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  • 43

    Enviado por

    Carlos Hernández
    16 visualizações201 páginas

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    43.txt

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    43

    Enviado por

    Carlos Hernández

    Direitos autorais:

    © All Rights Reserved
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    de 201

    var title_f0_43_688="CBD transection MRCP";

    var content_f0_43_688=[" <div id=\"graphicsToolbar\">",


    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
    " <div id=\"graphicsLinks\">",
    " <a href=\"?imageKey=GAST
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    " <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
    title=\"Print this page\"/>",
    " </a>",
    " <a class=\"icontxt textLink\" href=\"?imageKey=GAST
    %2F70654&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\"
    title=\"Print this page\">",
    " Print",
    " </a>",
    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
    title=\"Email graphic(s)\"/>",
    " </a>",
    " <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
    " Email",
    " </a>",
    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 470px\">",
    " <div class=\"ttl\">",
    " Complete common bile duct transection after cholecystectomy",
    " </div>",
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    ,
    " </div>",
    " <div class=\"lgnd\">",
    " MRCP showing absence of the common bile duct and dilated intrahepatic ducts in
    a patient with complete transection of the common bile duct. A pool of fluid is
    seen at the confluence of the right and left hepatic ducts (arrow).",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Courtesy of Michael J Bourke, MBBS, FRACP.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_43_688=[""].join("\n");
    var outline_f0_43_688=null;
    var title_f0_43_689="Axial CT six months";
    var content_f0_43_689=[" <div id=\"graphicsToolbar\">",
    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
    " <div id=\"graphicsLinks\">",
    " <a href=\"?imageKey=ONC
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    " </a>",
    " <a class=\"icontxt textLink\" href=\"?imageKey=ONC
    %2F67299&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=2\" onclick=\"\"
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    " Print",
    " </a>",
    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
    title=\"Email graphic(s)\"/>",
    " </a>",
    " <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
    " Email",
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    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 470px\">",
    " <div class=\"ttl\">",
    " Axial CT six months",
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    " </div>",
    " <div class=\"lgnd\">",
    " A 77-year-old woman with biopsy-proven 1.8 cm left lower lobe adenocarcinoma
    (stage IA NSCLC) who was not considered a surgical candidate due to chronic
    obstructive pulmonary disease and cardiac risk factors. Contrast-enhanced axial CT
    at six-months. The area treated has decreased in size without evidence of
    enhancement (arrow), findings consistent with successful tumor ablation. A small
    calcified granuloma is present anteriorly.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Courtesy of Schirmang, T, MD and Dupuy, D, MD.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
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    var title_f0_43_690="Erythema multiforme elbow";
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    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
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    " <a class=\"icontxt textLink\" href=\"?imageKey=DERM
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    " Print",
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    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
    title=\"Email graphic(s)\"/>",
    " </a>",
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    " Email",
    " </a>",
    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 470px\">",
    " <div class=\"ttl\">",
    " Erythema multiforme",
    " </div>",
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    nsxAwD+dNmjktZmiuEAcYOVOQwPQgjqDWrNE6X1hI1zJG9uAAqRM/mc5LoVGG355z61na5IBcwxAAPEhDqD
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    7m6mr2nqCQSB93P5UUVMjSHQ5fVL2a9uS07ZCZVVHAUewqlRRXVHY45O7YUUUUyQooooAWiiigBKWiigApK
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    PHaiigtI//2Q==);\">",
    " </div>",
    " <div class=\"lgnd\">",
    " This child with erythema multiforme has multiple erythematous plaques and some
    vesicles on the elbows. A few true target lesions are present.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Reproduced with permission from: www.visualdx.com. Copyright Logical Images,
    Inc.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_43_690=[""].join("\n");
    var outline_f0_43_690=null;
    var title_f0_43_691="Nedocromil: Drug information";
    var content_f0_43_691=[" <noscript>",
    " <div id=\"javascriptDisabled\">",
    " It seems to us that you have your JavaScript turned off on your browser.
    JavaScript is required in order for our site to behave correctly. Please enable
    your JavaScript to continue use our site.",
    " </div>",
    " </noscript>",
    " <div id=\"printHeader\">",
    " <div id=\"printHeaderLogo\">",
    " <img alt=\"UpToDate\" src=\"./../images/UTD2_masthead.myextg\">",
    " <img align=\"right\" alt=\"Wolters Kluwer Health\" height=\"40\"
    src=\"./../images/logoWKH.myextg\" width=\"175\">",
    " <br>",
    " <div id=\"printHeaderText\">",
    " Official reprint from UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " <br>",
    " <a href=\"file://www.uptodate.com\">",
    " www.uptodate.com",
    " </a>",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
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    " </br>",
    " </div>",
    " </br>",
    " </img>",
    " </img>",
    " </div>",
    " <div id=\"printHeaderLinks\">",
    " <a class=\"TOPIC\" href=\"#\" id=\"printHeaderPrint\" rel=\"2\" title=\"Click
    here to print\">",
    " Print",
    " </a>",
    " <span class=\"pipeSpace\">",
    " |",
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    " <a href=\"#\" id=\"printHeaderBack\" title=\"Back to normal view\">",
    " Back",
    " </a>",
    " </div>",
    " </div>",
    " <!-- TC:TOPIC_PAGE -->",
    " <div id=\"topicContent\">",
    " <div id=\"drugTitle\">",
    " Nedocromil: Drug information",
    " </div>",
    " <div id=\"lexiTitleImg\">",
    " <img height=\"17\" src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\"
    width=\"71\"/>",
    " </div>",
    " <div class=\"clear\">",
    " </div>",
    " <div id=\"drugCopy\">",
    " Copyright 1978-2013 Lexicomp, Inc. All rights reserved.",
    " </div>",
    " <div id=\"topicText\">",
    " (For additional information",
    " <a class=\"drug drug_patient\" href=\"UTD.htm?7/41/7828?source=see_link\">",
    " see \"Nedocromil: Patient drug information\"",
    " </a>",
    " and",
    " <a class=\"drug drug_pediatric\" href=\"UTD.htm?22/37/23122?
    source=see_link\">",
    " see \"Nedocromil: Pediatric drug information\"",
    " </a>",
    " )",
    " <br/>",
    " For abbreviations and symbols that may be used in Lexicomp (",
    " <a class=\"graphic graphic_table\" href=\"UTD.htm?23/39/24183\">",
    " show table",
    " </a>",
    " )",
    " <div class=\"list ubnlist drugH1Div drugBrandNames\" id=\"F200225\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Brand Names: U.S.",
    " </span>",
    " <ul>",
    " <li>",
    " Alocril&reg;",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"list cbnlist drugH1Div drugBrandNames\" id=\"F200226\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Brand Names: Canada",
    " </span>",
    " <ul>",
    " <li>",
    " Alocril&reg;",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ex_sect_xr thclist drugH1Div drugBrandNames\" id=\"F200259\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Pharmacologic Category",
    " </span>",
    " <ul>",
    " <li>",
    " Mast Cell Stabilizer",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"block doa drugH1Div\" id=\"F200228\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Dosing: Adult",
    " </span>",
    " <p style=\"text-indent:0em;text-align:justify;display:inline\">",
    " <b>",
    " Allergic conjunctivitis:",
    " </b>",
    " Ophthalmic: 1-2 drops in each eye twice daily throughout the period of
    exposure to allergen",
    " </p>",
    " </div>",
    " <div class=\"block dop drugH1Div\" id=\"F200243\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Dosing: Pediatric",
    " </span>",
    " <p>",
    " (For additional information",
    " <a class=\"drug drug_pediatric\" href=\"UTD.htm?22/37/23122?
    source=see_link\">",
    " see \"Nedocromil: Pediatric drug information\"",
    " </a>",
    " )",
    " </p>",
    " <p style=\"text-indent:0em;display:inline\">",
    " <b>",
    " Allergic conjunctivitis:",
    " </b>",
    " Ophthalmic: Children &ge;3 years: Refer to adult dosing.",
    " </p>",
    " </div>",
    " <div class=\"block doe drugH1Div\" id=\"F200229\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Dosing: Geriatric",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Refer to adult dosing.",
    " </p>",
    " </div>",
    " <div class=\"block foc drugH1Div\" id=\"F200207\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Dosage Forms: U.S.",
    " </span>",
    " <p style=\"text-indent:0em;text-align:justify;display:inline\">",
    " Excipient information presented when available (limited, particularly for
    generics); consult specific product labeling.",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " Solution, ophthalmic, as sodium [drops]:",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Alocril&reg;: 2% (5 mL) [contains benzalkonium chloride]",
    " </p>",
    " </div>",
    " <div class=\"block geq drugH1Div\" id=\"F200196\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Generic Equivalent Available: U.S.",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " No",
    " </p>",
    " </div>",
    " <div class=\"block adm drugH1Div\" id=\"F5283261\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Administration",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " For ophthalmic use only; do not allow tip of container to touch eye,
    surrounding structures, fingers, or other surfaces to avoid bacterial
    contamination.",
    " </p>",
    " </div>",
    " <div class=\"block use drugH1Div\" id=\"F200210\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Use",
    " </span>",
    " <p style=\"text-indent:0em;text-align:justify;display:inline\">",
    " Treatment of itching associated with allergic conjunctivitis",
    " </p>",
    " </div>",
    " <div class=\"block ars drugH1Div\" id=\"F200257\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Adverse Reactions Significant",
    " </span>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " &gt;10%:",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Central nervous system: Headache",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Gastrointestinal: Unpleasant taste",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Ocular: Burning, irritation, stinging",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Respiratory: Nasal congestion",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " 1% to 10%:",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Ocular: Conjunctivitis, eye redness, photophobia",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Respiratory: Asthma, rhinitis",
    " </p>",
    " </div>",
    " <div class=\"block coi drugH1Div\" id=\"F200213\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Contraindications",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Hypersensitivity to nedocromil or any component of the formulation",
    " </p>",
    " </div>",
    " <div class=\"block war drugH1Div\" id=\"F200199\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Warnings/Precautions",
    " </span>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " <b>",
    " <i>",
    " Dosage form specific issues:",
