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At present discount 20mg vardenafil with mastercard erectile dysfunction 16 years old, rifampicin (see Chapter 9) is the drug of choice for the treatment of leprosy cheap 20mg vardenafil otc erectile dysfunction injection therapy video. Plasmid-Borne Resistance to Sulfonamides Sulfonamide insusceptibility was one of the ﬁrst antibiotic resis- tance traits found to be transferable (see Chapter 10) discount 10mg vardenafil erectile dysfunction doctors in queens ny. Since sulfonamide is a synthetic antibacterial agent, resistance by plasmid-mediated drug-degrading or drug-modifying enzymes was not to be expected. Instead, nonallelic, drug-resistant vari- eties of the chromosomal dihydropteroate synthase drug target enzyme were found to mediate high levels of sulfonamide resis- tance (Fig. Three types of plasmid-borne genes expressing such varieties are known: sul1, sul2, and sul3. These three genes differ among themselves (40% similarity at the amino acid level). The occurrence of these three plasmid-borne genes is the most common form of sulfonamide resistance among clinically isolated enterobacteria. Remarkably, only sul1andsul2 or both were long found in isolates of sulfonamide-resistant enterobacteria from various parts of the world. This is in contrast to trimethoprim resistance, described later in the chapter, at which more than 20 different plasmid- borne resistance genes have been found and characterized. The reason for this could be limited possibilities of conﬁguration variation in the catalytic center of dihydropteroate synthase. The sulfonamide-resistant enzyme must be able to distinguish between its normal substrate p-aminobenzoic acid and the struc- turally very similar sulfonamide (see 3-1 and 3-2). The folP gene is marked on the large circular chromosome representing the chromosomal sulfonamide- sensitive dihydropteroate synthase. Plasmid-borne genes for sulfonamide resistance, sul, express dihydropteroate synthases that are insusceptible to inhibition by sulfonamides. Minimum inhibitory concentrations for sul- fonamides are given for the different plasmid-mediated dihydropteroate synthases. In particular, sul2showsasharp acuity in its ability to distinguish between normal substrate and sulfonamide. In a study from the early 1990s, a large number of sulfonamide-resistant clinical isolates of enterobacteria from different parts of the world were shown to harbor either sul1 or sul2 or both as plasmid-borne genes mediating sulfonamide resistance. In addition to being borne on plasmids, the three sul genes have further genetic mechanisms available for their rapid spread. Regarding sul1, for example, it is almost always located in an integron of the Tn21 type (Chapter 10) together with other resistance genes. The sul3 observed later is mediated by a composite transposon with ﬂanks of known insertion sequences (Chapter 10). As mentioned, the two resistance genes sul1ad sul2 occurred in about the same frequencies among clinical isolates of sulfonamide-resistant enterobacteria. Furthermore, it was seen that the relative frequency of sul2 had increased and that it was now to be found mostly on large transferable plasmids (Chapter 10) together with many other resistance genes. The explanation of this unexpected phenomenon could be that sul2 had become associated with other resistance genes and then been selected via the use of other antibacterial agents. This is an important interpretation, since it bears on the spread of resistance by linkage between different resistance genes. Another, location of sul2, found relatively recently, is on the chromosome of Haemophilus inﬂuenzae. Methotrexate and aminopterin cannot be used as antibacterial agents, however, since they are not selective for bacteria. At the methylation reaction the tetrahydrofolate is oxidized and its rereduction by dihydrofolate reductase is inhibited by trimethoprim. The selective action of trimethoprim on bacterial dihydrofolate reductase, leaving mammalian enzymes untouched, allows the clinical use of trimethoprim as an antibac- terial drug inhibiting bacterial dihydrofolate reductases at very low concentrations. There is a structural explanation for this, elucidated by x-ray crystallography studies, showing that trimethoprim ﬁts well into the nucleotide binding site of the dihydrofolate reductase from, for example, E. This can vary slightly with analogs of trimethoprim such as iclaprim (3-9) and epiroprim (3-10). Since sulfonamides and trimethoprim attack successive steps in the same enzymic pathway leading to tetrahydrofolate, there is a synergistic effect that has been exploited in the combi- nation drug co-trimoxazole, which contains trimethoprim in combination with the sulfonamide sulfamethoxazole. This sul- fonamide was chosen for the combination in order to match the pharmacokinetic properties of trimethoprim. Trimethoprim was introduced around 1970 as a useful antibacterial agent for sys- temic use. It can be said that aside from linezolid from the 1990s (Chapter 7), trimethoprim was the last new antibacterial agent inthetruesenseoftheword:newinthesensethatitsmolecu- lar mechanism of antibacterial action had not been used earlier. Trimethoprim has been much appreciated