1. Describe the treatment of a patient who presents with lower gastrointestinal (GI) bleeding.

Show answer
Treatment begins with the ABCs (airway, breathing, circulation). Place two large-bore intravenous (IV) catheters in the upper extremities. Obtain hemoglobin and hematocrit levels, blood type, and cross-match. A Foley catheter should be placed to help monitor volume status.

2. What is the next step in evaluating the patient?

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A nasogastric tube should be placed to rule out an upper GI source. If the aspirate is bilious, the examiner can be fairly certain that the source is distal to the ligament of Treitz. However, if the aspirate reveals no bile, the patient may still be bleeding in the duodenum with a competent pylorus.

3. What are the two most common causes of massive lower GI bleeding?

Show answer
Diverticular hemorrhage (diverticulosis) and bleeding vascular ectasias. Diverticular disease was previously thought to be the most common cause of lower GI bleeding, but vascular ectasias are now quite frequent.
4. What are the other causes of blood per rectum? Show answer

* Colon cancer
* Polyps
* Ischemic colitis
* Infectious colitis
* Inflammatory bowel disease
* Anorectal disorders (e.g., hemorrhoids, fissure)
* Meckel’s diverticulum

5. After a thorough history and physical examination, what is the first step toward identifying the specific site of bleeding?

Show answer
Anoscopy and rigid proctosigmoidoscopy to rule out anorectal fissures and an extraperitoneal source.

6. Name four options for localizing lower GI bleeding.

Show answer

1. Tagged red blood cell scan
2. Sulfur colloid scan
3. Angiography
4. Colonoscopy

7. Discuss the differences between sulfur colloid scan and tagged red blood cell (RBC) scan.

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The sulfur colloid scan can be accomplished quickly and detects bleeding as minimal as 0.1 mL/min. The radiolabeled sulfur colloid is cleared quickly by the liver and spleen, which may obscure the bleeding site if it is located in the hepatic or splenic flexure. The test is complete within 20 minutes of administration of the radionuclide.
The tagged red blood cell scan requires a 60-minute delay while the autologous RBCs are labeled with isotope. The test detects bleeding as slow as 0.5 mL/min. Because the tagged cells stay in the patient’s system, it is also helpful in identifying the source when the patient is bleeding intermittently. The study takes at least 2 hours.

8. What is the role of angiography?

Show answer
Angiography detects bleeding rates of 0.5-1.0 mL/min but only if the patient is actively bleeding. When a bleeding site is identified, the angiographic appearance may provide further insight into the cause of the bleeding. Whereas diverticular bleeding is often seen as extravasation of contrast, vascular ectasias may be identified by a vascular tuft or early filling vein.

9. What therapeutic options are available with angiography?

Show answer
(1) Infusion of vasopressin (Pitressin) into a selected vessel and (2) embolization of the bleeding vessel.
KEY POINTS: LOWER GI BLEEDING

1. The most common causes of massive lower GI bleeding are diverticular hemorrhage and bleeding vascular ectasias.
2. The most common cause of lower GI bleeding in children is Meckel’s diverticulum.
3. After a thorough history and physical exam, the first steps in identifying the specific site of bleeding are anoscopy and rigid proctosigmoidoscopy.
4. Tagged red blood cell scan, sulfur colloid scan, colonoscopy, and angiography are four options for localizing lower GI bleeding.
5. Indications for surgery include patients who have received 6 U of blood without resolution of bleeding and patients who continue to bleed after vasopressin or embolization.

10. Which patients should have angiographic embolization of the bleeding site?

Show answer
Most surgeons believe that embolization should be reserved for patients who are poor operative risks in that a 15% complication rate is associated with the procedure. Patients may perforate or develop a stricture as a result of bowel wall ischemia.

11. What is the role of vasopressin infusion?

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Vasopressin is only a temporizing measure. Control of the bleeding with vasopressin allows time for resuscitation and essentially converts an emergent case into an urgent one. Vasopressin occasionally may be used as the only treatment for diverticular bleeding. If the patient has a repeated episode of bleeding after weaning from vasopressin, the surgeon must decide between embolization and surgery.

12. Do lower GI hemorrhages ever spontaneously resolve?

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Spontaneous resolution occurs in 75% of patients with vascular ectasias and 90% of patients with diverticular bleeding.

13. What are the indications for operative intervention?

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When the patient has received 6 units of blood (two thirds of the patient’s blood volume in 24 hours) without resolution of bleeding. Any patient who continues to bleed or has recurrent bleeding after vasopressin or embolization should undergo resection.

14. What is the role of blind subtotal colectomy in the management of patients with massive lower GI bleeding?

Show answer
Blind subtotal colectomy is limited to the small group of patients in whom a specific bleeding source cannot be identified. The procedure is associated with a 16% mortality rate. Younger patients tend to tolerate the procedure better than elderly patients. Older patients often suffer with severe diarrhea, urgency, and incontinence. However, blind segmental colectomy is associated with an even higher mortality rate (40%) and a 50% rebleeding rate.

15. What is the most common cause of lower GI hemorrhage in the pediatric population?

Show answer
Meckel’s diverticulum.

References
BIBLIOGRAPHY
1. American Society for Gastrointestinal Endoscopy: The role of endoscopy in the patient with lower gastrointestinal bleeding. Gastrointest Endosc 48:685-688, 1998.
2. Belaiche J, Louis E, D’Haens G, et al: Acute lower gastrointestinal bleeding in Crohn’s disease: Characteristics of a unique series of 34 patients. Belgian IBD Research Group. Am J Gastroenterol 94:2177-2181, 1999. Full article
3. Cynamon J, Atar E, Steiner A, et al: Catheter-induced vasospasm in the treatment of acute lower gastrointestinal bleeding. J Vasc Interv Radiol 14:211-216, 2003. Medline Similar articles
4. Gunderman R, Leef JA, Lipton MJ, Reba RC: Diagnostic imaging and the outcome of acute lower gastrointestinal bleeding. Acad Radiol Suppl 2:S303-S305, 1998.
5. Mallant-Hent RC, Van Bodegraven AA, Meuwissen SG, Manoliu RA: Alternative approach to massive gastrointestinal bleeding in ulcerative colitis: Highly selective transcatheter embolization. Eur J Gastroenterol Hepatol 15:189-193, 2003. Medline Similar articles Full article
6. So JB, Kok K, Hgoi SS: Right-diverticular disease as a source of lower gastrointestinal bleeding. Am Surg 65:299-302, 1999. Medline Similar articles
7. Wilcox CM, Clark WS: Causes and outcome of upper and lower gastrointestinal bleeding: The Grady Hospital experience. South Med J 92:44-50, 1999. Medline Similar articles

1. What is a colonic diverticulum?

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A protrusion of mucosa and submucosa through the muscular layers of the bowel wall. It has no muscular covering. Because diverticula do not involve all layers of the bowel wall, they are really “false” diverticula. Diverticulum formation may be related either to weakness of the bowel wall at the sites of vessel perforation or to increased intraluminal pressure caused by low dietary fiber and constipation.

2. What is the difference between diverticulosis and diverticulitis?

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Diverticulosis is colonic diverticula without associated inflammation. Diverticulitis is inflammation and infection. Only 15% of patients with diverticulosis develop diverticulitis.

3. How does a diverticulum cause pain?

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Pain apparently results from perforation of the diverticulum The resulting leakage may be scant and contained within pericolic fat or extensive, involving the mesentery, other organs, or the peritoneal cavity. Sigmoid diverticulitis typically causes pain in the left lower quadrant.