    " </i>",
    " </b>",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " &bull; Ophthalmic solution: Contains benzalkonium chloride, which may be
    absorbed by contact lenses; users of contact lenses should not wear them during
    periods of symptomatic allergic conjunctivitis.",
    " </p>",
    " </div>",
    " <div class=\"block cyt drugH1Div\" id=\"F13299748\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Metabolism/Transport Effects",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " None known.",
    " </p>",
    " </div>",
    " <div class=\"block dri drugH1Div\" id=\"F6221824\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Drug Interactions",
    " </span>",
    " <br/>",
    " <br/>",
    " <div class=\"lexi\" id=\"lexiInteractAddInfo\">",
    " (For additional information:",
    " <a class=\"dip\" href=\"./drug-interaction\" target=\"_blank\">",
    " Launch Lexi-Interact&trade; Drug Interactions Program",
    " </a>",
    " )",
    " </div>",
    " <div class=\"lexi\" id=\"lexiInteractImgB\">",
    " <img border=\"0\" height=\"17\"
    src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\" width=\"71\"/>",
    " </div>",
    " <div class=\"clear\">",
    " </div>",
    " <p style=\"text-indent:0em;display:inline\">",
    " There are no known significant interactions.",
    " </p>",
    " </div>",
    " <div class=\"block prf drugH1Div\" id=\"F200204\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Pregnancy Risk Factor",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " B (",
    " <a class=\"graphic graphic_table\" href=\"UTD.htm?16/42/17068\">",
    " show table",
    " </a>",
    " )",
    " </p>",
    " </div>",
    " <div class=\"block pri drugH1Div\" id=\"F5282499\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Pregnancy Implications",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " There are no well-controlled studies in pregnant women. Animal studies show
    no evidence of teratogenicity or harm to fetus. Additionally, nedocromil has
    minimal systemic absorption.",
    " </p>",
    " </div>",
    " <div class=\"block lac drugH1Div\" id=\"F200231\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Lactation",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Excretion in breast milk unknown/use caution",
    " </p>",
    " </div>",
    " <div class=\"block fee drugH1Div\" id=\"F200215\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Pricing: U.S. (Medi-Span&reg;)",
    " </span>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " <b>",
    " Solution",
    " </b>",
    " (Alocril Ophthalmic)",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " 2% (5 mL): $142.54",
    " </p>",
    " </div>",
    " <div class=\"list fbnlist drugH1Div drugBrandNames\" id=\"F200216\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " International Brand Names",
    " </span>",
    " <ul>",
    " <li>",
    " Brionil (ES);",
    " </li>",
    " <li>",
    " Cetimil (ES);",
    " </li>",
    " <li>",
    " Halamid (DE);",
    " </li>",
    " <li>",
    " Ildor (ES);",
    " </li>",
    " <li>",
    " Irtan (DE, MX);",
    " </li>",
    " <li>",
    " Kovilen (IT);",
    " </li>",
    " <li>",
    " Kovinal (IT);",
    " </li>",
    " <li>",
    " Nedocromil-Natrium &rdquo;Schoeller Pharma&rdquo; (AT);",
    " </li>",
    " <li>",
    " Telavist (FR);",
    " </li>",
    " <li>",
    " Tilad (ES);",
    " </li>",
    " <li>",
    " Tilade (AR, AT, BR, CZ, DE, DK, ES, FI, GB, GR, HU, ID, IE, IT, LU, NL,
    PL);",
    " </li>",
    " <li>",
    " Tilade CFC Free (AU);",
    " </li>",
    " <li>",
    " Tilade Mint (AE, BH, CY, EG, IL, IQ, IR, JO, KW, LB, LY, OM, QA, SA, SY,
    YE);",
    " </li>",
    " <li>",
    " Tilarin (AT, FI, IT, PL);",
    " </li>",
    " <li>",
    " Tilavist (AT, CH, DK, ES, IL, IT, NL, NO, PL, PT, SE)",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"block pha drugH1Div\" id=\"F200198\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Mechanism of Action",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Inhibits the activation of and mediator release from a variety of
    inflammatory cell types associated with hypersensitivity reactions including
    eosinophils, neutrophils, macrophages, mast cells, monocytes, and platelets; it
    inhibits the release of histamine, leukotrienes, and slow-reacting substance of
    anaphylaxis.",
    " </p>",
    " </div>",
    " <div class=\"block phk drugH1Div\" id=\"F200212\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Pharmacodynamics/Kinetics",
    " </span>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " Absorption: Low (&lt;4%)",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " Excretion: Urine 70% (as unchanged drug); feces 30% (as unchanged drug)",
    " </p>",
    " </div>",
    " </div>",
    " <div id=\"topicAgreement\">",
    " Use of UpToDate is subject to the",
    " <a class=\"licenseLink\" href=\"./license\" id=\"sla_in_page\"
    target=\"_blank\">",
    " Subscription and License Agreement",
    " </a>",
    " .",
    " </div>",
    " <div id=\"topicVersionRevision\">",
    " Topic 9987 Version 31.0",
    " </div>",
    " </div>",
    " <div id=\"footer\">",
    " <div id=\"supportFooter\">",
    " <span class=\"sfInfo\">",
    " &copy; 2013 UpToDate, Inc. All rights reserved.",
    " </span>",
    " <span class=\"pipeSpace\">",
    " |",
    " </span>",
    " <a class=\"licenseLink\" href=\"./license\" id=\"sla_footer\">",
    " Subscription and License Agreement",
    " </a>",
    " <span class=\"sfInfo\">",
    " <span class=\"pipeSpace\">",
    " |",
    " </span>",
    " Release: 21.6- C21.56",
    " </span>",
    " <br/>",
    " <span class=\"sfInfo\">",
    " Licensed to:",
    " <span class=\"emphasis\">",
    " AsanBook Dig. Med. Lib.",
    " </span>",
    " </span>",
    " <span class=\"sfInfo\">",
    " <span class=\"pipeSpace\">",
    " |",
    " </span>",
    " Support Tag: [1003-61.234.146.186-AFBC45AB80-S244013.14]",
    " <br/>",
    " </span>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_43_691=[""].join("\n");
    var outline_f0_43_691=[" <div id=\"toggleOutline\">",
    " <a href=\"#\" title=\"Collapse Topic Outline\">",
    " <img alt=\"\" src=\"./../images/orange_arrow_left.myextg\"/>",
    " </a>",
    " </div>",
    " <div id=\"innerOutline\">",
    " <h1>",
    " TOPIC OUTLINE",
    " </h1>",
    " <div id=\"outline\">",
    " <ul>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200225\">",
    " Brand Names: U.S.",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200226\">",
    " Brand Names: Canada",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200259\">",
    " Pharmacologic Category",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200228\">",
    " Dosing: Adult",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200243\">",
    " Dosing: Pediatric",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200229\">",
    " Dosing: Geriatric",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200207\">",
    " Dosage Forms: U.S.",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200196\">",
    " Generic Equivalent Available: U.S.",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F5283261\">",
    " Administration",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200210\">",
    " Use",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200257\">",
    " Adverse Reactions Significant",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200213\">",
    " Contraindications",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200199\">",
    " Warnings/Precautions",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F13299748\">",
    " Metabolism/Transport Effects",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
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    " Pregnancy Implications",
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    " Lactation",
    " </a>",
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    " <a class=\"outlineLink\" href=\"#F200215\">",
    " Pricing: U.S. (Medi-Span&reg;)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200216\">",
    " International Brand Names",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200198\">",
    " Mechanism of Action",
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    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F200212\">",
    " Pharmacodynamics/Kinetics",
    " </a>",
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    " <h1>",
    " <div class=\"openRelatedGraphics\" id=\"DRUG_GEN/9987\" rel=\"outline_link\">",
    " GRAPHICS",
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    var title_f0_43_692="Patient information: Type 1 diabetes (The Basics)";
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    " <img src=\"file://www.uptodate.com/images/basics-more-title.png\"/>",
    " </h4>",
    " <dl>",
    " <dt class=\"basics\">",
    " The Basics",
    " </dt>",
    " <dd>",
    " <a href=\"UTD.htm?36/52/37699\">",
    " Patient information: Carb counting and your child&rsquo;s diet (The
    Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?38/26/39331\">",
    " Patient information: Checking your child&rsquo;s blood sugar level (The
    Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?35/40/36483\">",
    " Patient information: Diabetes and diet (The Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?19/52/20292\">",
    " Patient information: Diabetes and infections (The Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?11/34/11810\">",
    " Patient information: Diabetic retinopathy (The Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?5/33/5651\">",
    " Patient information: Giving your child insulin (The Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?0/14/227\">",
    " Patient information: Hemoglobin A1C tests (The Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?35/25/36243\">",
    " Patient information: Keeping your child&rsquo;s blood sugar under control
    (The Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?14/12/14531\">",
    " Patient information: Low blood sugar in people with diabetes (The
    Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?37/11/38066\">",
    " Patient information: Managing diabetes in school (The Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?17/48/18179\">",
    " Patient information: My child has diabetes: How will we manage? (The
    Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?19/47/20208\">",
    " Patient information: Nerve damage caused by diabetes (The Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?6/47/6899\">",
    " Patient information: Should I switch to an insulin pump? (The Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?21/40/22144\">",
    " Patient information: The ABCs of diabetes (The Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?32/44/33475\">",
    " Patient information: Type 2 diabetes (The Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?27/58/28579\">",
    " Patient information: Using insulin (The Basics)",
    " </a>",
    " </dd>",
    " <dt class=\"beyondthebasics\">",
    " Beyond the Basics",
    " </dt>",
    " <dd>",
    " <a href=\"UTD.htm?34/31/35317\">",
    " Patient information: Diabetes mellitus type 1: Insulin treatment (Beyond
    the Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?35/26/36259\">",
    " Patient information: Diabetes mellitus type 1: Overview (Beyond the
    Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?24/4/24644\">",
    " Patient information: Diabetic kidney disease (diabetic nephropathy)
    (Beyond the Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?3/63/4083\">",
    " Patient information: Hypoglycemia (low blood sugar) in diabetes mellitus
    (Beyond the Basics)",
    " </a>",
    " </dd>",
    " <dd>",
    " <a href=\"UTD.htm?3/20/3397\">",
    " Patient information: Type 1 diabetes mellitus and diet (Beyond the
    Basics)",
    " </a>",
    " </dd>",
    " </dl>",
    " <div id=\"tooltipper\">",
    " </div>",
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    " <div id=\"basicsTopicLeft\">",
    " <div id=\"topicTitle\">",
    " Patient information: Type 1 diabetes (The Basics)",
    " </div>",
    " <span class=\"view\">",
    " View in",
    " <a class=\"lang\" href=\"./es-419/type-1-diabetes-the-basics?