as an inexpensive and efﬁcient agent in treating, for example, bacterial infections of the urinary tract, and has been used widely and extensively. Astonishing results from rather recent research have shown that these bacteria have no chromosomal gene (folA) for dihydrofolate reductase and thus do not offer any target for antifolates. The dominant requirement for reduced folates in actively growing bacteria is for the methylation of deoxyuridylic acid to deoxythymidine-5 - monophosphate (thymidylate) under the catalysis of thymidylate synthase (thyA). This means that tetrahydrofolate is not oxidized at the methylation reac- tion, leading to thymidylate in these bacteria. Dihydrofolate is not produced, which obviates the rereduction catalyzed by dihydrofolate reductase. Chromosomal Resistance to Trimethoprim Resistance to trimethoprim by mutations in the folA gene express- ing the trimethoprim target enzyme dihydrofolate reductase is known from several pathogenic bacteria. One was a pro- moter up mutation in the −35 region of the promoter; the second was an insertion of one base pair, increasing the distance between the −10 region of the promoter and the start codon. There were also several mutations optimizing the ribosome binding site, and ﬁnally, there were mutations in the structural gene, effecting changes to more frequently used codons. The changes described rep- resent a remarkable evolutionary adaptation to the antibacterial action of trimethoprim. Different parts of the structural gene were changed in different isolates and also in the C-terminal area, which is not known to participate in substrate or trimethoprim binding. These changes were suggested to involve alterations in the secondary structure, mediating a decrease in trimethoprim binding. Resistant strains were shown to express dihy- drofolate reductases, which resisted trimethoprim concentrations 50-fold higher than those inhibiting the corresponding enzyme from susceptible bacteria. In a study of 11 trimethoprim-resistant isolates, a substantial variability was seen in the nucleotide sequences of their dihydrofolate reductases genes. The resistant isolates could be divided into two groups with six amino acid changes in common. One of the two groups showed two extra changes, and the other, six additional changes. The usual location of plasmid-borne foreign trimethoprim resistance genes (see later in the chapter) on the chromosome of C. In a survey of clinical isolates of this pathogen, it was found that a majority of them carried foreign genes expressing trimethoprim- resistant variations of dihydrofolate reductase. Remnants of the transposon known to carry dfr9 were observed in its context on the Campylobacter chromosome, and the dfr1 was found as an integron cassette (see Chapter 10). The occurrence of these genes could, of course, mediate a very high resistance to trimethoprim, but as mentioned earlier, it is known that C.
Families may benefit from participation in support groups offered through the hospital purchase vardenafil with a mastercard erectile dysfunction caused by vasectomy, rehabilitation facility order 10 mg vardenafil free shipping impotence 35 years old, or community organizations generic vardenafil 20mg without prescription erectile dysfunction herbs. The patient with a neurologic disorder is often pronounced brain dead before the heart stops beating. The term brain death describes irreversible loss of all functions of the entire brain, including the brain stem (Booth, Boone, Tomlinson, et al. The term may be misleading to the family because, although brain function has ceased, the patient appears to be alive, with the heart rate and blood pressure sustained by vasoactive medications and breathing continued by mechanical ventilation. When discussing a patient who is brain dead with family members, it is important to provide accurate, timely, understandable, and consistent information (Henneman & Karras, 2004). The longer the period of unconsciousness, the greater the risk for pulmonary complications. Vital signs and respiratory function are monitored closely to detect any signs of respiratory failure or distress. Total blood count and arterial blood gas measurements are assessed to determine whether there are adequate red blood cells to carry oxygen and whether ventilation is effective. Chest physiotherapy and suctioning are initiated to prevent respiratory complications such as pneumonia. If pneumonia develops, cultures are obtained to identify the organism so that appropriate antibiotics can be administered. Factors that contribute to impaired skin integrity (eg, incontinence, inadequate dietary intake, pressure on bony prominences, edema) are addressed. Care is taken to prevent bacterial contamination of pressure ulcers, which may lead to sepsis and septic shock. Prophylaxis such as subcutaneous heparin or low-molecular-weight heparin (Fragmin, Orgaran) should be prescribed if not contraindicated (Kurtoglu, Yanar, Bilsel, et al. Thigh-high elastic compression stockings or pneumatic compression devices should also be prescribed to reduce the risk for clot formation. Nursing Interventions Maintaining a Patent Airway The patency of the airway is assessed. The patient is hyperoxygenated before and after