4. Where in the colon are diverticula usually located?

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In the United States, 95% of all diverticula occur in the left colon, primarily in the sigmoid colon. Diverticula, however, may occur anywhere in the colon. In Asia, right colonic diverticula are more common.

5. At what age is diverticulitis most common?

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The sixth or seventh decade of life. Patients younger than 50 with diverticulitis tend to have more complications. Younger patients are more likely than older patients to have right colonic diverticulitis.

6. What strategy may decrease diverticulitis in patients with diverticula?

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A diet high in fiber. Large bulk in the colon decreases segmentation and intraluminal pressure.

7. What is the best imaging test for diagnosing acute diverticulitis?

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Computed tomography (CT) scan, which can also diagnose local complications of diverticulitis.

8. What complications can result from perforation of a colonic diverticulum?

* Inflammatory phlegmon or abscess in the bowel mesentery
* Peritonitis
* Intra-abdominal abscess
* Internal fistula
* Bowel obstruction

9. Can diverticular disease cause bleeding?

Show answer
Yes. Diverticulosis (not-itis) is a common cause of lower gastrointestinal bleeding. Bleeding from diverticulitis is uncommon.

10. How can the site of diverticular bleeding be localized?

Show answer
It is localized with angiography performed via the inferior mesenteric artery and, if necessary, the superior mesenteric artery. Tagged red blood cell studies are less useful. Colonoscopy is rarely helpful.
KEY POINTS: LOCALIZATION OF LOWER GI BLEEDING

1. Common causes: diverticulosis, cancer, angiodysplasia.
2. Proctosigmoidoscopy without prep is helpful in ruling out rectal source of bleeding (more proximal bleeding lmiits the utility of endoscopy).
3. Tagged red blood cell nuclear scans are useful for slower GI bleeding (detects bleeding at 0.2-0.5 mL/min).
4. Arteriography is the preferred imaging modality because it can be therapeutic and detects bleeding at 0.5-2 mL/min.
5. Start arteriography with the IMA, then the SMA, then the celiac axis if necessary; administer vasopressin or embolize (85% success rate).

11. When should an operation be performed for a bleeding colonic diverticulum?

Show answer
Replacement of 5-6 units of blood (two thirds of a patient’s blood volume) within 24 hours and rebleeding during hospitalization are standard indications for resection of the segment of colon containing a bleeding diverticulum.

12. If bleeding is life threatening but cannot be localized within the colon, what treatment is required?

Show answer
Subtotal colectomy with ileostomy and closure of the distal sigmoid colon at the peritoneal reflection (Hartmann’s operation) or total abdominal colectomy with ileorectal anastomosis is required.

13. Which three procedures may be used when perforation of the diverticulum results in an abscess? Which has the lowest operative mortality rate?

Show answer

1. Diverting colostomy and abscess drainage (first of three stages)
2. Resection of involved colon with proximal colostomy and distal mucous fistula or closure by Hartmann’s operation (first of two stages)
3. Resection with primary anastomosis (one stage)

Operative mortality is lowest after resection and proximal colostomy for fecal diversion. Despite reports of success with the one-stage procedure, most surgeons favor a safer two-stage approach for perforated diverticulitis (this strategy requires a second operation after 3 months for colostomy takedown and colonic re-anastomosis).

14. What is the clinical evidence of a vesicocolic or ureterocolic fistula after diverticular perforation?

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Pneumaturia, fecaluria, and chronic urinary tract infections (polymicrobial).

15. What procedure is required to repair a vesicocolic fistula?

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A staged procedure was the standard until recently. Now most patients can be treated with a single procedure that includes sigmoid resection, colonic anastomosis, and primary repair of bladder defect with absorbable suture. A Foley catheter is usually left in place for 10 days after surgery. Some viable tissue should be placed between the colonic and bladder repairs to prevent a recurrent fistula.

References
WEB SITE
http://www.acssurgery.com/abstracts/acs/acs0327.htm
BIBLIOGRAPHY
1. Bouillot JL, Berthou JC, Champault G, et al: Elective laparoscopic colonic resection for diverticular disease: Results of a multicenter study in 179 patients. Surg Endosc 16:1320-1323, 2002. Full article
2. Eijbouts QA, de Haan J, Berends F, et al: Laparoscopic elective treatment of diverticular disease. A comparison between laparoscopic-assisted and resection-facilitated techniques. Surg Endosc 14:726-730, 2000.
3. Faynsod M, Stamos MJ, Arnell T, et al: A case-control study of laparoscopic versus open sigmoid colectomy for diverticulitis. Am Surg 66:841-843, 2000. Medline Similar articles
4. Gooszen AW, Tollenaar RA, Geelkerken RH, et al: Prospective study of primary anastomosis following sigmoid resection for suspected acute complicated diverticular disease. Br J Surg 88:693-697, 2001. Medline Similar articles Full article
5. Schwesinger WH, Page CP, Gaskill HV 3d, et al: Operative management of diverticular emergencies: Strategies and outcomes. Arch Surg 135:558-562, 2000. Full article
6. Simpson J, Scholefield JH, Spiller RC: Pathogenesis of colonic diverticula. Br J Surg 89:546-554, 2002.
7. Wolff BG, Devine RM: Surgical management of diverticulitis. Am Surg 66:153-156, 2000. Medline Similar articles Full article
8. Young-Fadok TM, Roberts PL, Spencer MP, et al: Colonic diverticular disease. Curr Probl Surg 37:457-514, 2000. Medline Similar articles

11. How are acute liver injuries classified?

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Liver wounds are generally graded on a scale of I to VI according the depth of parenchymal laceration and involvement of the hepatic veins or retrohepatic portion of the inferior vena cava. Optimal methods of obtaining hemostasis vary with the severity of the injury.

12. Do all patients with a traumatic liver injury require surgery?

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No. Nonoperative treatment is the standard for victims of blunt trauma who remain hemodynamically stable (approximately 85% of patients). One third of such patients require blood transfusions, but if the volume exceeds 6 units in the first 24 hours, angiography should be done. CT scan should be repeated in 5-7 days for grade IV and V injuries. Complications, including perihepatic infection, biloma, and hemobilia, have been reported in 10% of nonoperative patients.

13. What are the options for temporary control of significant hemorrhage in victims of hepatic trauma?

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Ongoing hemorrhage leads to the vicious cycle of acidosis, hypothermia, and coagulopathy. Manual compression, perihepatic packing, and the Pringle maneuver are the most effective temporary strategies.

14. What is the Pringle maneuver?

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The Pringle maneuver is a manual or vascular clamp occlusion of the hepatoduodenal ligament to interrupt blood flow into the liver. Included in the hepatoduodenal ligament are the hepatic artery, portal vein, and common bile duct. Failure of the Pringle maneuver to control liver hemorrhage suggests either (1) injury to the retrohepatic vena cava or hepatic vein or (2) arterial supply from an aberrant right or left hepatic artery (see question 9).

15. What is the finger fracture technique?

Show answer
Finger fracture hepatotomy or tractotomy is the method of exposing bleeding points deep within liver lacerations by blunt dissection. Pushing apart the liver parenchyma enables points to be identified and ligated. This method is most commonly required for penetrating injuries.

16. What is the role of selective hepatic artery ligation in securing hemostasis in patients with a major liver injury?

Show answer

Deep lacerations of the right or left hepatic lobe may result in bleeding that cannot be completely controlled by suture ligation of specific bleeding points within the liver parenchyma. In this situation, either the right or left artery can be ligated for control of the bleeding with little risk of ischemic liver necrosis.