    source=topic_page\">",
    " Spanish",
    " </a>",
    " </span>",
    " <a class=\"contributor contributor_credentials\" href=\"./authors-and-
    editors/patient-information\">",
    " Written by the doctors and editors at UpToDate",
    " </a>",
    " <div id=\"topicText\">",
    " <p class=\"headingAnchor\" id=\"H31795486\">",
    " <span class=\"h1\">",
    " What is type 1 diabetes?",
    " </span>",
    " &nbsp;&mdash;&nbsp;Type 1 diabetes (sometimes called type 1 &ldquo;diabetes
    mellitus&rdquo;) is a disorder that disrupts the way your body uses sugar.",
    " </p>",
    " <p>",
    " All the cells in your body need sugar to work normally. Sugar gets into
    cells with the help of a hormone called insulin. If there is not enough insulin, or
    if the body stops responding to insulin, sugar builds up in the blood. That is what
    happens to people with diabetes.",
    " </p>",
    " <p>",
    " There are two types of diabetes. People with type 1 diabetes make little or
    no insulin. People with type 2 diabetes sometimes also make too little insulin, but
    more often the problem is that their cells do not respond to insulin.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H31795493\">",
    " <span class=\"h1\">",
    " What are the symptoms of type 1 diabetes?",
    " </span>",
    " &nbsp;&mdash;&nbsp;The symptoms include:",
    " </p>",
    " <p>",
    " <ul class=\"bulletCompact-block\">",
    " <li>",
    " Intense thirst",
    " </li>",
    " <li>",
    " Being very tired",
    " </li>",
    " <li>",
    " Urinating often",
    " </li>",
    " <li>",
    " Losing weight",
    " </li>",
    " <li>",
    " Blurred vision",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " In extreme cases, type 1 diabetes can also cause nausea or vomiting, belly
    pain, and panting.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H31795500\">",
    " <span class=\"h1\">",
    " How do I know if I have type 1 diabetes?",
    " </span>",
    " &nbsp;&mdash;&nbsp;Your doctor or nurse can do a blood test to measure the
    amount of sugar in your blood. The test will show whether you have diabetes. If you
    do, your doctor or nurse can then decide whether it is type 1 or type 2&mdash;based
    on your age, your weight, and other factors.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H31795507\">",
    " <span class=\"h1\">",
    " How is type 1 diabetes treated?",
    " </span>",
    " &nbsp;&mdash;&nbsp;Treatment for type 1 diabetes involves two key parts:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Measuring your blood sugar often, to make sure it does not get too high or
    too low. (Your doctor or nurse will explain how to measure your blood sugar, and
    how often to do it.)",
    " </li>",
    " <li>",
    " Using insulin shots or an insulin pump to keep your blood sugar levels in
    the right range. (An insulin pump is a device that you wear close to your body. It
    is connected to tube that goes under your skin and supplies insulin.)",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " People with type 1 diabetes also need to carefully plan their meals and
    activity levels. That's because eating raises blood sugar, while being active
    lowers it. Despite the need to plan, people with diabetes can have normal diets, be
    active, eat out, and do all the things that most other people do.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H31795514\">",
    " <span class=\"h1\">",
    " How often do I need to see my doctor or nurse?",
    " </span>",
    " &nbsp;&mdash;&nbsp;You will probably need to see your doctor or nurse at
    least 3 or 4 times a year. Sometimes you will need more visits to learn how to
    manage your diabetes or if your blood sugar is not well controlled.",
    " </p>",
    " <p>",
    " During your visits, your doctor or nurse will want to measure your blood
    sugar using a test called &ldquo;A1c.&rdquo; This test tells you your average blood
    sugar level over the last few months. Its results will help your doctor or nurse
    decide whether to adjust your treatment.",
    " </p>",
    " <p>",
    " During some of your visits, your doctor or nurse will also check other
    aspects of your health. For instance, he or she might measure your blood pressure
    or cholesterol. It is very important that you keep all your appointments with your
    doctor or nurse.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H31795521\">",
    " <span class=\"h1\">",
    " Why is it important to keep my blood sugar close to normal?",
    " </span>",
    " &nbsp;&mdash;&nbsp;Having high blood sugar can cause serious problems over
    time. It can lead to:",
    " </p>",
    " <p>",
    " <ul class=\"bulletCompact-block\">",
    " <li>",
    " Nerve damage",
    " </li>",
    " <li>",
    " Kidney disease",
    " </li>",
    " <li>",
    " Vision problems (or even blindness)",
    " </li>",
    " <li>",
    " Pain or loss of feeling in the hands and feet",
    " </li>",
    " <li>",
    " The need to have fingers, toes, or other body parts removed (amputated)",
    " </li>",
    " <li>",
    " Heart disease and strokes",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " Having",
    " <strong>",
    " low",
    " </strong>",
    " blood sugar can cause problems, too. It can make your heart beat fast, and
    make you shake and sweat. If blood sugar gets really low, it can cause more serious
    problems, too. People with very low blood sugar can get headaches, get very sleepy,
    pass out, or even have seizures.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H31795528\">",
    " <span class=\"h1\">",
    " Why is it important to keep my blood pressure and cholesterol low?",
    " </span>",
    " &nbsp;&mdash;&nbsp;People with diabetes have a much higher risk of heart
    disease and strokes than people who do not have diabetes. Keeping blood pressure
    and cholesterol low can help lower those risks.",
    " </p>",
    " <p>",
    " If your doctor or nurse puts you on blood pressure or cholesterol medicines,
    be sure to take them. Studies show that these medicines can prevent heart attacks,
    strokes, and even death.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H31795535\">",
    " <span class=\"h1\">",
    " What if I want to get pregnant?",
    " </span>",
    " &nbsp;&mdash;&nbsp;Many women with type 1 diabetes have healthy pregnancies.
    If you want to have a baby, make sure you control your blood sugar really well
    before and during pregnancy. This will protect you and your baby from problems.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H31795542\">",
    " <span class=\"h1\">",
    " More on this topic",
    " </span>",
    " </p>",
    " <p>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?35/40/36483?
    source=see_link\">",
    " Patient information: Diabetes and diet (The Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?0/14/227?
    source=see_link\">",
    " Patient information: Hemoglobin A1C tests (The Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?32/44/33475?
    source=see_link\">",
    " Patient information: Type 2 diabetes (The Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?21/40/22144?
    source=see_link\">",
    " Patient information: The ABCs of diabetes (The Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?11/34/11810?
    source=see_link\">",
    " Patient information: Diabetic retinopathy (The Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?19/47/20208?
    source=see_link\">",
    " Patient information: Nerve damage caused by diabetes (The Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?14/12/14531?
    source=see_link\">",
    " Patient information: Low blood sugar in people with diabetes (The Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?27/58/28579?
    source=see_link\">",
    " Patient information: Using insulin (The Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?35/25/36243?
    source=see_link\">",
    " Patient information: Keeping your child&rsquo;s blood sugar under control
    (The Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?17/48/18179?
    source=see_link\">",
    " Patient information: My child has diabetes: How will we manage? (The
    Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?37/11/38066?
    source=see_link\">",
    " Patient information: Managing diabetes in school (The Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?5/33/5651?
    source=see_link\">",
    " Patient information: Giving your child insulin (The Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?38/26/39331?
    source=see_link\">",
    " Patient information: Checking your child&rsquo;s blood sugar level (The
    Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?36/52/37699?
    source=see_link\">",
    " Patient information: Carb counting and your child&rsquo;s diet (The
    Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?19/52/20292?
    source=see_link\">",
    " Patient information: Diabetes and infections (The Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?6/47/6899?
    source=see_link\">",
    " Patient information: Should I switch to an insulin pump? (The Basics)",
    " </a>",
    " </p>",
    " <p>",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?34/31/35317?
    source=see_link\">",
    " Patient information: Diabetes mellitus type 1: Insulin treatment (Beyond
    the Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?35/26/36259?
    source=see_link\">",
    " Patient information: Diabetes mellitus type 1: Overview (Beyond the
    Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?3/63/4083?
    source=see_link\">",
    " Patient information: Hypoglycemia (low blood sugar) in diabetes mellitus
    (Beyond the Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?3/20/3397?
    source=see_link\">",
    " Patient information: Type 1 diabetes mellitus and diet (Beyond the
    Basics)",
    " </a>",
    " <br/>",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?24/4/24644?
    source=see_link\">",
    " Patient information: Diabetic kidney disease (diabetic nephropathy) (Beyond
    the Basics)",
    " </a>",
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    " <ul>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H31795486\">",
    " What is type 1 diabetes?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H31795493\">",
    " What are the symptoms of type 1 diabetes?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H31795500\">",
    " How do I know if I have type 1 diabetes?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H31795507\">",
    " How is type 1 diabetes treated?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H31795514\">",
    " How often do I need to see my doctor or nurse?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H31795521\">",
    " Why is it important to keep my blood sugar close to normal?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H31795528\">",
    " Why is it important to keep my blood pressure and cholesterol low?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H31795535\">",
    " What if I want to get pregnant?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H31795542\">",
    " More on this topic",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " <h1>",
    " RELATED TOPICS",
    " </h1>",
    " <div id=\"relatedTopics\">",
    " <ul>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?36/52/37699?
    source=related_link\">",
    " Patient information: Carb counting and your child&rsquo;s diet (The
    Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?38/26/39331?
    source=related_link\">",
    " Patient information: Checking your child&rsquo;s blood sugar level (The
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    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?35/40/36483?
    source=related_link\">",
    " Patient information: Diabetes and diet (The Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?19/52/20292?
    source=related_link\">",
    " Patient information: Diabetes and infections (The Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?34/31/35317?
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    " Patient information: Diabetes mellitus type 1: Insulin treatment (Beyond the
    Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?35/26/36259?
    source=related_link\">",
    " Patient information: Diabetes mellitus type 1: Overview (Beyond the
    Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?24/4/24644?
    source=related_link\">",
    " Patient information: Diabetic kidney disease (diabetic nephropathy) (Beyond
    the Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?11/34/11810?
    source=related_link\">",
    " Patient information: Diabetic retinopathy (The Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?5/33/5651?
    source=related_link\">",
    " Patient information: Giving your child insulin (The Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?0/14/227?
    source=related_link\">",
    " Patient information: Hemoglobin A1C tests (The Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?3/63/4083?
    source=related_link\">",
    " Patient information: Hypoglycemia (low blood sugar) in diabetes mellitus
    (Beyond the Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?35/25/36243?
    source=related_link\">",
    " Patient information: Keeping your child&rsquo;s blood sugar under control
    (The Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?14/12/14531?
    source=related_link\">",
    " Patient information: Low blood sugar in people with diabetes (The Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?37/11/38066?
    source=related_link\">",
    " Patient information: Managing diabetes in school (The Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?17/48/18179?
    source=related_link\">",
    " Patient information: My child has diabetes: How will we manage? (The
    Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?19/47/20208?
    source=related_link\">",
    " Patient information: Nerve damage caused by diabetes (The Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?6/47/6899?
    source=related_link\">",
    " Patient information: Should I switch to an insulin pump? (The Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?21/40/22144?
    source=related_link\">",
    " Patient information: The ABCs of diabetes (The Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?3/20/3397?
    source=related_link\">",
    " Patient information: Type 1 diabetes mellitus and diet (Beyond the Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?32/44/33475?
    source=related_link\">",
    " Patient information: Type 2 diabetes (The Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?27/58/28579?
    source=related_link\">",
    " Patient information: Using insulin (The Basics)",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " </div>"].join("\n");
    var title_f0_43_693="Dienogest: Patient drug information";
    var content_f0_43_693=[" <noscript>",
    " <div id=\"javascriptDisabled\">",
    " It seems to us that you have your JavaScript turned off on your browser.
