Surgery for complex fistulas or failure to resolve w/ external drainage

& TPN

■ Antibiotics: broad spectrum initially, & then based on culture results

follow-up

■ Frequent clinical evaluation early after drainage

■ Serial imaging when treated w/ catheter drainage to confirm catheter

w/i abscess & abscess closed

complications and prognosis

JAMES SEWARD, MD and JEFFREY P CALLEN, MD

REVISED BY JEFFREY P CALLEN, MD

history & physical

History

■ A cutaneous marker of insulin resistance states

■ Other etiologies: hereditary, endocrine disorders, obesity, drugs, and

malignancy

r Not associated with an internal cancer

➣ Type II (Benign AN)

r Associated with various endocrine disorders

r drome, Cushing’s, diabetes mellitus, hypothyroidism, Addison’sdisease, hyperandrogenic states, and hypogonadal syndromes

Examplesincludeacromegaly,gigantism,Stein-Leventhalsyn-➣ Type III (formerly called Pseudo-AN; however, this probably is

the result of an endocrinopathy, namely insulin resistance)

r Most common form

r Associated with obesity and insulin resistance states

r Not associated with malignancy

➣ Type IV (Drug-induced):

r Nicotinicacid,niacinamide,diethylstilbestrol,triazineate,oralcontraceptives, testosterone, topical fusidic acid, and gluco-corticoids

r Seen in 10% of renal transplant patients

➣ Type V (Associated with malignancy):

r Rare

r Most often in adults

r Highly suspected if occurs in non-obese male

r Tends to be more widespread and involve mucosal surfaces

r Precedes 18%, accompanies 60%, or follows 22% the internalmalignancy

r Most often associated with adenocarcinoma of nal tract (60% stomach)

gastrointesti-r Also associated with lung and bgastrointesti-reast adenocagastrointesti-rcinoma

r Other cancers also seen

Signs & Symptoms

■ Often asymptomatic; skin looks “dirty”

■ Velvety brown thickening of skin on intertriginous surfaces, most

commonly the axilla, the neck

■ Other sites: genitalia, knuckles, lips, submammary area, umbilicus,

eyelids, and conjunctiva

Acanthosis Nigricans Acne 9

■ Exclude malignancy in non-obese patients with no obvious cause

■ Screen for malignancy as appropriate for patients age, risk factors,

➣ Weight loss if obese

➣ Treat underlying endocrinopathy

➣ Discontinue offending drug

➣ Treat underlying malignancy

■ Topical urea, lactic acid, tretinoin, and oral etretinate used with

complications and prognosis

■ Depends on underlying cause

■ Obesity related AN improves with weight loss

■ Endocrinopathy associated AN improves with treatment of

under-lying disease

■ Removal of malignancy may be followed by regression of AN

ACNE

ALFRED L KNABLE, MD

history & physical

■ May exist transiently during neonatal period

■ Commonly begins during early puberty with increased activity

throughout the teens with spontaneous resolution thereafter (stronggenetic influence recognized)