17. Why is retrohepatic vena caval laceration lethal?

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Exposure requires either extensive hepatotomy, extensive mobilization of the right lobe, or right lobectomy, or transection of the vena cava. The large caliber and high flow of the inferior vena cava results in massive hemorrhage during surgical exposure, whereas clamping of the inferior vena cava often results in hypotension attributable to an abrupt decrease in venous return to the heart.

18. What is the physiologic rationale for use of a shunt in attempted repair of retrohepatic vena caval injuries?

Show answer
Hemorrhage control requires maintenance of venous return to the heart while both antegrade and retrograde bleeding through the laceration is stopped. These requirements are met by shunting blood through a tube spanning the laceration between the right atrium and lower inferior vena cava.

19. What is the intrahepatic balloon tamponading device?

Show answer
For transhepatic penetrating injuries, a 1-inch Penrose drain is sutured around a red rubber catheter. This forms a long balloon that is threaded through the bleeding liver injury and inflated with contrast media through a stopcock in the red rubber catheter. The balloon tamponades liver hemorrhage. The catheter is brought out through the abdominal wall, deflated, and removed 24-48 hours later.

20. What are the indications for perihepatic packing?

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Liver packing with planned reoperation for definitive treatment of injuries in patients who have hypothermia, acidosis, and coagulopathies is a life-saving maneuver. Laparotomy pads (> 20) are packed around the liver to compress and control hemorrhage. The skin of the abdomen is then closed with towel clips (abbreviated laparotomy), and the patient’s metabolic abnormalities are corrected with planned reoperation within 24 hours.

21. What is the abdominal compartment syndrome?

Show answer
The abdominal compartment syndrome is a potentially lethal complication of perihepatic packing. It may occur when intraabdominal pressure exceeds 20 cmH2O. Intraabdominal pressure increases because of bowel and liver edema secondary to ischemia and reperfusion injury or continued hemorrhage into the abdominal cavity. As pressure increases beyond 20 cmH2O, venous return, cardiac output, and urine output decrease, but ventilatory pressures increase. Patients must return promptly to the operating room for decompression of the abdomen. A manometer attached to the Foley catheter is useful in following intraabdominal pressure.

1. What is upper gastrointestinal (GI) bleeding?

Show answer
Bleeding from proximal to the ligament of Treitz (the transition point between duodenum and jejunum).

2. What are the most common causes of upper GI bleeding?

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In descending order of frequency, they are gastritis, duodenal ulcer, esophageal varices, benign gastric ulcer, esophagitis, and Mallory-Weiss tear. All other causes account for < 5% of cases.

3. What is the overall mortality rate of upper GI bleeding?

Show answer
Approximately 10%. Mortality is usually associated with comorbid factors such as cardiac, pulmonary, hepatic, and renal disease as well as age (> 60 years) and large transfusion requirements (> 5 units of blood). Patients who rebleed during the same hospitalization have a mortality rate of 30%.

4. What is the most common presentation of upper GI bleeding?

Show answer
Eighty percent of patients present with melena (blood is a cathartic, and patients pass black, tarry, or maroon-colored stools) or hematochezia (bright red blood in the rectum). Hematemesis (bright red or coffee-ground emesis) is diagnostic of an upper source of GI bleeding. Occult bleeding may present only with guaiac-positive stool.

5. How much GI blood loss is necessary to cause melena?

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As little as 50 mL. Occult bleeding (guaiac- or Hematest-positive) can be detected with as little as 10 mL of blood loss.

6. A 45-year-old man presents to the emergency department with massive hematemesis, tachycardia, and hypotension. What should the initial approach be?

Show answer
Acute GI hemorrhage requires a prompt and systematic approach. As in all critically ill patients, initially assess the ABCs (airway, breathing, circulation). Start two large-bore intravenous (IV) lines, and give 1 L of Ringer’s lactate while monitoring the patient. Place a nasogastric tube (NGT) and Foley catheter and irrigate the NGT with saline. Send blood for type and crossmatch and coagulation and liver function tests.

7. This patient stabilizes after your interventions. Is a medical history of any value in determining a cause of the bleeding?

Show answer
Yes. The following are pertinent:

* Previous symptoms of peptic ulcer disease or nonsteroidal anti-inflammatory drug use: bleeding duodenal or gastric ulcer
* History of gastroesophageal reflux disease: esophagitis
* Heavy alcohol use: gastritis or bleeding varices
* Recent retching or vomiting: Mallory-Weiss tear
* Weight loss: upper GI malignancy

8. What physical finding may be helpful in establishing the source of bleeding?

Show answer
Physical examination is generally not helpful. The stigmata of liver disease (jaundice, caput medusa, ascites, muscle wasting) raise the suspicion of variceal bleeding or multiple superficial gastric erosions.

9. What percentage of patients with known esophageal varices are bleeding from the varices on presentation?

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Only 50%.

10. Does bilious or clear NGT aspirate rule out an upper GI source of hemorrhage?

Show answer
No. Although NGT aspiration can be useful in directing the search for a bleeding site, one should keep in mind that the false-negative rate may be as high as 20%.

11. What studies can be used to determine the source of bleeding?

Show answer
Esophagogastroduodenoscopy (EGD) is the first and best test. Barium studies may miss a significant source of upper GI bleeding, such as erosive gastritis, and interfere with other more definitive tests, especially arteriography. Nuclear scans are of limited value in acute upper GI hemorrhage.

12. What is the sensitivity of EGD?

Show answer
EGD identifies the source of bleeding in up to 95% of cases. EGD has the advantage of directly visualizing the source of blood loss and provides the opportunity to biopsy a lesion and perform therapeutic maneuvers such as cauterizing a bleeder in a duodenal ulcer.
KEY POINTS: UPPER GI BLEEDING

1. Upper GI bleeding is defined as bleeding proximal to the ligament of Treitz.
2. The most common causes are gastritis, duodenal ulcer, esophageal varices, benign gastric ulcer, esophagitis, and Mallory-Weiss tear.
3. Eight percent of patients present with melena or hematochezia.
4. EGD identifies the source of bleeding in 95% of cases.

13. How can EGD be used to control nonvariceal bleeding?

Show answer
Electrocautery and injection of vasoconstrictors are well-established techniques. Other modalities such as argon beam coagulation, hemoclips, and cyanoacrylates (super glue) are promising.

14. What amount of bleeding is required to see a “blush” on arteriography?

Show answer
Less than 5 mL per minute. Although angiography is the most invasive of these tests, the catheter can be left in place and used for delivery of therapeutic vasopressin or embolization.

15. What treatment options are available to control variceal bleeding?

Show answer
Upper endoscopy with sclerotherapy or band ligation. In experienced hands, placement of a Sengstaken-Blakemore tube (a double balloon tube that permits direct tamponade of both gastric and esophageal varices) temporarily controls bleeding in 90% of cases. IV infusion of vasopressin or octreotide should decrease blood flow to the varices but is less successful in patients with more severe liver disease.

16. What are the indications for surgery in patients with upper GI hemorrhage?

Show answer
About 10% of patients eventually require surgery. Indications include:

* Persistent hypotension or shock (failure of resuscitative therapy)
* Recurrent bleeding while on maximal medical therapy
* High-risk patients with significant comorbid disease
* Large transfusion requirements (transfusion of more than two thirds of the patient’s blood volume in 24 hours)

17. What is the surgical approach to an unstable patient with a nonlocalized upper GI bleed who does not respond to initial resuscitation?