    JavaScript is required in order for our site to behave correctly. Please enable
    your JavaScript to continue use our site.",
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    " <div id=\"printHeader\">",
    " <div id=\"printHeaderLogo\">",
    " <img alt=\"UpToDate\" src=\"./../images/UTD2_masthead.myextg\">",
    " <img align=\"right\" alt=\"Wolters Kluwer Health\" height=\"40\"
    src=\"./../images/logoWKH.myextg\" width=\"175\">",
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    " Official reprint from UpToDate",
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    " &reg;",
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    " www.uptodate.com",
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    here to print\">",
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    " <!-- TC:TOPIC_PAGE -->",
    " <div id=\"topicContent\">",
    " <div id=\"disclaimer\">",
    " The content on the UpToDate website is not intended nor recommended as a
    substitute",
    "for medical advice, diagnosis, or treatment. Always seek the advice of your own
    physician or",
    "other qualified health care professional regarding any medical questions or
    conditions. The",
    "use of this website is governed by the",
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    " UpToDate Terms of Use",
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    " &copy;2013 UpToDate, Inc.",
    " </div>",
    " <div id=\"drugTitle\">",
    " Dienogest: Patient drug information",
    " </div>",
    " <div id=\"lexiTitleImg\">",
    " <img height=\"17\" src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\"
    width=\"71\"/>",
    " </div>",
    " <div class=\"clear\">",
    " </div>",
    " <div id=\"drugCopy\">",
    " Copyright 1978-2013 Lexicomp, Inc. All rights reserved.",
    " </div>",
    " <div id=\"topicText\">",
    " <p>",
    " (For additional information",
    " <a class=\"drug drug_general\" href=\"UTD.htm?26/46/27366?source=see_link\">",
    " see \"Dienogest: Drug information\"",
    " </a>",
    " )",
    " </p>",
    " <div class=\"list cbnlist drugH1Div drugBrandNames\" id=\"F13450885\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Brand Names: Canada",
    " </span>",
    " <ul>",
    " <li>",
    " Visanne&reg;",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yya-os drugH1Div\" id=\"F13452138\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " What is this drug used for?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2691540",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " It is used to stop pain caused by endometriosis.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt coi-os drugH1Div\" id=\"F13452099\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " What do I need to tell my doctor before I take this drug?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s3576284",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you have an allergy to dienogest or any other part of this drug.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2705171",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you are allergic to any drugs, foods, or other substances. Tell your
    doctor about the allergy and what signs you had, like rash; hives; itching;
    shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or
    any other signs.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s3576322",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you have any of these health problems: Blood clots, diseased arteries in
    the brain, eyesight loss, recent heart attack, disease of a heart valve with
    problems, liver disease, liver tumor, very bad headache, tumor where estrogen makes
    it grow, or vaginal bleeding.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2701080",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you are pregnant or may be pregnant.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2701047",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you are breast-feeding.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yye-os drugH1Div\" id=\"F13452101\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " What are some things I need to know or do while I take this drug?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699677",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Keep a list of all your drugs (prescription, natural products, vitamins,
    OTC) with you. Give this list to your doctor.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2697169",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you have any blood flow problems, talk with your doctor.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2697258",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you have heart disease, talk with your doctor.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2697197",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you have high blood sugar (diabetes), talk with your doctor.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2697307",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you have mental illness, talk with your doctor.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2697315",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you have soft, brittle bones (osteoporosis), talk with your doctor.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2697012",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you are a heavy smoker, talk with the doctor.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698463",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Have your blood work checked often. Talk with your doctor.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2696717",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Check all drugs you are taking with your doctor. This drug may not mix well
    with some other drugs.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2696618",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Avoid beer, wine, or mixed drinks.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yyf-os drugH1Div\" id=\"F13452319\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " What are some side effects of this drug?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698119",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Headache.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2697997",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Low mood (depression).",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698612",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Breast soreness.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698272",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Upset stomach or throwing up. Many small meals, good mouth care, sucking
    hard, sugar-free candy, or chewing sugar-free gum may help.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698392",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Weight gain.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yyh-os drugH1Div\" id=\"F13452102\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " What are some side effects that I need to call my doctor about right away?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698721",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you think there has been an overdose, call 1-800-222-1222 (the American
    Association of Poison Control Centers), your local poison control center
    (file://www.aapcc.org), or emergency room (ER) right away.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699066",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Signs of an allergic reaction, like rash; hives; itching; red, swollen,
    blistered, or peeling skin with or without fever; wheezing; tightness in the chest
    or throat; trouble breathing or talking; unusual hoarseness; or swelling of the
    mouth, face, lips, tongue, or throat.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699077",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Signs of infection. These include a fever of 100.5&deg;F (38&deg;C) or
    higher, chills, very bad sore throat, ear or sinus pain, cough, more sputum or
    change in color of sputum, pain with passing urine, mouth sores, wound that will
    not heal, or anal itching or pain.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s3576463",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Signs of high blood pressure.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699042",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Very upset stomach or throwing up.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699050",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Very bad swelling or pain of hands or feet.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699008",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Very bad belly pain.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698706",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you are planning to harm yourself or the want to harm yourself gets
    worse.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698981",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Not able to eat.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698658",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Feeling very tired or weak.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698634",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Dark urine or yellow skin or eyes.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699049",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Very bad skin irritation.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699087",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Sudden change in eyesight.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698603",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Any rash.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698977",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Side effect or health problem is not better or you are feeling worse.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yyc-os drugH1Div\" id=\"F13452139\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " How is this drug best taken?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2695852",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Take this drug at the same time of day.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2695913",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Take with or without food.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2762619",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you throw up within 2 hours of taking this drug, take 1 more dose.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yyd-os drugH1Div\" id=\"F13452100\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " What do I do if I miss a dose?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2696563",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Take a missed dose as soon as you think about it.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2696496",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If it is close to the time for your next dose, skip the missed dose and go
    back to your normal time.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2696485",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Do not use 2 doses or extra doses.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2696457",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Do not change the dose or stop this drug. Talk with the doctor.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yyi-os drugH1Div\" id=\"F13452320\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " How do I store and/or throw out this drug?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699336",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Store at room temperature.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699266",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Store in a dry place. Do not store in a bathroom.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yyj-os drugH1Div\" id=\"F13452103\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " General drug facts",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699675",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If your symptoms or health problems do not get better or if they become
    worse, call your doctor.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699673",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Do not share your drugs with others and do not take anyone else's drugs.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699678",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Keep all drugs out of the reach of children and pets.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699709",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you have any questions about this drug, please talk with your doctor,
    pharmacist, or other health care provider.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s3302581",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " In Canada, take any unused drugs to the pharmacy. Also, visit
    file://www.hc-sc.gc.ca/hl-vs/iyh-vsv/med/disposal-defaire-eng.php#th to learn about
    the right way to get rid of unused drugs.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699677",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Keep a list of all your drugs (prescription, natural products, vitamins,
    OTC) with you. Give this list to your doctor.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699671",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " These are not all of the side effects that may occur. If you have questions
    about side effects, call your doctor. Call your doctor for medical advice about
    side effects.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699683",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Talk with the doctor before starting any new drug, including prescription
    or OTC, natural products, or vitamins.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " </div>",
    " <div id=\"topicAgreement\">",
    " Use of UpToDate is subject to the",
    " <a class=\"licenseLink\" href=\"./license\" id=\"sla_in_page\"
    target=\"_blank\">",
    " Subscription and License Agreement",
    " </a>",
    " .",
    " </div>",
    " <div id=\"topicVersionRevision\">",
    " Topic 17069 Version 8.0",
    " </div>",
    " </div>",
    " <div id=\"footer\">",
    " <div id=\"supportFooter\">",
    " <span class=\"sfInfo\">",
    " &copy; 2013 UpToDate, Inc. All rights reserved.",
    " </span>",
    " <span class=\"pipeSpace\">",
    " |",
    " </span>",
    " <a class=\"licenseLink\" href=\"./license\" id=\"sla_footer\">",
    " Subscription and License Agreement",
    " </a>",
    " <span class=\"sfInfo\">",
    " <span class=\"pipeSpace\">",
    " |",
    " </span>",
    " Release: 21.6- C21.56",
    " </span>",
    " <br/>",
    " <span class=\"sfInfo\">",
    " Licensed to:",
    " <span class=\"emphasis\">",
    " AsanBook Dig. Med. Lib.",
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    " |",
    " </span>",
    " Support Tag: [0503-61.234.146.186-71969A6E96-S244013.14]",
    " <br/>",
    " </span>",
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    " </div>",
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    " <div id=\"innerOutline\">",
    " <h1>",
    " TOPIC OUTLINE",
    " </h1>",
    " <div id=\"outline\">",
    " <ul>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F13450885\">",
    " Brand Names: Canada",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F13452138\">",
    " What is this drug used for?",
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    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F13452099\">",
    " What do I need to tell my doctor before I take this drug?",
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    " What are some things I need to know or do while I take this drug?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F13452319\">",
    " What are some side effects of this drug?",
    " </a>",
    " </li>",
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    " <a class=\"outlineLink\" href=\"#F13452102\">",
    " What are some side effects that I need to call my doctor about right away?",
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    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F13452139\">",
    " How is this drug best taken?",
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    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F13452100\">",
    " What do I do if I miss a dose?",
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    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F13452320\">",
    " How do I store and/or throw out this drug?",
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    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F13452103\">",
    " General drug facts",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " <h1>",
    " RELATED TOPICS",
    " </h1>",
    " <div id=\"relatedTopics\">",
    " <ul>",
    " <li class=\"plainItem\">",
    " <a class=\"drug drug_general\" href=\"UTD.htm?26/46/27366?
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    " Dienogest: Drug information",
    " </a>",
    " </li>",
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    var title_f0_43_694="Allergic contact dermatitis face";
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    " </div>",
    " <div class=\"lgnd\">",
    " An intense inflammatory eruption is present on the face.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Reproduced with permission from: www.visualdx.com. Copyright Logical Images,
    Inc.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_43_694=[""].join("\n");
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    var title_f0_43_695="Hemangioblastoma";
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    " <!-- TC:TOPIC_PAGE -->",
    " <div id=\"topicContent\">",
    " <div id=\"topicTitle\">",
    " Hemangioblastoma",
    " </div>",
    " <div id=\"topicContributors\">",
    " <div>",
    " <a id=\"authors\">",
    " </a>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"UTD.htm?0/43/695/contributors\">",
    " Authors",
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    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/43/695/contributors\">",
    " Eric T Wong, MD",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/43/695/contributors\">",
    " Jeffrey Joseph, MD, PhD",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/43/695/contributors\">",
    " Julian K Wu, MD",
    " </a>",
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    href=\"UTD.htm?0/43/695/contributors\">",
    " Section Editors",
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    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/43/695/contributors\">",
    " Jay S Loeffler, MD",
    " </a>",
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    0/43/695/contributors\">",
    " Patrick Y Wen, MD",
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    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/43/695/contributors\">",
    " April F Eichler, MD, MPH",
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    " Sep 28, 2012.",
    " </div>",
    " <div id=\"topicText\">",
    " <p class=\"headingAnchor\" id=\"H1\">",
    " <span class=\"h1\">",
    " INTRODUCTION",
    " </span>",
    " &nbsp;&mdash;&nbsp;Hemangioblastomas are uncommon, slow-growing tumors of the
    central nervous system, which most commonly occur in the cerebellum, brainstem, or
    spinal cord. They account for approximately 4 percent of all spinal cord tumors,
    and 7 to 10 percent of tumors arising in the posterior fossa in adults.",
    " </p>",
    " <p>",
    " Hemangioblastomas occur both sporadically and as an important component of von
    Hippel-Lindau (VHL) disease, along with retinal angiomas, renal cell carcinoma,
    pheochromocytomas, pancreatic cysts and neuroendocrine tumors.",
    " </p>",
    " <p>",
    " The clinical manifestations and management of patients with hemangioblastomas
    are reviewed here. The clinical manifestations and overall management of patients
    with VHL disease are discussed separately. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/5/22618?
    source=see_link\">",
    " \"Clinical features, diagnosis, and management of von Hippel-Lindau
    disease\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H2\">",
    " <span class=\"h1\">",
    " CLINICAL MANIFESTATIONS",
    " </span>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H3\">",
    " <span class=\"h2\">",
    " Sporadic versus VHL-associated tumors",
    " </span>",
    " &nbsp;&mdash;&nbsp;Hemangioblastomas may occur either sporadically or as a
    manifestation of VHL disease. Although approximately 75 percent of all
    hemangioblastomas appear to be sporadic [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/1\">",
    " 1",
    " </a>",
    " ], some of these may represent occult cases of VHL that can be detected if
    patients are appropriately screened for germline VHL mutations. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/5/22618?
    source=see_link&amp;anchor=H3#H3\">",
    " \"Clinical features, diagnosis, and management of von Hippel-Lindau
    disease\", section on 'Hemangioblastomas'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Sporadic and VHL-related hemangioblastomas differ significantly in their
    presentation:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Sporadic hemangioblastomas are usually solitary. Thus, the presence of
    multiple tumors within the neuraxis should raise suspicion for VHL disease.",
    " </li>",
    " <li>",
    " Hemangioblastomas associated with VHL are generally diagnosed at a younger
    age than sporadic tumors. In one series, the mean age at initial diagnosis was 29
    years in patients with VHL, while the average age at presentation in those without
    VHL is one to two decades older [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/1\">",
    " 1",
    " </a>",
    " ].",
    " </li>",
    " <li>",
    " In patients with VHL disease, approximately one-half of tumors are in the
    spinal cord, 40 percent are in the cerebellum, and 10 percent are in the brainstem
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/2\">",
    " 2",
    " </a>",
    " ]. Supratentorial lesions are rare. For those with sporadic tumors, isolated
    cerebellar lesions are substantially more common [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/1\">",
    " 1",
    " </a>",
    " ].",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " The presence of more than one hemangioblastoma, an early age at diagnosis, or
    the presence of other manifestations of VHL disease should all serve as an
    indication for genetic screening for germline VHL mutations (",
    " <a class=\"graphic graphic_table graphicRef66320 \" href=\"UTD.htm?