suctioning to maintain adequate oxygenation. The lung fields are auscultated at least every 8 hours to determine the presence of adventitious sounds or any areas of congestion. Elevating the head of the bed may aid in clearing secretions and improve venous drainage of the brain. Achieving an Adequate Breathing Pattern The patient must be monitored constantly for respiratory irregularities. Increased pressure on the frontal lobes or deep midline structures may result in Cheyne-Stokes respirations, whereas pressure in the midbrain can cause hyperventilation. If the lower portion of the brain stem (the pons and medulla) is involved, respirations become irregular and eventually cease. Repeated assessments of the patient are made (sometimes minute by minute) so that improvement or deterioration may be noted immediately. The head is kept in a neutral (midline) position, maintained with the use of a cervical collar if necessary, to promote venous drainage. Elevation of the head is maintained at 0 to 60 degrees to aid in venous drainage unless otherwise prescribed (Fan, 2004). When moving or being turned in bed, the patient can be instructed to exhale (which opens the glottis) to avoid the Valsalva maneuver. Before suctioning, the patient should be preoxygenated and briefly hyperventilated using 100% oxygen on the ventilator (Hickey, 2003). Corticosteroids may be used to reduce cerebral edema (except when it results from trauma), and fluids may be restricted (Brain Trauma Foundation, 2003). Skin turgor, mucous membranes, urine output, and serum and urine osmolality are monitored to assess fluid status. For the patient receiving mannitol, the nurse observes for the possible development of heart failure and pulmonary edema, because the intent of treatment is to promote a shift of fluid from the intracellular compartment to the intravascular system, thus controlling cerebral edema. For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. An output greater than 250 mL/hour for 2 consecutive hours may indicate the onset of diabetes insipidus (Suarez, 2004). These patients also need careful oral hygiene, because mouth dryness occurs with dehydration. Frequently rinsing the mouth with nondrying solutions, lubricating the lips, and removing encrustations relieve dryness and promote comfort. Most health care facilities have written protocols for managing these systems and maintaining their sterility; strict adherence to the protocols is essential. The patient is monitored for signs and symptoms of meningitis: fever, chills, nuchal (neck) rigidity, and increasing or persistent headache. The pulse pressure (the difference between the systolic and the diastolic pressures) widens. Temperature, pulse, and respirations are closely monitored for systemic signs of infection. All connections and stopcocks are checked for leaks, because even small leaks can distort pressure readings and lead to infection. For subsequent pressure readings, the head should be in the same position relative to the transducer. Fiberoptic catheters are calibrated before insertion and do not require further referencing; they do not require the head of the bed to be at a specific position to obtain an accurate reading. Whenever technology is associated with patient management, the nurse must be certain that the technological equipment is functioning properly. The most important concern, however, must be the patient who is attached to the equipment. The patient and family must be informed about the technology and the goals of its use. Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to replace and slow the urine output. Assessing respiratory function is essential, because even a small degree of hypoxia can increase cerebral ischemia. The respiratory rate and pattern are monitored, and arterial blood gas values are assessed frequently. The nurse must be alert to the development of complications; all assessments are carried out with these problems in mind. Chart 61-2 provides an overview of the nursing management of the patient who has undergone intracranial surgery. Seizures are a potential complication, and any seizure activity is carefully recorded and reported.
It provides detail about the anatomy of the pancreas and the pancreatic and biliary ducts order vardenafil master card causes for erectile dysfunction and its symptoms. It is also helpful in obtaining tissue for analysis and differentiating pancreatitis from other conditions order vardenafil australia erectile dysfunction at age 27, such as carcinoma order vardenafil overnight erectile dysfunction treatment chandigarh. Medical Management The management of chronic pancreatitis depends on its probable cause in each patient. Treatment is directed toward preventing and managing acute attacks, relieving pain and discomfort, and managing exocrine and endocrine insufficiency of pancreatitis. Nonsurgical Management Nonsurgical approaches may be indicated for the patient who refuses surgery, who is a poor surgical risk, or whose disease and symptoms do not warrant surgical intervention. Endoscopy to remove pancreatic duct stones and stent strictures may be effective in selected patients to manage pain and relieve obstruction. Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents. Surgical Management Surgery is generally carried out to relieve abdominal pain and discomfort, restore drainage of pancreatic secretions, and reduce the frequency of acute attacks of pancreatitis. The surgery performed depends on the anatomic and functional abnormalities of the pancreas, including the location of disease within the pancreas, diabetes, exocrine insufficiency, biliary stenosis, and pseudocysts of the pancreas. A Whipple resection (pancreaticoduodenectomy) has been carried out to relieve the pain of chronic pancreatitis. Pancreatic Cysts As a result of the local necrosis that occurs at the time of acute pancreatitis, collections of fluid may form in the vicinity of the pancreas. Less common cysts occur as a result of congenital anomalies or are secondary to chronic pancreatitis or trauma to the pancreas. Because of their location behind the posterior peritoneum, when they enlarge they impinge on and displace the stomach or the colon, which are adjacent. Eventually, through pressure or secondary infection, they produce symptoms and require drainage Cancer of the Pancreas The incidence of pancreatic cancer has decreased slightly over the past 25 years in non-Caucasian men. It is the fifth leading cause of cancer deaths in the United States and occurs most frequently in the fifth to seventh decades of life. Cigarette smoking, exposure to industrial chemicals or toxins in the environment, and a diet high in fat, meat, or both are associated with pancreatic cancer, although their role is not completely clear. The risk for pancreatic cancer increases as the extent of cigarette smoking increases. Diabetes mellitus, chronic pancreatitis, and hereditary pancreatitis are also associated Cancer may arise in any portion of the pancreas (in the head, the body, or the tail); clinical manifestations vary depending on the location of the lesion and whether functioning, insulinsecreting pancreatic islet cells are involved. Approximately 75% of pancreatic cancers originate in the head of the pancreas and give rise to a distinctive clinical picture. Functioning islet cell tumors, 88 whether benign (adenoma) or malignant (carcinoma), are responsible for the syndrome of hyperinsulinism. Clinical Manifestations Pain, jaundice, or both are present in more than 90% of patients and, along with weight loss, are considered classic signs of pancreatic carcinoma. Other signs include rapid, profound, andprogressive weight loss as well as vague upper or midabdominal pain or discomfort that is unrelated to any gastrointestinal function and is often difficult to describe. Meals often aggravate epigastric pain, which usually occurs before the appearance of jaundice and pruritus. Assessment and Diagnostic Findings Magnetic resonance imaging and computed tomography are used to identify the presence of pancreatic tumors. Gastrointestinal x-ray findings may demonstrate deformities in adjacent viscera caused by the impinging pancreatic mass. Percutaneous fine-needle aspiration biopsy of the pancreas is used to diagnose pancreatic tumors and confirm the diagnosis Percutaneous transhepatic cholangiography is another procedure that may be performed to identify obstructions of the biliary tract by a pancreatic tumor. Intraoperative ultrasonography has been used to determine if there is metastatic disease to other organs. Medical Management If the tumor is resectable and localized (typically tumors in the head of the pancreas), the surgical procedure to remove it is usually extensiveHowever, definitive surgical treatment (ie, total excision of the lesion) is often not possible because of the extensive growth when the tumor is finally diagnosed and because of the probable widespread metastases (especially to the liver, lungs, and bones). Nursing Management Pain management and attention to nutritional requirements are important nursing measures to improve the level of comfort. Skin care and nursing measures are directed toward relief of pain and discomfort associated with jaundice, anorexia, and profound weight loss. Pain associated with pancreatic cancer may be severe and may require liberal use of opioids; Promoting Home and Community-Based Care specific patient and family teaching indicated varies with the stage of disease and the treatment choices made by the patient. If the patient elects to receive chemotherapy, the nurse focuses teaching on prevention of side effects and complications of the agents used. If surgery is performed to relieve obstruction and establish biliary drainage, teaching addresses management of the drainage system and monitoring for complications. Continuing Care A referral for home care is indicated to help the patient and family deal with the physical problems and discomforts associated with pancreatic cancer and the psychological impact of the disease. The home care nurse assesses the patient‘s physical status, fluid and nutritional status, and skin integrity and the adequacy of pain management. Tumors Of The Headof The Pancreas Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region of the pancreas obstruct the common bile duct where the duct passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The tumors producing the obstruction may arise from the pancreas, the common bile duct, or the ampulla