Show answer
At laporotomy start with a generous gastroduodenotomy centered over the pylorus. If this does not reveal a source of bleeding, proceed with a proximal gastrotomy.

18. A patient presents with hematemesis and has a remote history of an abdominal aortic aneurysm repair. What uncommon cause of upper GI bleeding needs to be considered?

Show answer
Aortoduodenal fistula. Any patient with a history of aortic surgery and evidence of GI bleeding should be aggressively worked up for aortoenteric fistula. The study of choice is endoscopy.

19. What is a Dieulafoy’s ulcer?

Show answer
A gastric vascular malformation with an exposed submucosal artery, usually within 2-5 cm of the gastroesophageal junction. It presents with painless hematemesis, often massive (fortunately, this is uncommon).

20. A patient recently admitted with a traumatic liver laceration is treated nonoperatively and later develops painless hematemesis. What do you suspect? How should you treat this patient?

Show answer
Hemobilia, another rare cause of upper GI bleeding, usually occurs after liver trauma or hepatic resection. Treatment consists of angiographic embolization.

21. What are other rare causes of upper GI bleeding?

Show answer
Watermelon stomach, portal hypertensive gastropathy, arteriovenous malformations, upper GI neoplasm, duodenal diverticulum, and pancreatitis (resulting in erosion into the splenic artery or splenic vein thrombosis with portal hypertension).

References
BIBLIOGRAPHY
1. Cameron JL: Current Surgical Therapy, 7th ed. St. Louis, Mosby, 2001.
2. Conrad SA: Acute upper gastrointestinal bleeding in critically ill patients: Causes and treatment modalities. Crit Care Med 30:365-368, 2002.
3. Fallah MA, Prakash C, Edmundowitz S: Acute gastrointestinal bleeding. Med Clin North Am 84:1183-1208, 2000. Medline Similar articles
4. Jamieson GG: Current status of indications for surgery in peptic ulcer disease. World J Surg 24:256, 2000. Medline Similar articles
5. Savides TJ, Jensen DM: Therapeutic endoscopy for nonvariceal gastrointestinal bleeding. Gastroenterol Clin North Am 29:465-487, 2000. Medline Similar articles

1. What is the surgeon’s responsibility when confronted by a patient with an acute abdomen?

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1. To identify how sick the patient is
2. To determine whether the patient (a) needs to go directly to the operating room, (b) should be admitted for resuscitation or observation, or (c) can be sent safely home

2. Which is the most dangerous course?

Show answer
To send the patient home.

3. Is it important to make the diagnosis in the emergency department?

Show answer
No. Frequently time spent confirming a diagnosis in the emergency department is lost to inhospital resuscitation or treatment in the operating room. The only patient who needs a relatively firm diagnosis is a patient who is to be sent home.

4. If the essential goal is not to make the diagnosis, what should the surgeon do?

Show answer

1. Resuscitate the patient. Most patients do not eat or drink when they are getting sick. Most patients are depleted of at least several liters of fluid. Fluid depletion is worse in patients with diarrhea or vomiting.
2. Start a big IV line.
3. Replace lost electrolytes (see Chapter 7).
4. Insert a Foley catheter.
5. Examine the patient (frequently).

5. Are symptoms and signs uniquely misleading in any groups of patients?

Show answer
Yes. Watch out for the following groups:

* The very young, who cannot talk.
* Diabetics, because of visceral neuropathy.
* The very old, in whom, much as in diabetics, abdominal innervation is dulled.
* Patients taking steroids, which depress inflammation and mask everything.
* Patients with immunosuppression (a heart or kidney transplant patient may act cheerful even with dead or gangrenous bowel).

6. Summarize the history needed.

Show answer

1. The patient’s age. Neonates present with intussusception; young women present with ectopic pregnancy, pelvic inflammatory disease, and appendicitis; the elderly present with colon cancer, diverticulitis, and appendicitis.
2. Associated problems. Previous hospitalizations, prior abdominal surgery, medications, heart and lung disease? An extensive gynecologic history is valuable; however, it is probably safer to assume that all women between 12 and 40 years old are pregnant.
3. Location of abdominal pain. Right upper quadrant: gallbladder or biliary disease, duodenal ulcer. Right flank: pyelonephritis, hepatitis. Midepigastrium: duodenal or gastric ulcer, pancreatitis, gastritis. Left upper quadrant: ruptured spleen, subdiaphragmatic abscess. Right lower quadrant: appendicitis (see Chapter 37), ectopic pregnancy, incarcerated hernia, rectus hematoma. Left lower quadrant: diverticulitis, incarcerated hernia, rectus hematoma. Note: Cancer, unless it obstructs (colon cancer), and bleeding (diverticulosis) typically do not hurt.
4. Duration of pain. The pain of a perforated duodenal ulcer or perforated sigmoid diverticulum is sudden, whereas the pain of pyelonephritis is gradual and persistent. The pain of intestinal obstruction is intermittent and crampy. Note: Although the surgeon is rotating through a gastrointestinal service, the patient may not know this and may present with urologic, gynecologic, or vascular pathology.

1. What are the four principles of medical ethics?

1. Beneficence describes the active role of doing good by intervention.
2. Nonmaleficence is equivalent to saying, “First do no harm.”
3. Autonomy accounts for informed consent, competence, and the patient’s right to refuse treatment and to know what’s going on.
4. Justice means that all patients should receive fair and equal care but that one patient’s care should not squander limited resources for others.

2. What is a do-not-resuscitate (DNR) order?

Show answer
A DNR order instructs the surgeon not to resuscitate the patient if cardiopulmonary arrest occurs; however, a DNR order is much more involved and complicated than the acronym would have you believe. DNR is not absolute.
The Joint Commission for the Accreditation of Healthcare Organizations mandates that hospitals have written guidelines that promote accountability for DNR orders. All DNR orders must be documented in writing, similar to all other orders, in the appropriate section of the patient’s chart. They should specify the treatments to be withheld and treatments that the patient wishes to have implemented. Patients and families must participate in the DNR decision. Moreover, the DNR status should be discussed and reviewed with the other members of the health care team. Finally, a DNR order does not mean that the patient should be medically abandoned.

3. What is the difference between withdrawing and withholding support?

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A decision to withdraw should not be more problematic than a decision to withhold, because one cannot be sure that an intervention will work until you try it. There is no moral or ethical distinction between withdrawal and withholding of support. Either of the two allows natural progression of disease without the interface of medical technology. The decision to withdraw or withhold support does not equate with patient death, although the probability of death may be greater. After the decision has been made, appropriate management should focus on the patient’s comfort and psychosocial support.

4. What is an advance directive?

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An advance directive is a method of delineating a competent patient’s wishes for application at a time when he or she is no longer competent. Medical management or the lack thereof can be based on the patient’s wishes rather than a perceived sense of what is best for the patient. Advance directives may be an informal document, such as a living will, or a formal legal document, such as medical durable power of attorney.

5. What is durable power of attorney?

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A durable power of attorney is a patient-appointed proxy decision maker. The proxy decision maker becomes active as soon as the patient is no longer able to make competent medical decisions. Hence, the durable power of attorney must have been established in advance of the cognitive decline of the patient.

6. What is a living will?

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A living will, much like a durable power of attorney, is a formal advanced directive in which a competent patient produces a pre-illness guideline for future care in accordance with his or her wishes.

7. What is included in informed consent?

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Information about the patient’s condition as well as risks and benefits of the recommended treatment are included. Moreover, the operative and nonoperative alternatives (including no treatment) should be discussed with the patient. The patient’s understanding of the information and alternatives should be assessed as part of the informed consent. Finally, informed consent is a voluntary decision made by the patient or on behalf of the patient by a proxy decision maker.