    12/45/13020\">",
    " table 1",
    " </a>",
    " ). (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/5/22618?
    source=see_link&amp;anchor=H20#H20\">",
    " \"Clinical features, diagnosis, and management of von Hippel-Lindau
    disease\", section on 'Genetic testing'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H4\">",
    " <span class=\"h2\">",
    " Symptoms",
    " </span>",
    " &nbsp;&mdash;&nbsp;Hemangioblastomas can cause local symptoms by compression
    of neural structures, bleeding, or paraneoplastic complications. In patients with
    VHL disease, asymptomatic hemangioblastomas are diagnosed based upon imaging
    surveillance. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/5/22618?
    source=see_link&amp;anchor=H23#H23\">",
    " \"Clinical features, diagnosis, and management of von Hippel-Lindau
    disease\", section on 'Surveillance protocols'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Hemangioblastomas can cause neurologic deficits by direct compression or
    tumor-associated hemorrhage.",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " The specific deficit from direct compression depends upon tumor location,
    and may include cerebellar ataxia, oculomotor nerve dysfunction, motor weakness, or
    sensory deficits. Patients with spinal hemangioblastomas frequently present with
    pain [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/3\">",
    " 3",
    " </a>",
    " ].",
    " </li>",
    " <li>",
    " Acute hemorrhage can be catastrophic. Intracerebral bleeding from a
    cerebellar hemangioblastoma may cause rapid obstructive hydrocephalus, cerebellar
    tonsillar herniation, or brainstem compression [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/4,5\">",
    " 4,5",
    " </a>",
    " ]. Bleeding from a spinal hemangioblastoma may result in acute quadriplegia
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/6\">",
    " 6",
    " </a>",
    " ], while headache, back pain, or radiculopathy may be caused by subarachnoid
    hemorrhage [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/7,8\">",
    " 7,8",
    " </a>",
    " ]. In these situations, emergency neurosurgical intervention is indicated.
    The risk of bleeding in treated or untreated hemangioblastomas is unknown. (See",
    " <a class=\"local\" href=\"#H9\">",
    " 'Treatment'",
    " </a>",
    " below.)",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " Paraneoplastic erythrocytosis has also been reported in patients with
    hemangioblastoma [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/9,10\">",
    " 9,10",
    " </a>",
    " ]. The elevated hematocrit and red cell mass are a result of excessive
    erythropoietin production by the hemangioblastoma [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/11,12\">",
    " 11,12",
    " </a>",
    " ]. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?24/12/24777?
    source=see_link\">",
    " \"Diagnostic approach to the patient with polycythemia\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H5\">",
    " <span class=\"h1\">",
    " DIAGNOSIS",
    " </span>",
    " &nbsp;&mdash;&nbsp;The preferred diagnostic procedure is gadolinium-enhanced
    magnetic resonance imaging (MRI). A CT scan of the neuraxis is not an adequate
    diagnostic procedure because bone artifacts may obscure small tumors in the
    posterior fossa or spinal canal. For patients who cannot undergo an MRI,
    conventional angiography together with CT scanning are alternative diagnostic tests
    to define the location and vasculature feeding the hemangioblastoma.",
    " </p>",
    " <p>",
    " The characteristic MRI feature of hemangioblastomas is an enhancing nodule
    associated with a cyst located in the cerebellum (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef63358 \" href=\"UTD.htm?
    40/11/41136\">",
    " image 1",
    " </a>",
    " ) or a homogeneously enhancing lesion on the surface of or within the spinal
    cord (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef79982 \" href=\"UTD.htm?
    35/57/36754\">",
    " image 2",
    " </a>",
    " ). These features are not pathognomonic, and the differential diagnosis
    includes astrocytoma, ganglioglioma, or metastatic tumors. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?2/1/2071?
    source=see_link\">",
    " \"Diagnosis and classification of low-grade gliomas\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?6/63/7161?
    source=see_link\">",
    " \"Spinal cord tumors\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Smaller hemangioblastomas (&lt;10 mm) may be isointense on T1-weighted images
    and hyperintense on T2-weighted images, with homogeneous contrast enhancement [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/13\">",
    " 13",
    " </a>",
    " ]. Spinal hemangioblastomas are often associated with a syrinx or spinal cord
    edema [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/3\">",
    " 3",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H6\">",
    " <span class=\"h1\">",
    " PATHOLOGY AND PATHOGENESIS",
    " </span>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H7\">",
    " <span class=\"h2\">",
    " Pathology",
    " </span>",
    " &nbsp;&mdash;&nbsp;Hemangioblastomas are well-circumscribed, highly vascular
    red nodules that are often located within the walls of large cysts (",
    " <a class=\"graphic graphic_picture graphicRef60110 \" href=\"UTD.htm?
    37/52/38721\">",
    " picture 1",
    " </a>",
    " ). On cross-section, these tumors appear beefy red due to their high
    vascularity and contrast with any adjacent pale cerebellar tissue.",
    " </p>",
    " <p>",
    " Microscopically, the two main components of both sporadic and VHL-associated
    hemangioblastomas are an extensive vascular network and the neoplastic \"stromal
    cells\" (",
    " <a class=\"graphic graphic_picture graphicRef79080 \" href=\"UTD.htm?
    16/1/16407\">",
    " picture 2",
    " </a>",
    " ). The capillaries have a normal structure, including normal endothelial cells
    and pericytes. Neoplastic stromal cells, embedded among the vascular channels, have
    abundant cytoplasm packed with lipid vacuoles [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/14\">",
    " 14",
    " </a>",
    " ]. The numerous lipid-containing vacuoles, which often impinge on the nucleus
    and scallop its edges, result in the typical \"clear cell\" morphology. These cells
    also have large nuclei that are often pleomorphic and hyperchromatic. Such nuclei
    are considered a degenerative feature rather than a sign of histologic grade,
    malignant potential or transformation [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/15\">",
    " 15",
    " </a>",
    " ]. The mitotic rate is typically low. Where the tumor borders brain, it often
    forms intertwined small nodules with the host tissue.",
    " </p>",
    " <p>",
    " Many of the clear-cell morphologic features of hemangioblastomas overlap with
    those of renal cell carcinomas (RCCs). RCCs, however, do not show the intimate
    relationship with the host tissue that can be found in a subset of
    hemangioblastomas, such at the intertwined nodules of brain, but instead have a
    border pushing against normal tissue. Since RCC is also a frequent manifestation of
    VHL disease and is histologically similar to hemangioblastomas, immunoperoxidase
    studies are often necessary to distinguish these tumors. Unlike RCCs,
    hemangioblastomas do not have an epithelial origin and so do not express
    cytokeratins or epithelial membrane antigen (EMA). Furthermore, hemangioblastomas
    typically display immunoreactivity to neuron specific enolase (NSE) unlike RCCs (",
    " <a class=\"graphic graphic_picture graphicRef69439 \" href=\"UTD.htm?
    9/23/9587\">",
    " picture 3",
    " </a>",
    " )&nbsp;[",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/16\">",
    " 16",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Retinal angiomas are hemangioblastomas that develop in the retina and within
    the optic nerve. If left untreated, retinal hemangioblastomas can hemorrhage,
    leading to retinal detachment, glaucoma and loss of vision. Retinal angiomas are a
    frequent manifestation in patients with VHL disease. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/5/22618?
    source=see_link&amp;anchor=H6#H6\">",
    " \"Clinical features, diagnosis, and management of von Hippel-Lindau
    disease\", section on 'Retinal capillary hemangioblastomas'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H8\">",
    " <span class=\"h2\">",
    " Molecular biology",
    " </span>",
    " &nbsp;&mdash;&nbsp;Inactivation of the VHL tumor suppressor gene, located on
    chromosome 3p, is involved in the pathogenesis of some sporadic as well as VHL-
    associated hemangioblastomas. Somatic mutations of the VHL gene",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " allelic deletion of the VHL gene may be present in as many as 50 percent of
    sporadic hemangioblastomas [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/17-20\">",
    " 17-20",
    " </a>",
    " ]. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/5/22618?
    source=see_link&amp;anchor=H3#H3\">",
    " \"Clinical features, diagnosis, and management of von Hippel-Lindau
    disease\", section on 'Hemangioblastomas'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?14/21/14678?
    source=see_link\">",
    " \"Molecular biology and pathogenesis of von Hippel-Lindau disease\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " The genetic changes are found in the stromal elements but not in the
    vasculature [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/18,21\">",
    " 18,21",
    " </a>",
    " ], suggesting that abnormal blood vessel formation might be caused by external
    factors produced by the stromal cells. In fact, expression of both erythropoietin
    and vascular endothelial growth factor (VEGF) is upregulated in the stromal cells
    of hemangioblastomas and may be involved in the pathogenesis of this disease [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/22\">",
    " 22",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H9\">",
    " <span class=\"h1\">",
    " TREATMENT",
    " </span>",
    " &nbsp;&mdash;&nbsp;Hemangioblastomas are highly vascular tumors that are often
    located in neurologically sensitive areas in the neuraxis (",
    " <a class=\"graphic graphic_picture graphicRef60110 \" href=\"UTD.htm?