of Vater. Clinical Manifestations The obstructed flow of bile produces jaundice, clay-colored stools, and dark urine. Malabsorption of nutrients and fat-soluble vitamins may result from obstruction by the tumor to entry of bile in the gastrointestinal tract. Medical Management Before extensive surgery can be performed, a fairly long period of preparation is often necessary because the patient‘s nutritional and physical condition is often quite compromised. Preoperative preparation includes adequate hydration, correction of prothrombin deficiency with vitamin K, and treatment of anemia to minimize postoperative complications. Total pancreatectomy (removal of the pancreas) may be performed if there is no evidence of direct extension of the tumor to adjacent tissues or regional lymph nodes. A pancreaticoduodenectomy (Whipple‘s procedure or resection) is used for potentially resectable cancer of the head of the pancreas79 This procedure involves removal of the gallbladder, distal portion of the stomach, duodenum, head of the pancreas, and common bile duct and anastomosis of the remaining pancreas and stomach to the jejunum The result is removal of the tumor, allowing flow of bile into the jejunum. When the tumor cannot be excised, the jaundice may be relieved by diverting the bile flow into the jejunum by anastomosing the jejunum to the gallbladder, a procedure known as cholecystojejunostomy. It is important to give careful attention to changes in vital signs, arterial blood gases and pressures, pulse oximetry, laboratory values,and urine output. The nurse must also consider the patient‘s compromised nutritional status and risk for bleeding. At that time, the nurse instructs the patient about the need to avoid smoking, to enhance pulmonary recovery postoperatively and to avoid respiratory complications. It also is important to instruct the patient to avoid the use of aspirin and other agents (over-the- counter medications and herbal remedies) that can alter coagulation and other biochemical processes. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion.
Free perforations and fecal peritonitis may occur occasionally discount vardenafil 10 mg fast delivery erectile dysfunction due to zoloft, but most perforations are localized and Figure 21 order 10 mg vardenafil fast delivery erectile dysfunction viagra. A 14- year-old boy is brought to the emergency department by anxious parents because he has been vomiting and has abdominal pain generic vardenafil 20mg line erectile dysfunction medications in india. Laparotomy Laparoscopy Shorter time in operating room Diagnosis of other conditions Lesser cost of operation Decreased wound infection Overall lesser cost of hospital stay Minimal decrease in hospital stay Possibly less risk of intraabdominal Possible decrease in time for abscess in perforated cases convalescence and return to work or normal activity Source: Based on meta-analysis and reviews of prior prospective controlled randomized trials (level I evidence), including Br J Surg 1997;84:1045–1050, Dis Colon Rectum 1998;41:398–403, J Am Coll Surg 1998;186:545–553. Small intestinal diverticuli are less common, but these do occur in the distal duodenum and the periampullary region. Of special inter- est, particularly in younger individuals, is the congenital Meckel’s diverticulum of the distal ileum. This diverticulum is capable of developing inﬂammatory diverticulitis, may invaginate, and may lead to an intussusception, or, because it often contains ectopic gastric mucosa, it may cause peptic ulceration at its base with bleeding or perforation. If he does not improve, further management may be required, such as abscess drainage done percutaneously or operative resection of the diseased colon with a temporary colostomy if there is ongoing infection. Acute Cholecystitis and Cholangitis The most common pain syndrome associated with gallbladder dys- function occurs as a result of transient mechanical outlet obstruction or dyskinetic motor activity. Typically, the patient develops a pressure- like pain in the right upper quadrant or epigastric area that may radiate to the right subscapular area. A 77-year-old woman is brought to the ofﬁce with severe left lower quadrant pain, tenderness, and fever. This syndrome often is called “gallbladder or biliary colic” and can be variable in duration and intensity and intermittent or constant in nature. Severe or fre- quently recurring episodes usually initiate ultrasonic examination of the biliary tree; demonstration of gallstones is the most common indi- cation for elective cholecystectomy. A 77-year-old woman is brought to the ofﬁce with severe left lower quadrant pain, tenderness, and fever. Contrast enema shows numerous diverticula, spasm, and intramural per- foration, ﬁndings that are consistent with acute sigmoid diverticulitis. Wise When the obstructive process is not self-limiting and invasive infec- tion of the gallbladder wall occurs, the pathologic process has advanced to acute cholecystitis. The gallbladder wall is thickened by the edema of the inﬂammatory process, and pus may accumulate within the lumen (empyema of the gallbladder) or gas may be detected within the lumen or wall as a result of gas-producing bacteria (emphy- sema or the gallbladder). The