8. What are futile care and medical futility?

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Ultimately, old age and disease will conquer us all. The definition of medically futile or inappropriate treatment is still debated. Nonetheless, there are four main concepts of medical futility:

1. Health care professionals are not required to provide physiologically futile treatment.
2. Imminent demise argues against treatment if the patient has no likelihood of survival to discharge.
3. Under the concept of lethal condition, medical care is considered futile if the patient will survive temporarily but ultimately expire as a result of the ongoing disease process.
4. Quality of life or qualitative futility argues against treatment if the patient’s quality of life is so poor that it would be unreasonable to prolong life.

Care must be taken, however, in making medical decisions based on futility because these decisions may lead to self-fulfilling prophecies.

9. What are the clinical determinants of brain death?

Show answer
Many of the current concepts of brain death are based on the 1968 report from the ad hoc committee at Harvard Medical School, which called for a new neurologic definition of brain death. But it was not until 1981 that BEMAT justified the neurologic criteria of brain death by stressing the need for intact brainstem integrative function in order for a person to function as a whole. By definition, brain death requires loss of brainstem reflexes in an irreversibly comatose patient. Brain death includes loss of the pupillary, corneal, oculovestibular, oculocephalic, oropharyngeal, and respiratory reflexes for ≥ 6 hours. The patient also should undergo an apnea test, in which the pCO2 is allowed to rise to at least 60 mmHg without coexistent hypoxia. The patient should be observed for the absence of spontaneous breathing. Other ancillary tests are not essential; for example, it is not necessary to perform an intravenous radioisotope cerebral angiogram or a four-vessel contrast cerebral angiogram or to document an isoelectric (”flat”) electroencephalogram.
Of note, all of the above criteria for brain death require the absence of central nervous system depression caused by barbiturates, narcotics, or hypothermia.

10. What is a persistent vegetative state?

Show answer
In a persistent vegetative state, typically seen after improvement of a comatose state, the patient lies motionless and without activity. The patient appears to be awake but does not have awareness of his or her surroundings or higher mental activity. Other names for this entity are coma vigil and akinetic mutism.

11. What is euthanasia?

Show answer
Euthanasia requires that the physician play an active role in assisting in the death of the patient. The concepts of physician-assisted suicide and active and passive euthanasia are highly controversial. In 1992, the Society of Critical Care Medicine published the results of a survey of critical care specialists; 87% had withdrawn life-prolonging support from patients. In addition, the most recent U.S. law pertaining to assisted suicide was passed in Oregon in 1994. This law makes it legal for a physician to prescribe medication to terminally ill patients for the purpose of committing suicide.

12. Who should approach patients’ families about organ donation?

Show answer
Some claim that the physician who has established good rapport with the patient’s family should raise the issue of organ donation. Others believe that the local organ procurement personnel should approach the family because they have greater interest and training in the process. The best approach is probably a combined one.

13. What should patients’ families be told when organ donation is feasible?

Show answer
The surgeon should stress that the patient has died despite an actively beating heart. The family should be questioned about the patient’s wishes regarding organ donation. All topics should be based on the concepts of informed consent. The family should be informed of the likelihood that several patients will benefit from the donated organs. The family needs to understand that there is no guarantee that the organs will be suitable for donation. They should be assured that they are not responsible for the cost of care provided after brain death is determined and that they may refuse organ donation without fear of prejudice.

14. What is the role of the hospital ethics committee?

Show answer
The hospital ethics committee educates hospital staff members, creates policy, and provides a source of consultation.
The function of education is accomplished through grand rounds, seminars, special lectures, and journal clubs. The hospital ethics committee should be viewed as an intrinsic part of the hospital community. Developed policies should be reviewed by other committees and divisions of the hospital to foster a better sense of cohesiveness when ethical and moral dilemmas arise. The consultative function of the ethics committee produces the greatest amount of controversy. In fact, many hospitals negate this function by stating that it interferes with the physician-patient relationship. The hospital ethics committee can and should provide an arena for collaboration and general ethical education within the hospital.

References
BIBLIOGRAPHY
1. Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death: A definition of irreversible coma. JAMA 205:337-340, 1968.
2. Aminoff MJ: The central nervous system. In Medical Diagnosis and Treatment. Norwalk, CT, Appleton & Lange, 1996.
3. Arnold RM, Siminoff LA, Frader JE: Ethical issues in organ procurement: A review for intensivists. Crit Care Med 12:29-48, 1996. Full article
4. Bernat JL, Culver CM, Gert B: On the definition and criterion of death. Ann Intern Med 94:389-394, 1981. Medline Similar articles Full article
5. Harken AH: Enough is enough. Arch Surg 10:1061-1063, 1999. Full article
6. Kelley DF, Hoyt JW: Ethics consultation. Crit Care Med 12:49-70, 1996.
7. McCollough L, Jones J, Brody B: Surgical Ethics. Oxford, Oxford University Press, 1998.
8. Nyman DJ, Eidelman AL, Sprung CL: Euthanasia. Crit Care Clin 12:85-96, 1996. Medline Similar articles
9. Society of Critical Care Ethics Committee: Attitudes of critical care medicine professionals concerning foregoing life-sustaining treatments. Crit Care Med 20:320-326, 1992.
10. State of Oregon: ORS.251.215, The Oregon Death with Dignity Act. Official 1994 Oregon General Election Handbook, 1994, pp 121-124.
11. Younger SJ: Medical futility. Crit Care Clin 12:165-178, 1996.

1. What are the causes of bladder injury?

Show answer
Iatrogenic manipulation and penetrating or blunt trauma. Because of the rich detrusor blood supply, bladder injury is usually accompanied by hematuria. Other signs may include suprapubic pain, inability to void, or incomplete recovery of catheter irrigation.

2. What types of bladder injury may occur with blunt trauma?

Show answer
Laceration or perforation may be either intra- or extraperitoneal. Hematuria with a normal cystogram defines bladder contusion in the absence of upper tract injury. Extraperitoneal injuries constitute the majority of bladder trauma and tend to concentrate at the bladder base or parasymphyseal area. These can be managed conservatively with urinary catheter drainage for at least 10 days. Intraperitoneal (IP) ruptures typically occur when the bladder is distended at the time of trauma, causing a blowout of the dome of a bladder. IP vesical rupture should be surgically repaired using a two-layer closure with absorbable sutures and placement of suprapubic and urethral catheters.
KEY POINTS: MANAGEMENT OF BLADDER INJURY DUE TO BLUNT TRAUMA

1. Diagnose with CT cystography and retrograde cystourethrography.
2. Extraperitoneal injuries are more common and may be managed conservatively with a Foley catheter for 10 days.
3. Intraperitoneal injuries are more likely if the bladder is distended at the time of injury; they require surgical repair with suprapubic and Foley drainage postoperatively.

3. What is the likelihood of a bladder injury in patients with a fractured pelvis?

Show answer
Extraperitoneal bladder injury occurs in 10% of all pelvic fractures. Conversely, approximately 85% of blunt bladder injury is associated with pelvic fracture. Bladder injuries occur more often with parasymphyseal pubic arch fractures and more often with bilateral than unilateral fractures. Isolated ramus fractures produce bladder laceration in 10% of cases.