    37/52/38721\">",
    " picture 1",
    " </a>",
    " ). The anatomic location of the lesion plays an important role in determining
    the therapeutic approach. Patients are best managed in a multidisciplinary fashion
    with input from neurosurgeons, interventional neuroradiologists, radiation
    oncologists, and neurooncologists with expertise in central nervous system
    malignancies.",
    " </p>",
    " <p>",
    " For patients with VHL disease, the frequent development of multiple lesions
    implies that therapeutic efforts should focus on avoiding treatment-related
    morbidity by minimizing the frequency of surgical interventions. Small asymptomatic
    lesions can be followed with careful surveillance. Although surgery can usually
    successfully remove lesions in the spinal cord, brainstem, and cerebellum,
    intervention is reserved until lesions become symptomatic [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/23-26\">",
    " 23-26",
    " </a>",
    " ]. Patients who demonstrate progression by neural imaging should be followed
    at more frequent intervals for evidence of clinical symptoms. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/5/22618?
    source=see_link&amp;anchor=H3#H3\">",
    " \"Clinical features, diagnosis, and management of von Hippel-Lindau
    disease\", section on 'Hemangioblastomas'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Women with existing retinal, brain, and spinal cord lesions are at risk for
    tumor growth during pregnancy [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/27\">",
    " 27",
    " </a>",
    " ]. A noncontrast MRI in the fourth month of pregnancy may be considered in
    these patients. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/5/22618?
    source=see_link&amp;anchor=H9384234#H9384234\">",
    " \"Clinical features, diagnosis, and management of von Hippel-Lindau
    disease\", section on 'Pregnancy and VHL'",
    " </a>",
    " .) Neuroimaging findings, along with clinical signs and symptoms, may be used
    to make decisions regarding the management of labor and delivery. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?20/9/20634?
    source=see_link&amp;anchor=H17#H17\">",
    " \"Neurologic disorders complicating pregnancy\", section on 'Brain tumors'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Both surgical resection and radiation therapy have a role in the management of
    appropriately selected patients. However, there are no randomized clinical trials
    that compare these approaches, nor are there any randomized trials that address the
    optimal timing of therapeutic intervention.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H10\">",
    " <span class=\"h2\">",
    " Surgery",
    " </span>",
    " &nbsp;&mdash;&nbsp;Surgical resection offers definitive therapy for sporadic,
    isolated hemangioblastomas, particularly those arising in the cerebellum. The role
    of surgery in patients with VHL disease is less well defined because of the
    frequent occurrence of additional synchronous and metachronous lesions.",
    " </p>",
    " <p>",
    " Hemangioblastomas are highly vascular, and patients frequently need a
    preoperative angiogram to identify feeding arteries. For large lesions,
    embolization of feeding arteries with polymer microspheres, ethanol, or polyvinyl
    alcohol particles is typically performed prior to surgery (",
    " <a class=\"graphic graphic_picture graphicRef55268 \" href=\"UTD.htm?
    1/47/1783\">",
    " picture 4",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/28-31\">",
    " 28-31",
    " </a>",
    " ]. Following preoperative embolization and using a microdissection technique
    with an intraoperative microscope, complete surgical resection of a
    hemangioblastoma is usually feasible with acceptable morbidity.",
    " </p>",
    " <p>",
    " The following contemporary series illustrate the outcomes following surgery
    for patients with hemangioblastomas in the cerebellum, spinal cord, and
    brainstem:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " In a series from the National Institutes of Health (NIH), 80 patients with
    VHL underwent 126 operations, during which 164 cerebellar lesions were resected [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/32\">",
    " 32",
    " </a>",
    " ]. Surgery was based upon the presence of symptoms (most frequently
    headache, ataxia, dysmetria, and hydrocephalus in 75, 55, 29, and 28 percent,
    respectively). Symptoms improved or stabilized in 98 percent of cases. Follow-up
    imaging at five years did not document any instances of recurrence.",
    " </li>",
    " <li>",
    " In a Japanese series, 40 of 48 VHL patients with hemangioblastomas of the
    spinal cord required surgery, including seven patients who required two operations
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/33\">",
    " 33",
    " </a>",
    " ]. Among the 48 patients, 46 (96 percent) had associated central nervous
    system lesions, primarily in the cerebellum. Resection of the spinal tumors
    resulted in improvement or stabilization of symptoms in 39 of 47 cases (83
    percent).",
    " </li>",
    " <li>",
    " In a French series, 34 patients (25 with VHL disease, 9 with sporadic
    lesions) underwent 40 operations, in which a total of 74 hemangioblastomas were
    resected [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/34\">",
    " 34",
    " </a>",
    " ]. Tumors were located in the brainstem in 14 cases (19 percent) and the
    remainder were in the spinal cord, predominantly in the cervical and thoracic
    spine. At a mean follow-up of five years, 82 percent of patients were either
    improved or stabilized, while 18 percent were worse.",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " The optimal timing of surgery for patients with a hemangioblastoma is
    uncertain. The risks associated with operative management include intraoperative
    bleeding and postoperative neurologic complications.",
    " </p>",
    " <p>",
    " The consensus among most neurosurgeons is to follow these patients with
    surveillance MRI scans of the neuraxis. If there is progression of neurologic
    symptoms, evidence of tumor or cyst growth, neurologic deficit, or hemorrhage,
    operative intervention should be considered.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H11\">",
    " <span class=\"h2\">",
    " Radiation therapy",
    " </span>",
    " &nbsp;&mdash;&nbsp;Although there are no randomized clinical trials comparing
    radiation therapy (RT) to surgery in patients with hemangioblastomas, increasing
    data with relatively long follow-up support the role of RT, particularly for
    patients with multiple tumors and those with surgically inaccessible lesions. Most
    of the contemporary data come from series using stereotactic radiosurgery (SRS),
    although external beam RT or proton beam RT may be useful in selected cases. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?32/5/32855?
    source=see_link\">",
    " \"Stereotactic cranial radiosurgery\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Contemporary series illustrating the outcomes following RT include the
    following:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " In a series of 31 patients (26 with VHL), 92 intracranial and spinal
    hemangioblastomas were treated with SRS [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/35\">",
    " 35",
    " </a>",
    " ]. At a median follow-up of 69 months, 84 percent of tumors were either
    unchanged or smaller, and the five-year local control rate was 82 percent. Lesion-
    associated symptoms were improved in 36 of 41 evaluable cases (88 percent).",
    " </li>",
    " <li>",
    " In another series that included 32 patients (13 with VHL disease), 74
    intracranial hemangioblastomas were treated with SRS [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/36\">",
    " 36",
    " </a>",
    " ]. On follow-up imaging, tumor control was achieved for 68 tumors (92
    percent). Progression-free survival at five years was 90 percent.",
    " </li>",
    " <li>",
    " In a series of 18 patients (five with VHL disease), 31 hemangioblastomas,
    including 20 in the cerebellum and 8 in the spinal cord, were treated with EBRT [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/695/abstract/37\">",
    " 37",
    " </a>",
    " ]. Indications for therapy included recurrence after surgery, residual
    disease following surgery, or definitive therapy of the lesion in 12, 4, and 2
    cases, respectively. With a median follow-up of five years, the five- and 10-year
    overall survival rates were 69 and 30 percent, respectively.",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H12\">",
    " <span class=\"h2\">",
    " Antiangiogenic therapy",
    " </span>",
    " &nbsp;&mdash;&nbsp;Because of the role of vascular endothelial growth factor
    in the formation of hemangioblastomas, inhibitors of angiogenesis may offer a
    potential therapeutic approach for lesions not amenable to surgery or radiation
    therapy. Preliminary experience with this approach has been derived from the
    treatment of patients with retinal angiomas. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/5/22618?
    source=see_link&amp;anchor=H6#H6\">",
    " \"Clinical features, diagnosis, and management of von Hippel-Lindau
    disease\", section on 'Retinal capillary hemangioblastomas'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H13\">",
    " <span class=\"h1\">",
    " SUMMARY AND RECOMMENDATIONS",
    " </span>",
    " &nbsp;&mdash;&nbsp;Hemangioblastomas are uncommon, slow-growing tumors of the
    central nervous system, which most commonly occur in the cerebellum, brainstem, or
    spinal cord. Hemangioblastomas occur both sporadically and as a component of von
    Hippel-Lindau (VHL) disease. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/5/22618?
    source=see_link\">",
    " \"Clinical features, diagnosis, and management of von Hippel-Lindau
    disease\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " For patients without VHL disease and with a single hemangioblastoma, we
    suggest surgery rather than observation both for treatment and to establish the
    diagnosis (",
    " <a class=\"grade\" href=\"._grade_6?title=Grade 2C\">",
    " Grade 2C",
    " </a>",
    " ). Radiation therapy is an option for recurrent or residual disease if the
    risk of reoperation is high. (See",
    " <a class=\"local\" href=\"#H9\">",
    " 'Treatment'",
    " </a>",
    " above.)",
    " <br/>",
    " <br/>",
    " Patients with a hemangioblastoma and without a history of VHL disease should
    be screened for VHL disease if they are relatively young or if they have other
    manifestations of VHL disease. Criteria for VHL screening are shown in the Table 1
    (",
    " <a class=\"graphic graphic_table graphicRef66320 \" href=\"UTD.htm?
    12/45/13020\">",
    " table 1",
    " </a>",
    " ). (See",
    " <a class=\"local\" href=\"#H3\">",
    " 'Sporadic versus VHL-associated tumors'",
    " </a>",
    " above and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/5/22618?
    source=see_link&amp;anchor=H20#H20\">",
    " \"Clinical features, diagnosis, and management of von Hippel-Lindau
    disease\", section on 'Genetic testing'",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " For patients with known VHL disease who are asymptomatic and have imaging
    evidence of one or more hemangioblastomas, we suggest observation with serial
    imaging unless there is rapid tumor growth or symptoms develop, rather than
    immediate therapeutic intervention (",
    " <a class=\"grade\" href=\"._grade_6?title=Grade 2C\">",
    " Grade 2C",
    " </a>",
    " ). Therapeutic intervention is indicated for patients with VHL disease and
    progressive symptoms. In this setting, we suggest surgical resection for accessible
    lesions and stereotactic radiosurgery for lesions that are not accessible or when
    the risk of postoperative neurologic deficits is high (",
    " <a class=\"grade\" href=\"._grade_6?title=Grade 2C\">",
    " Grade 2C",
    " </a>",
    " ). (See",
    " <a class=\"local\" href=\"#H9\">",
    " 'Treatment'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H3\">",
    " 'Sporadic versus VHL-associated tumors'",
    " </a>",
    " above.)",
    " </li>",
    " </ul>",
    " </p>",
    " </div>",
    " <div id=\"topicAgreement\">",
    " Use of UpToDate is subject to the",
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    target=\"_blank\">",
    " Subscription and License Agreement",
    " </a>",
    " .",
    " </div>",
    " <div class=\"headingAnchor\" id=\"references\">",
    " <h1>",
    " REFERENCES",
    " </h1>",
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    " Vortmeyer AO, Gnarra JR, Emmert-Buck MR, et al. von Hippel-Lindau gene
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/695/abstract/25\">",
    " Lonser RR, Weil RJ, Wanebo JE, et al. Surgical management of spinal cord
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/695/abstract/26\">",
    " Weil RJ, Lonser RR, DeVroom HL, et al. Surgical management of brainstem
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    " Tampieri D, Leblanc R, TerBrugge K. Preoperative embolization of brain and
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    " </li>",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/695/abstract/30\">",
    " Lonser RR, Heiss JD, Oldfield EH. Tumor devascularization by intratumoral
    ethanol injection during surgery. Technical note. J Neurosurg 1998; 88:923.",
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    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/695/abstract/31\">",
    " V&aacute;zquez-A&ntilde;&oacute;n V, Botella C, Beltr&aacute;n A, et al.
