Prevention of a First Variceal Hemorrhage

Patients with cirrhosis should be endoscopically screened for varices so that appropriate therapy can be initiated if varices are present. Because the prevalence of varices increases with the severity of liver disease, screening is based on Child's classification at the time of the diagnosis of cirrhosis. Patients with Child's Class A cirrhosis should be screened when there is evidence of portal hypertension, such as thrombocytopenia (platelets less than 140,000 per mm3), an enlarged portal vein (diameter > 13 mm), or evidence of collateral circulation on ultrasound. Screening should occur in anyone with Child's Class B or C cirrhosis at the time of the diagnosis of cirrhosis. If the patient is free from varices at initial screening, follow up endoscopy should be carried out. The timing of follow up will vary with the etiology of the patient's liver disease. Patients with ALD require more frequent screening (every 1 to 2 years), whereas those with cirrhosis due to hepatitis C only need to be screened every 3 to 5 years. If small (< 5 mm) varices are present initially, endoscopy should be repeated every 1 to 2 years to monitor for variceal enlargement. There is currently no evidence to recommend treatment in patients who lack varices or who present with small varices. All patients with medium or large varices, however, should receive treatment aimed at preventing variceal bleeding, either pharmacologic (Table 117-2) or endoscopic.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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