4. How is bladder injury evaluated?

Show answer
Both computed tomography (CT) cystography and retrograde cystourethrography provide great diagnostic accuracy for bladder rupture. The bladder should be filled under gravity with a total of 300-400 mL of a 50% dilution of standard radiocontrast agent using the Foley catheter. Films should include anteroposterior, lateral, and oblique views. Finally, a postvoid film should be obtained. When renal or distal ureteral injury is suspected, upper tract imaging (intravenous pyelogram [IVP] or CT scan) should precede the cystogram.

5. What are the retrograde cystourethrographic patterns of bladder injury?

Show answer
Extraperitoneal injury allows contrast agent to escape adjacent to the symphysis, but it is confined to the bladder base by the intact peritoneum. Intraperitoneal extravasation produces a “sunburst” appearance from the bladder dome, which may collect in the paracolic gutters, outline loops of bowel, or pool under the liver or spleen. It is pivotal to obtain postvoid films.

6. How is bladder rupture managed?

Show answer
Extraperitoneal lacerations can be managed with an indwelling catheter for 7-10 days, at which time cystogram usually confirms resolution of extravasation. Intraperitoneal lacerations require operative repair. Bladder contusion requires catheter drainage until gross bleeding has subsided.

7. When should urethral injury be investigated?

Show answer
The mechanism of injury (e.g., crushing or deceleration/impact, straddle injuries) and associated trauma (e.g., pelvic fracture), blood at the meatus, penile or scrotal swelling and ecchymosis, upward prostatic displacement on digital rectal examination, and inability to void or to pass a urethral catheter (do not try this) should be investigated.

8. When a patient presents with a pelvic fracture, is concomitant urethral injury a major concern?

Show answer
Yes. Urethral trauma occurs in 10% of pelvic fractures; it is more common with anterior disruption of the pelvic ring, including 20% of unilateral and 50% of bilateral parasymphyseal fractures. Posterior (prostatomembranous) avulsion is associated with potentially disabling sequelae and requirements for complex and challenging operative corrections. In contrast, more distal urethral injuries avoid impotence and incontinence issues and are more surgically accessible.

9. How is urethral injury best assessed?

Show answer
Retrograde urethrography must always be performed before inserting a Foley catheter. Incomplete urethral transection produces local contrast dye extravasation and bladder opacification. Total avulsion produces extensive local extravasation, and no contrast dye gets into the bladder. Incomplete transection is more common with anterior (50%) than posterior (10%) urethral injuries.

10. How is urethral injury managed?

Show answer
For incomplete transection regardless of site, either catheter stenting across the defect or diversion by suprapubic cystostomy permits resolution. With complete urethral transection, the bladder should be decompressed initially via suprapubic cystostomy. Early restoration of continuity by placement of a bridging urethral catheter should be performed endoscopically. A bridging catheter reduces complex scarring and avoids subsequent surgery in many patients.

11. What are the complications of urethral injury?

Show answer
Strictures, incontinence, and impotence (associated with traumatic prostatic displacement). Iatrogenic complications are associated with retropubic dissection.

12. What is the differential diagnosis in blunt scrotal trauma?

Show answer
Testicular rupture, hematocele, scrotal hematoma, intratesticular hematoma, and testicular torsion. Ultrasonography helps sort this out.

13. What is the sonographic sign of testicular rupture?

Show answer
The sign is loss of the normal homogenous echo texture of the testicle, with areas of irregular hyper- or hypoechogenicity.

14. How are patients with acute testicular rupture managed?

Show answer
Management includes surgical exploration and debridement of extruded, nonviable tubules and evacuation of the hematoma. After proper hemostasis is achieved, the tunica albuginea should be closed with running absorbable suture.

15. What is the most common cause of penile fractures?

Show answer
Penile fracture is a rupture of the corpus cavernosum, most commonly associated with sexual intercourse, masturbation, or an abnormally forced bending of the erect penis. Characteristically the patient hears a popping sound, followed by pain and detumescence.

16. What are the physical examinations findings with a penile fracture?

Show answer
Injury to the tunica albuginea causes formation of hematoma and deviation of the shaft to the opposite side of injury. If Buck’s fascia is intact, the hematoma will be confined to the penis; disruption of Buck’s fascia allows spread of the hematoma under Colles’ and Scarpa’s fascia onto the perineum and abdominal wall.

17. How are penile fractures managed?

Show answer
Surgically. A retrograde urethrogram should be performed when urethral injury is suspected. Closure of the defect (or defects) along the tunica albuginea and evacuation of hematoma are performed after degloving the penis.

18. In penile amputation injuries, how should the amputated portion of the penis be preserved for transport?

Show answer
The amputated portion of the penis should be wrapped in saline-soaked gauze, placed in a plastic bag with ice slush surrounding the bag.

19. How is major scrotal skin loss managed?

Show answer
If primary repair is not possible, meshed split-thickness skin grafts may be used to cover the testis. When delayed repair is necessary, thigh pouches should be created until permanent reconstruction is feasible.

20. A 50-year-old woman complains of urine leakage from her vagina after a hysterectomy. What is the most likely diagnosis?

Show answer
Unrecognized bladder injury during hysterectomy with subsequent urine extravasation into the surgical field and drainage via the vaginal cuff suture line leads to formation of vesicovaginal fistula.

21. What is the best time to repair a vesicovaginal fistula secondary to an uncomplicated hysterectomy?

Show answer
Although 3-6 months after injury has been recommeded in the past, early repair can be successful if there is minimal inflammation and there are no complicating factors.

References
WEB SITES

1. http://www.east.org/tpg/GUmgmt.pdf
2. http://www.acssurgery.com/abstracts/acs/acs0510.htm

BIBLIOGRAPHY
1. Armstrong PA, Litscher LJ, Key DW, McCarthy MC: Management strategies for genitourinary trauma. Hosp Phys 34:19-25, 1998.
2. Jacob TD, Gruen GS, Udekwu AO, Peitzman AB: Pelvic fracture. Surg Rounds (Aug):583, 1993.
3. Jordan GH: Lower Genitourinary Tract Trauma and Male External Genital Trauma (Nonpenetrating Injuries, Penetrating Injuries, and Avulsion Injuries). In American Urological Association Update Series, Vol. XIX, Lesson 11, part 2. Baltimore, American Urological Association, 2000.
4. Kim FJ: Urologic trauma. In Feliciano DV, Moore EE, Mattox KL (eds): Trauma Companion Handbook, 4th ed. New York, McGraw-Hill, 2002.
5. McAninch JW: Traumatic and Reconstructive Urology. Philadelphia, W.B. Saunders, 1996.
6. Peterson NE: Current management of urethral injuries. In Rous S (ed): 1998 Urology Annual. New York, Appleton-Century-Crofts, 1988, pp 143-179.
7. Peterson NE: Traumatic posterior urethral avulsion. Mongr Urol 7:61, 1986.
8. Spirnak JP: Pelvic fracture and injury to the lower urinary tract. Surg Clin North Am 68:1057, 1988. Medline Similar articles

7. Are vital signs important?

Show answer
Yes. They are vital. If heart rate and blood pressure are on the wrong side of 100 (heart rate > 100 beats/min, systolic blood pressure < 100 mmHg), watch out! Tachypnea (respiratory rate >16) reflects either pain or systemic acidosis. Fever may develop late, particularly in the immunosuppressed patient who may be afebrile in the face of florid peritonitis.

8. What is rebound?

Show answer
The peritoneum is well innervated and exquisitely sensitive. It is not necessary to hurt the patient to elicit peritoneal signs. Depress the abdomen gently and release. If the patient winces, the peritoneum is inflamed (rebound tenderness).