    Preoperative embolization of solid cervicomedullary junction hemangioblastomas:
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    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/695/abstract/32\">",
    " Jagannathan J, Lonser RR, Smith R, et al. Surgical management of cerebellar
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    108:210.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/695/abstract/33\">",
    " Kanno H, Yamamoto I, Nishikawa R, et al. Spinal cord hemangioblastomas in
    von Hippel-Lindau disease. Spinal Cord 2009; 47:447.",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/695/abstract/34\">",
    " Parker F, Aghakhani N, Ducati LG, et al. Results of microsurgical treatment
    of medulla oblongata and spinal cord hemangioblastomas: a comparison of two
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    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/695/abstract/35\">",
    " Moss JM, Choi CY, Adler JR Jr, et al. Stereotactic radiosurgical treatment
    of cranial and spinal hemangioblastomas. Neurosurgery 2009; 65:79.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/695/abstract/36\">",
    " Kano H, Niranjan A, Mongia S, et al. The role of stereotactic radiosurgery
    for intracranial hemangioblastomas. Neurosurgery 2008; 63:443.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/695/abstract/37\">",
    " Koh ES, Nichol A, Millar BA, et al. Role of fractionated external beam
    radiotherapy in hemangioblastoma of the central nervous system. Int J Radiat Oncol
    Biol Phys 2007; 69:1521.",
    " </a>",
    " </li>",
    " </ol>",
    " </div>",
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    " Topic 5209 Version 5.0",
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    var outline_f0_43_695=[" <div id=\"toggleOutline\">",
    " <a href=\"#\" title=\"Collapse Topic Outline\">",
    " <img alt=\"\" src=\"./../images/orange_arrow_left.myextg\"/>",
    " </a>",
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    " <div id=\"innerOutline\">",
    " <h1>",
    " TOPIC OUTLINE",
    " </h1>",
    " <div id=\"outline\">",
    " <ul>",
    " <li>",
    " <a class=\"sr_button\" href=\"#H13\" id=\"summRecButton\">",
    " <span>",
    " SUMMARY &amp; RECOMMENDATIONS",
    " </span>",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H1\">",
    " INTRODUCTION",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H2\">",
    " CLINICAL MANIFESTATIONS",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H3\">",
    " Sporadic versus VHL-associated tumors",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H4\">",
    " Symptoms",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H5\">",
    " DIAGNOSIS",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H6\">",
    " PATHOLOGY AND PATHOGENESIS",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H7\">",
    " Pathology",
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    " <a class=\"outlineLink\" href=\"#H8\">",
    " Molecular biology",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H9\">",
    " TREATMENT",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H10\">",
    " Surgery",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H11\">",
    " Radiation therapy",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H12\">",
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    H1ryF/bsf+fb/8Cf8Akf/Z);\">",
    " </div>",
    " <div class=\"lgnd\">",
    " Low (left panel) and high (right panel) views of muscle biopsy in
    polymyositis. There is an intense interstitial mononuclear infiltrate with some
    myocyte degeneration.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Courtesy of Cynthia Magro, MD and William W Pendlebury, MD.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_43_696=[""].join("\n");
    var outline_f0_43_696=null;
    var title_f0_43_697="Evaluation of acute pelvic pain in the adolescent female";
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    " <div id=\"topicContent\">",
    " <div id=\"topicTitle\">",
    " Evaluation of acute pelvic pain in the adolescent female",
    " </div>",
    " <div id=\"topicContributors\">",
    " <div>",
    " <a id=\"authors\">",
    " </a>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"UTD.htm?0/43/697/contributors\">",
    " Authors",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/43/697/contributors\">",
    " Kathleen Brown, MD",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/43/697/contributors\">",
    " June A Lee, MD",
    " </a>",
    " <br/>",
    " </div>",
    " <div>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"UTD.htm?0/43/697/contributors\">",
    " Section Editor",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/43/697/contributors\">",
    " Stephen J Teach, MD, MPH",
    " </a>",
    " <br/>",
    " </div>",
    " <div>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"UTD.htm?0/43/697/contributors\">",
    " Deputy Editor",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/43/697/contributors\">",
    " James F Wiley, II, MD, MPH",
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    " <br/>",
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    " <a href=\"UTD.htm?0/43/697/contributor-disclosure\" target=\"_blank\">",
    " Disclosures",
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    " <div id=\"reviewProcess\">",
    " <span>",
    " All topics are updated as new evidence becomes available and our",
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    " peer review process",
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    " is complete.",
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    " <div id=\"literatureReviewDate\">",
    " <span class=\"emphasis\">",
    " Literature review current through:",
    " </span>",
    " Oct 2013.",
    " <span class=\"pipeSpace\">",
    " |",
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    " <span class=\"emphasis\">",
    " This topic last updated:",
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    " May 23, 2012.",
    " </div>",
    " <div id=\"topicText\">",
    " <p class=\"headingAnchor\" id=\"H13206028\">",
    " <span class=\"h1\">",
    " INTRODUCTION",
    " </span>",
    " &nbsp;&mdash;&nbsp;A wide range of conditions can cause or contribute to
    pelvic pain in the adolescent female. Pelvic pain can be defined as any abdominal
    pain below the umbilicus, or lower abdominal pain. As a female enters adolescence
    and begins menstruation, the differential diagnosis of pelvic pain expands
    greatly.",
    " </p>",
    " <p>",
    " This topic will review the differential diagnosis and approach to the
    adolescent female presenting with pelvic pain with an emphasis on gynecologic
    conditions. The gastrointestinal and urologic causes of abdominal pain are
    discussed in greater detail separately. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?11/20/11593?
    source=see_link\">",
    " \"Causes of acute abdominal pain in children and adolescents\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " The evaluation of acute pelvic pain in older women is also discussed
    separately. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?16/44/17095?
    source=see_link\">",
    " \"Evaluation of acute pelvic pain in women\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H13206035\">",
    " <span class=\"h1\">",
    " DIFFERENTIAL DIAGNOSIS",
    " </span>",
    " &nbsp;&mdash;&nbsp;Pelvic pain most often involves the gastrointestinal or the
    urinary systems in prepubertal girls. However, gynecologic conditions become more
    prevalent as etiologies for pelvic pain, especially during late adolescence. The
    gynecologic causes of acute pelvic pain in adolescent females are listed in the
    table (",
    " <a class=\"graphic graphic_table graphicRef75310 \" href=\"UTD.htm?
    35/5/35931\">",
    " table 1",
    " </a>",
    " ).",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H13206042\">",
    " <span class=\"h2\">",
    " Life-threatening conditions",
    " </span>",
    " &nbsp;&mdash;&nbsp;Complications of pregnancy (eg, ectopic pregnancy, acute
    abruption, uterine rupture) comprise the most frequent life-threatening gynecologic
    causes of pelvic pain in adolescent females. Gastrointestinal causes of pelvic pain
    can be life-threatening if they lead to peritonitis and sepsis. Of these,
    appendicitis is most common and will be presented here. Other conditions (eg,
    abscess, bowel obstruction) are reviewed separately. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?11/20/11593?
    source=see_link&amp;anchor=H3#H3\">",
    " \"Causes of acute abdominal pain in children and adolescents\", section on
    'Life-threatening causes'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Life-threatening pelvic trauma in female adolescents is usually the result of
    a high-energy mechanism, such as a fall from a height or motor vehicle crash.
    Injury patterns and management are similar to the approach in adults and are
    discussed elsewhere. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/7/22650?
    source=see_link&amp;anchor=H7#H7\">",
    " \"Pelvic trauma: Initial evaluation and management\", section on 'Fracture
    types'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/7/22650?
    source=see_link&amp;anchor=H16#H16\">",
    " \"Pelvic trauma: Initial evaluation and management\", section on 'Initial
    management'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H4155804\">",
    " <span class=\"h3\">",
    " Ectopic pregnancy",
    " </span>",
    " &nbsp;&mdash;&nbsp;Patients usually present with vaginal bleeding and crampy
    pelvic pain approximately six to eight weeks after the last menstrual period
    although later presentation is possible, especially if the pregnancy is not in the
    fallopian tube. Incidence is increased in those with a prior history of ectopic
    pregnancy, tubal surgery, and pelvic infection, along with those who use an
    intrauterine device for contraception.",
    " <strong>",
    " </strong>",
    " Rupture may initially bring temporary relief of pain; however, massive
    intraperitoneal hemorrhage may ensue with high maternal mortality soon after
    rupture. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?21/15/21752?
    source=see_link&amp;anchor=H3#H3\">",
    " \"Incidence, risk factors, and pathology of ectopic pregnancy\", section on
    'Risk factors'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?1/9/1178?
    source=see_link&amp;anchor=H2#H2\">",
    " \"Clinical manifestations, diagnosis, and management of ectopic pregnancy\",
    section on 'Clinical manifestations'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H4155837\">",
    " <span class=\"h3\">",
    " Placental abruption",
    " </span>",
    " &nbsp;&mdash;&nbsp;An acute, clinical abruption classically presents with
    vaginal bleeding, abdominal",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " back pain, and uterine contractions. Peak incidence is between the 24",
    " <sup>",
    " th",
    " </sup>",
    " and 26",
    " <sup>",
    " th",
    " </sup>",
    " week of gestation although placental abruption may occur at any time. The
    contractions are usually high frequency and low amplitude, but a mild to moderate
    contraction pattern is also possible. In the presence of a severe abruption (&ge;50
    percent placental separation), both fetal and maternal compromise may occur. Acute
    disseminated intravascular coagulation (DIC) develops because blood is exposed to
    large amounts of tissue factor over a brief period of time. This exposure leads to
    massive generation of thrombin, resulting in the acute triggering of coagulation.
    The clinical consequence is a profound systemic bleeding diathesis in the mother
    and due to widespread intravascular fibrin deposition, tissue ischemic injury, and
    a microangiopathic hemolytic anemia. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?28/46/29417?
    source=see_link&amp;anchor=H5#H5\">",
    " \"Placental abruption: Clinical features and diagnosis\", section on 'Acute
    abruption'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H4155912\">",
    " <span class=\"h3\">",
    " Uterine rupture",
    " </span>",
    " &nbsp;&mdash;&nbsp;Signs and symptoms of uterine rupture can include
    nonreassuring fetal heart rate tracing or fetal death, uterine tenderness,
    peritoneal irritation, vaginal bleeding, loss of fetal station, and shock. Most
    uterine ruptures occur in laboring women with a prior cesarean delivery or prior
    uterine surgery. Rupture of the unscarred uterus during labor is rare. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?35/44/36554?
    source=see_link&amp;anchor=H2677735#H2677735\">",
    " \"Approach to abdominal pain and the acute abdomen in pregnant and postpartum
    women\", section on 'Uterine rupture'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H13206049\">",
    " <span class=\"h3\">",
    " Appendicitis",
    " </span>",
    " &nbsp;&mdash;&nbsp;Acute appendicitis is the most common cause for emergent
    abdominal surgery in children; incidence increases with age and peaks in
    adolescence. Initial periumbilical pain, which later localizes to the area of
    peritoneal irritation, usually the right lower quadrant, followed by fever,
    vomiting, and anorexia is the most common presentation. Obstruction of the
    appendiceal lumen can lead to thrombosis, necrosis, and if untreated, perforation.