severity of this infectious process is vari- able, but it may advance to necrosis of the gallbladder. Clinically, the patient develops fever, tachycardia, malaise, and poly- morphonuclear leukocytosis. Abdominal examination demonstrates right upper quadrant tenderness and involuntary muscle guarding. Murphy’s sign, the abrupt cessation of inspiratory effort during palpation in the right subcostal area, occurs when the inﬂamed gallbladder descends to encounter pressure from the examiner’s ﬁngers. Treatment may be immediate cholecystec- tomy or a period of “cooling off” and interval cholecystectomy (Table 21. Although jaundice may occur with acute cholecystitis, in the absence of obstruction the bilirubin levels usually are not elevated greatly. Migration of stones from the gallbladder into the bile ducts with varying degrees of obstruction is more likely to account for signiﬁcant jaundice. Obstruction of the bile ducts that occurs acutely usually pro- duces a pain syndrome not unlike that produced by cardiac ischemia. The pain may be severe, is relatively constant and pressing in nature, and is located high in the epigastrium or the lower substernal area. Obstruction of the bile ducts that occurs gradually, as is characteristic Figure 21. A 52-year-old woman pre- sents with acute right upper quadrant pain, tenderness, and fever. Ultrasound shows a thickened gallbladder wall and gallstones, ﬁndings that are consistent with acute cholecystitis and cholelithiasis. A 52-year-old woman presents with acute right upper quadrant pain, tenderness, and fever. Painless or silent jaundice, as it often is referred to, traditionally is attributed to a malignant extrahepatic obstruction, but this clearly is not always the case. Ascending cholangitis, a serious infection of the bile ducts, almost always is associated with the presence of obstructing foreign bodies, such as stones, sludge, or parasites. These bacteremic patients often exhibit Charcot’s triad: upper abdominal pain, chills and fever, and jaundice. In the most severe cases, patients exhibit circulatory insufﬁ- ciency and impaired mental function as a result of septic shock. Because of its high mortality, ascending cholangitis requires rapid intervention with intra- venous antibiotics and drainage of the biliary tract. Drainage is per- formed best by endoscopic sphincterotomy and placement of a ductal drain, but when this is not possible, open surgical choledochotomy and T-tube drainage is indicated. Pancreatitis Probably the most protean of intraabdominal inﬂammatory condi- tions productive of severe abdominal pain is acute pancreatitis. Usually abrupt in onset, an attack of pancreatitis may be mild and self-limiting or rapidly may progress to a catastrophic local and sys- temic life-threatening event. In the severest of cases, necrotizing hemorrhagic pancreatitis, the initial visceral inﬂammation rapidly progresses to widespread retroperitoneal and intraoperitoneal inﬂam- mation, tissue destruction, and bleeding. Cholecystitis Herpes zoster Choledocholithiasis Myocardial ischemia Hepatitis Pericarditis Hepatic abscess Pneumonia Hepatomegaly from congestive heart failure Empyema Peptic ulcer Gastritis Pancreatitis Duodenitis Retrocecal appendicitis Intestinal obstruction Pyelonephritis Inﬂammatory bowel disease Nephrolithiasis bacterial infection occurs due to loss of alimentary tract and lymphatic integrity. The etiology of pancreatitis is quite variable, but the majority of cases are due to either transient gallstone obstruction of the common pan- creaticobiliary ampulla or destructive effects of alcohol abuse. Initially, the patient experiences severe upper abdominal band-like pain that radiates to the back, is aggravated by recumbency, and partially relieved by sitting or leaning forward. Elevations of serum amylase and lipase are highly diagnostic for acute pancreatitis, and these levels most likely are elevated when drawn shortly after the onset of symptoms. The extent of the elevation, however, is not related directly to the severity of the process. Evidence of hypoxia, cardiac and renal dysfunction, and systemic acidosis, par- ticularly lactic acidosis, has negative prognostic implications. Diminished perfusion of the pancreas and peripan- creatic areas implies hemorrhage or necrosis, while gas in the soft tissues suggests secondary bacterial infection. Gallstone-induced pancreatitis rarely requires emergency surgery for removal of a stone impacted at the distal end of the bile duct. There is evidence that, unless increasing jaundice supervenes, the gallstone probably has passed on into the duodenum. Most cases are mild, and treatment with supportive care and observation usually results in clin- ical improvement within a few days, at which time cholecystectomy, intraoperative cholangiography, and the occasional choledocholithot- omy, when indicated, complete the treatment. Seriously ill patients with multiple risk factors should be treated in an intensive care unit where monitoring and treatment of multisystem organ failure can be performed. Early surgery is generally contraindi- cated, but it may be required where there is evidence of continued intraabdominal hemorrhage or the cause of the intraabdominal catas- trophe is not clear.