9. What is mittelschmerz?

Show answer
Mittelschmerz is pain in the middle of the menstrual cycle. Ovulation frequently is associated with intraperitoneal bleeding. Blood irritates the sensitive peritoneum and hurts.

10. What do bowel sounds mean?

Show answer
If something hurts (e.g., a sprained ankle), the patient tends not to use it. Inflamed bowel is quiet. Bowel contents squeezed through a partial obstruction produce high-pitched tinkles. Bowel sounds are notoriously unreliable, however.

11. Explain the significance of abdominal distention.

Show answer
Distention may derive from either intraenteric or extraenteric gas or fluid (worst of all, blood). Abdominal distention is always significant and bad.

12. Is abdominal palpation important?

Show answer
Yes. Remember, the patient is (or should be) the surgeon’s friend. There is no need to cause pain. Palpation guides the surgeon to the anatomic zone of most tenderness (usually the diseased area). It is best to start palpation in an area that does not hurt. Rectal (test stool for blood) and pelvic examinations localize pathology further.

13. What is Kehr’s sign?

Show answer
The diaphragm and the back of the left shoulder enjoy parallel innervation. Concurrent left upper quadrant and left shoulder pain indicate diaphragmatic irritation from a ruptured spleen or subdiaphragmatic abscess.

14. What is a psoas sign?

Show answer
Irritation of the retroperitoneal psoas muscle by an inflamed retrocecal appendix causes pain on flexion of the right hip or extension of the thigh.

1. List the causes of mitral regurgitation.

Show answer

* Rheumatic fever
* Endocarditis
* Ruptured chordae tendineae
* Senile mitral annular calcification
* Papillary muscle dysfunction from ischemia
* Annular dilatation from left ventricular dilation

2. What is the pathophysiology of mitral regurgitation?

Show answer
The left ventricle ejects blood via two routes: (1) antegrade, through the aortic valve, or (2) retrograde, through the mitral valve. The amount of each stroke volume ejected retrograde into the left atrium is the regurgitant fraction. To compensate for the regurgitant fraction, the left ventricle must increase its total stroke volume. This ultimately produces volume overload of the left ventricle and leads to ventricular dysfunction.

3. What are the symptoms of mitral regurgitation?

Show answer
Dyspnea on exertion and loss of exercise tolerance are the symptoms of heart failure.

4. What determines left atrial pressure in mitral regurgitation?

Show answer
The compliance of the left atrium.

5. Why does acute mitral regurgitation cause severe symptoms?

Show answer
With acute mitral regurgitation, the normal left atrium is noncompliant. Hence, left atrial pressure increases rapidly, flooding the lungs (i.e., congestive heart failure) and causing severe symptoms. Conversely, chronic mitral regurgitation is associated with progressive dilatation of the left atrium. With increased left atrial compliance, the left atrial pressure may not increase.

6. What hemodynamic conditions exacerbate mitral regurgitation?

Show answer
Increased left ventricular afterload: Increased systemic arterial blood pressure increases the impedance against which the left ventricle must pump to eject blood antegrade. The regurgitant fraction is therefore increased (more blood goes backwards through the mitral valve).
Tachycardia: Because mitral regurgitation occurs during systole, tachycardia (i.e., more systoles per minute) increases the regurgitant fraction.
Volume overload: Left ventricular distension secondary to volume overload stretches the mitral anulus, impairs coaptation of the mitral valve leaflets, and increases mitral regurgitation.

7. What is the murmur of mitral regurgitation?

Show answer
A holosystolic murmur is best heard at the apex with radiation to the left axilla.

8. How is the diagnosis confirmed?

Show answer
By color Doppler echocardiography, especially transesophageal echocardiography (TEE; the left atrium lies right on the esophagus). The regurgitant jet may be accurately visualized and quantitated. Echocardiography also allows determination of the anatomic abnormality of the mitral valve apparatus that is responsible for the regurgitation.

9. What is the medical therapy for mitral regurgitation?

Show answer

* Afterload reduction with angiotensin-converting enzyme (ACE) inhibitors
* Diuretics (furosemide) for lower left ventricular preload
* Digoxin provides ventricular rate control for patients in atrial fibrillation
* Warfarin (Coumadin) is used for patients in atrial fibrillation

10. What are the indications for surgery in patients with mitral regurgitation?

Show answer

* Severe mitral regurgitation, especially with a ruptured chordae tendineae
* Symptoms despite medical therapy
* Progressive mitral regurgitation by echocardiography
* Deteriorating left ventricular systolic function. Because mitral regurgitation lowers the total impedance of left ventricular ejection (much of each stroke volume escapes via the low resistance mitral valvular “back door”), the left ventricular ejection fraction (LVEF) should be greater than normal in the presence of mitral regurgitation. An LVEF < 55% in the presence of mitral regurgitation suggests left ventricular dysfunction.
* Pulmonary artery pressure increases with exercise

KEY POINTS: MITRAL REGURGITATION

1. The symptoms are dyspnea on exertion and loss of exercise tolerance.
2. The murmur of mitral regurgitation is a holosystolic murmur heard best at the apex with radiation to the left axilla.
3. Mitral valve regurgitation is corrected with mitral valve repair or mitral valve replacement.
4. Mitral valve repair is preferable to replacement because of lower operative mortality rates, less risk of thromboembolism, less risk of endocarditis, better long-term left ventricular function, and less need (if any) for chronic anticoagulation.
5. Repair also avoids prosthetic valve-related complications.

11. How is mitral regurgitation corrected?

Show answer
Mitral valve repair. Mitral valve repair is the preferred surgical procedure. This preserves the mitral apparatus, maintaining the continuity between the left ventricular muscle and the mitral anulus via the chordae tendineae. Loss of this continuity by resection of the apparatus places the left ventricle at a mechanical disadvantage that over time leads to left ventricular dilatation and dysfunction.
Mitral valve replacement. An inability to repair the regurgitant valve mandates replacement. If replacement is necessary, efforts should be made to preserve the posterior leaflet of the mitral valve. In most series, mitral valve replacement is required in < 30% of cases.

12. Why is it preferable to repair rather than replace the mitral valve?

Show answer

* Lower operative mortality
* Less risk of thromboembolism
* Less risk of endocarditis
* Less need (if any) for chronic anticoagulation
* Better long-term left ventricular function
* Avoids valve-related complications

13. How is the mitral valve repaired?

Show answer
The redundant portion(s) of the valve leaflet(s) is resected, the leaflet is reapproximated, and the mitral anulus is plicated and reinforced with a prosthetic anuloplasty ring. The anuloplasty ring is sewn around the perimeter of the anulus on the left atrial side of the valve. In so doing, the mitral leaflets are supported by competent chordae tendineae, and the circumference of the mitral anulus is decreased. Competency of the repaired valve is assessed intraoperatively using TEE.

14. What is the operative mortality of mitral valve repair versus mitral valve replacement?

Show answer
Repair: 2%; replacement: 6%.

15. How durable are mitral valve repairs?

Show answer
The risk of requiring another mitral valve operation is approximately 2% per year.

1. How common a problem is infertility?

Show answer
Infertility is the inability to establish a pregnancy during 1 year of well-timed intercourse. This affects 15% of all couples in the United States. In 50% of such couples, the woman is responsible; in 30% of couples, a male factor prevents pregnancy; and in 20% of couples, it is a combination of both.

2. What are the odds that a fertile couple will become pregnant after a single episode of well-timed intercourse?

Show answer
During a given ovulatory cycle, 18% of fertile couples become pregnant after well-timed intercourse.

3. What is the best timing for intercourse if a couple is trying to conceive?

Show answer
Sperm can survive in the cervical mucus for 48 hours. To achieve pregnancy, therefore, the most effective timing of intercourse is every other day, starting a few days before ovulation.

4. What environmental factors may play a role in male infertility?

Show answer
Although reproductive function is relatively durable, various toxins have a negative impact on male fertility. Cigarette smoke and alcohol have been implicated as dose-dependent gonadotoxins, as have recreational drugs, including marijuana, cocaine, and heroin. Radiation (in amounts as low as 200 rads) can influence spermatogenesis, as can chemotherapeutic agents. Calcium channel blockers may interfere with the ability of sperm to fertilize eggs.

5. Can a vasectomy be successfully reversed?

Show answer
Yes, but the success rate is affected by the amount of time since the original vasectomy. Among patients who are less than 3 years from vasectomy, the conception rate after reversal is roughly 75%. This success rate declines to about 50% when the reversal is performed 3-8 years after vasectomy and further declines to 30% when 15 or more years have passed.

6. What is in vitro fertilization (IVF)?

Show answer
With IVF, eggs are harvested from a woman and combined with sperm in a laboratory setting. The resulting embryos are then transferred to the uterine cavity, where they mature into a fetus. In a specialized version of this technology (i.e., intracytoplasmic sperm injection), an individual sperm is injected into each egg, thus facilitating fertilization and allowing pregnancy even in the presence of small numbers of motile sperm.

7. What is the role of IVF in male infertility?

Show answer
Because use of IVF greatly reduces the number of motile sperm needed to generate a pregnancy, it can be quite helpful in men with poor semen quality. The IVF team needs only as many motile sperm as there are oocytes (eggs) to be fertilized.

8. Can sperm obtained directly from the testicle be used to generate a pregnancy?

Show answer

For the past several years, it has been recognized that incubation of testicular tissue generally yields small numbers of motile sperm. Through the use of IVF, such sperm can generate pregnancies. Even among men suffering from severe testicular failure, it may be possible to retrieve adequate sperm for use in IVF.

9. What is the role of sperm freezing in the treatment of infertility?

Show answer
Sperm can be frozen (cryopreserved) with relative ease. After they are cryopreserved, sperm remain viable for extended periods (years). Cryopreservation can be helpful among men planning to undergo treatment with chemotherapy or radiation therapy.

10. Does wearing boxer shorts versus tight underwear affect male fertility?

Show answer
No.
KEY POINTS: SURGICAL APPROACH TO INFERTILITY

1. Infertility is defined as the inability to establish pregnancy during 1 year of well-timed intercourse.
2. In 50% of infertile couples a female factor prevents pregnancy, in 30% of couples a male factor prevents pregnancy, and in 20% of couples infertility is due to a combination of both female and male factors.
3. The most common cause of male infertility is varicocele.

11. Because normal levels of testosterone are necessary for sperm production, is it helpful to give subfertile men additional testosterone?

Show answer
Although decreased levels of testosterone can cause impaired male fertility, giving additional testosterone to men with normal testosterone levels can actually cause a dramatic decline in semen quality. Administration of exogenous testosterone causes the patient to cease production of native testosterone within the testes. The resultant decrease in intratesticular testosterone actually results in a decline in sperm production.

12. What is the most common cause of male infertility?

Show answer
Varicocele, a collection of dilated veins above one or both testes. Among men presenting for treatment of infertility, 40% have a varicocele. Correction of varicocele leads to improvement in semen quality in 70% of patients.

13. If we can clone Dolly (a sheep derived from cloning a fully differentiated mammary cell), can we clone humans?

Show answer
Although for a number of critical ethical reasons cloning technology is not currently used in human reproduction, it theoretically allows the cloning of any individual, creating a genetic duplicate. However, cloning probably will not play a role in the treatment of human infertility.

14. Is IVF associated with an increase in genetic abnormalities?

Show answer
This issue is controversial, but probably no. At least one recent publication suggested that infants conceived by either intracytoplasmic sperm injection or IVF have twice the risk of major birth defects compared with naturally conceived infants.

15. Will giving supplemental testosterone improve male fertility?

Show answer
No. Exogenous testosterone induces a profound decrease in spermatogenesis and has been explored as a means of male contraception.

16. What is cloning as it pertains to humans?

Show answer
Just like Dolly the sheep, human cloning involves nuclear transplantation of the desired clone into an egg devoid of its nucleus. Rather than creating whole human beings, the more controversial ethical dilemma is whether to permit cloning of cells or organs for subsequent transplantation in order to cure human disease.

17. Are undescended testes associated with male infertility?

Show answer
Yes. Cryptorchidism is associated with male infertility. The decreased fertility correlates with severely reduced total germ cell counts in prepubertal undescended testes. Bilateral testicular maldescent does decrease semen quality. Interestingly, unilateral cryptorchidism may impair semen quality as well. This suggests that both the abnormally descended testis and its normally positioned counterpart are adversely affected. Surgical repositioning of the testis improves semen quality; the earlier it is done, the better.

References
WEB SITE
http://www.auanet.org
BIBLIOGRAPHY
1. Cortes D, Thorp JM, Visfeldt J: Cryptorchidism: Aspects of fertility and neoplasms. A study of 1,335 consecutive boys who underwent testicular biopsy simultaneously with surgery for cryptorchidism. Horm Res 55:21-27, 2001. Full article
2. Hansen M, Kurinczuk JJ, Bower C, Webb S: The risk of major birth defects after intracytoplasmic sperm injection and in vitro fertilization. N Engl J Med 346:725-730, 2002. Medline Similar articles Full article
3. Hargreave T, Ghosh C: Male fertility disorders. Endocrinol Metab Clin North Am 27:765-782, 1998. Similar articles
4. Ismail MT, Sedor J, Hirsch IH: Are sperm motion parameters influenced by varicocele ligation? Fertil Steril 71:886-890, 1999.
5. Johnson MD: Genetic risks of intracytoplasmic sperm injection in the treatment of male infertility: Recommendations for genetic counseling and screening. Fertil Steril 70:397-411, 1998. Similar articles Full article
6. Kim ED, Winkel E, Orejuela F, et al: Pathological epididymal obstruction unrelated to vasectomy: Results with microsurgical reconstruction. J Urol 160(6 pt 1):2078-2080, 1998.
7. Meriggiola MC, Costantino A, Cerpolini S: Recent advances in hormonal male contraception. Contraception 64:269-272, 2002. Full article
8. Naysmith TE, Blake DA, Harvey VJ, et al: Do men undergoing sterilizing cancer treatments have a fertile future? Hum Reprod 13:3250-3255, 1998.
9. Palermo GD, Schlegel PN, Hariprashad JJ, et al: Fertilization and pregnancy outcome with intracytoplasmic sperm injection for azoospermic men. Hum Reprod 14:741-748, 1999.
10. Pellegrino ED, Kilner JF, Fitzgerald KT, et al: Therapeutic cloning. N Engl J Med 347:1619-1622, 2002. Similar articles Full article
11. Rutkowski SB, Geraghty TJ, Hagen DL, et al: A comprehensive approach to the management of male infertility following spinal cord injury. Spinal Cord 37:508-514, 1999.
12. Scherr D, Goldstein M: Comparison of bilateral versus unilateral varicocelectomy in men with palpable bilateral varicoceles. J Urol 162:85-88, 1999.
13. Wilmut I: Cloning for medicine. Sci Am 279:58-63, 1998. Medline Similar articles