    Complications involve ileus, abscess formation, intestinal obstruction,
    peritonitis, sepsis, and shock. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?32/3/32826?
    source=see_link&amp;anchor=H5#H5\">",
    " \"Acute appendicitis in children: Clinical manifestations and diagnosis\",
    section on 'Clinical manifestations'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H3093327\">",
    " <span class=\"h3\">",
    " Ovarian torsion",
    " </span>",
    " &nbsp;&mdash;&nbsp;Ovarian torsion refers to twisting of the adnexa upon its
    pedicle and typically presents with an acute onset of sharp, intermittent abdominal
    pain associated with nausea and vomiting. Formation of ovarian cysts may predispose
    to torsion, and therefore, torsion has a higher incidence in adolescents than
    prepubertal girls. This condition requires prompt surgical intervention to prevent
    necrosis and loss of the ovary. Although typically not life-threatening, ovarian
    torsion does present a significant risk to future fertility. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?23/8/23690?
    source=see_link&amp;anchor=H327710#H327710\">",
    " \"Ovarian and fallopian tube torsion\", section on 'Clinical presentation'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H13206084\">",
    " <span class=\"h2\">",
    " Common conditions",
    " </span>",
    " &nbsp;&mdash;&nbsp;Dysmenorrhea is the most common gynecologic cause of pelvic
    pain during adolescence. Pelvic inflammatory disease and mittelschmerz are also
    frequent. Urinary tract infections (cystitis, pyelonephritis) are very common
    causes of lower abdominal pain. Nephrolithiasis is an increasingly common cause of
    pelvic pain in adolescents. Other common urologic etiologies (eg, urinary tract
    infection) as well as gastrointestinal conditions (eg, constipation,
    gastrointestinal infection, functional abdominal pain) are discussed separately.
    (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?11/20/11593?
    source=see_link&amp;anchor=H14#H14\">",
    " \"Causes of acute abdominal pain in children and adolescents\", section on
    'Common causes'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?1/17/1306?
    source=see_link&amp;anchor=H12#H12\">",
    " \"Evaluation of the child and adolescent with chronic abdominal pain\",
    section on 'Functional disorders'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H4156466\">",
    " <span class=\"h3\">",
    " Dysmenorrhea",
    " </span>",
    " &nbsp;&mdash;&nbsp;Menstrual",
    " <strong>",
    " </strong>",
    " pain affects at least two-thirds of postmenarchal females in the United
    States, some of whom experience severe pain sufficient to affect daily activities.
    Dysmenorrhea is",
    " <strong>",
    " </strong>",
    " usually crampy and intermittent. Nausea, vomiting,",
    " <strong>",
    " </strong>",
    " diarrhea, headache, dizziness, or back pain may accompany the crampy abdominal
    pain. The pain and associated symptoms typically begin several hours prior to the
    onset",
    " <strong>",
    " </strong>",
    " of menstruation and continue for one to three days. The severity of the
    disorder can be categorized by a grading system based upon the degree of menstrual
    pain, presence of systemic symptoms, and impact on daily activities (",
    " <a class=\"graphic graphic_table graphicRef65347 \" href=\"UTD.htm?
    22/16/22795\">",
    " table 2",
    " </a>",
    " )",
    " <strong>",
    " .",
    " </strong>",
    " Dysmenorrhea can be divided into primary causes (absence of any pelvic
    pathology and the more common form which typically begins during adolescence) or
    secondary causes (underlying pelvic pathology, such as endometriosis).",
    " <strong>",
    " </strong>",
    " (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?30/25/31125?
    source=see_link&amp;anchor=H2#H2\">",
    " \"Primary dysmenorrhea in adolescents\", section on 'Clinical
    manifestations'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H4156418\">",
    " <span class=\"h3\">",
    " Mittelschmerz",
    " </span>",
    " &nbsp;&mdash;&nbsp;This ovulatory event causes recurrent midcycle pain in
    females with regular ovulatory cycles. This pain is caused by normal follicular
    enlargement just prior to ovulation or to normal follicular bleeding at ovulation.
    The pain is typically mild and unilateral; it occurs midway between menstrual
    periods and lasts for a few hours to a couple of days. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?9/40/9863?
    source=see_link&amp;anchor=H6#H6\">",
    " \"Evaluation and management of ruptured ovarian cyst\", section on
    'Differential diagnosis'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H4156366\">",
    " <span class=\"h3\">",
    " Pelvic inflammatory disease",
    " </span>",
    " &nbsp;&mdash;&nbsp;Pelvic inflammatory disease (PID) is most commonly caused
    by C. trachomatis and N. gonorrhoeae, both of which have the highest prevalence in
    the adolescent population. PID is an infection of the upper genital tract in
    females and includes endometritis, salpingitis, tubo-ovarian abscess, and pelvic
    peritonitis.",
    " </p>",
    " <p>",
    " Lower abdominal pain is the cardinal presenting symptom in adolescents with
    PID, although the character of the pain may be quite subtle. The recent onset of
    pain that worsens during coitus or with jarring movement may be the only presenting
    symptom of PID; the onset of pain during or shortly after menses is particularly
    suggestive. About half of patients with PID have fever. On pelvic examination, the
    findings of a purulent endocervical discharge",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " acute cervical motion and adnexal tenderness with bimanual examination are
    strongly suggestive of the diagnosis. Additional nonspecific symptoms may include
    abnormal vaginal bleeding, dysmenorrhea, vaginal discharge, or gastrointestinal
    symptoms. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?1/0/1032?
    source=see_link&amp;anchor=H2#H2\">",
    " \"Clinical features and diagnosis of pelvic inflammatory disease\", section
    on 'Clinical features'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H4156405\">",
    " <span class=\"h3\">",
    " Ruptured ovarian cyst",
    " </span>",
    " &nbsp;&mdash;&nbsp;An ovarian cyst that ruptures can cause sudden, severe,
    unilateral pelvic pain without fever or any gastrointestinal, urinary, or vaginal
    symptoms. Historically, they occur preceding a menstrual period. The pain often
    begins during strenuous physical activity, such as exercise or sexual intercourse.
    Blood from the rupture site may seep into the ovary, which can cause pain from
    stretching of the ovarian cortex, or it may flow into the abdomen, which has an
    irritant effect on the peritoneum. Significant hemorrhage leading to shock is rare.
    (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?9/40/9863?
    source=see_link&amp;anchor=H2#H2\">",
    " \"Evaluation and management of ruptured ovarian cyst\", section on 'Clinical
    manifestations'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H4156549\">",
    " <span class=\"h3\">",
    " Nephrolithiasis",
    " </span>",
    " &nbsp;&mdash;&nbsp;Kidney stones, an increasingly common cause of pelvic pain
    in adolescents, typically presents with intense, paroxysmal flank pain, which may
    radiate",
    " <strong>",
    " </strong>",
    " to the lower abdomen and groin regions. The pain is usually colicky and causes
    the patient to writhe about because they are unable to find a position of comfort.
    Nausea, vomiting, and urinary symptoms may accompany the pain. The diagnosis of
    nephrolithiasis is initially suspected by the presentation and clinical evaluation
    (including urinalysis). It is confirmed by the detection of a stone on imaging
    studies or by retrieval of a passed stone. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?13/19/13623?
    source=see_link&amp;anchor=H2#H2\">",
    " \"Clinical features and diagnosis of nephrolithiasis in children\", section
    on 'Clinical presentation'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H832927\">",
    " <span class=\"h3\">",
    " Urinary tract infection",
    " </span>",
    " &nbsp;&mdash;&nbsp;Symptomatic cystitis causes suprapubic pain and dysuria.
    Fever, urinary frequency, and urinary hesitancy may also be present. Pyelonephritis
    frequently presents with fever, vomiting, flank, and upper back pain. Symptoms of
    cystitis may also be present. Rapid urine dipstick tests",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " microscopic urinalysis establish the diagnosis. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?20/40/21129?
    source=see_link&amp;anchor=H4#H4\">",
    " \"Clinical features and diagnosis of urinary tract infections in infants and
    children older than one month\", section on 'Older children'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H13206115\">",
    " <span class=\"h2\">",
    " Other gynecologic conditions",
    " </span>",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " <strong>",
    " Pregnancy",
    " </strong>",
    " &ndash; Intrauterine pregnancy is the most common diagnosis for the
    presentation of secondary amenorrhea. Other common symptoms include morning
    sickness, breast tenderness, urinary frequency, weight gain, fatigue, and abdominal
    pain. Pelvic pain is an uncommon primary presenting symptom for pregnancy, although
    round ligament pain, pubic symphysis separation, or pelvic girdle pain (sacroiliac
    joint pain) is relatively common. Care must be taken not to miss other causes of
    pelvic pain (eg, appendicitis, ovarian torsion) in pregnant females. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?43/48/44808?
    source=see_link&amp;anchor=H9#H9\">",
    " \"Clinical manifestations and diagnosis of early pregnancy\", section on
    'Diagnosis'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?2/1/2074?
    source=see_link&amp;anchor=H12#H12\">",
    " \"Musculoskeletal changes and pain during pregnancy and postpartum\",
    section on 'Pregnancy related pelvic joint pain'",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " <strong>",
    " Spontaneous abortion",
    " </strong>",
    " &ndash; Abortion is the outcome of at least 20 percent of all pregnancies,
    presenting with crampy pelvic pain, vaginal bleeding, and passage of some or all of
    the products of conception. In the face of a nonsterile abortive procedure or
    incomplete evacuation of all fetal and placental tissue, sepsis may develop.
    Clinical findings of a septic abortion include fever, diffuse pelvic pain, and
    malodorous vaginal discharge. Complications, such as septic shock and rarely,
    pelvic thrombophlebitis, can occur. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?19/23/19834?
    source=see_link&amp;anchor=H24#H24\">",
    " \"Spontaneous abortion: Risk factors, etiology, clinical manifestations,
    and diagnostic evaluation\", section on 'Clinical manifestation and diagnosis'",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " <strong>",
    " Developmental anomalies of the M&uuml;llerian duct",
    " </strong>",
    " &ndash; Anomalies of the M&uuml;llerian duct may cause pelvic pain that
    first presents at puberty. Of these anomalies, imperforate hymen",
    " <strong>",
    " </strong>",
    " is the most common outflow tract obstruction, and it is most often diagnosed
    at puberty when menstrual fluid collects. Imperforate hymen can cause primary
    amenorrhea, a pelvic mass, hydrometrocolpos (dilatation of the uterus and vagina),
    and pelvic pain. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?12/11/12473?
    source=see_link&amp;anchor=H9#H9\">",
    " \"Diagnosis and management of congenital anomalies of the vagina\", section
    on 'Anomalies of the hymen'",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " <strong>",
    " Endometriosis",
    " </strong>",
    " &ndash; Endometrial tissue found outside of the uterus in ectopic locations
    can cause crampy pelvic pain associated with menses. It has even been known to
    cause painful defecation and dyspareunia, depending on its location. Though more
    commonly found in adult women, detection of endometriosis in adolescents is
    increasing and should be included in the differential. Early diagnosis may impact
    disease progression and long-term prognosis, especially concerning fertility.
    (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?18/48/19210?
    source=see_link&amp;anchor=H11#H11\">",
    " \"Pathogenesis, clinical features, and diagnosis of endometriosis\",
    section on 'Clinical features'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?18/48/19210?
    source=see_link&amp;anchor=H21#H21\">",
    " \"Pathogenesis, clinical features, and diagnosis of endometriosis\",
    section on 'Adolescents'",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " <strong>",
    " Reproductive organ and vulvar tumors",
    " </strong>",
    " &ndash; Neoplasm is rare in the pediatric population, but includes ovarian,
    uterine, cervical, vaginal, and even vulvar disease. Ovarian tumors occur in
    approximately 2 percent of adolescents and young adult women. Germ cell tumors are
    the most common histologically, and the most common of these is the dermoid cyst,
    or mature cystic teratoma, a benign neoplastic cyst. These tumors contain
    ectodermal, mesodermal, and endodermal tissue (ie, hair, bone, teeth, brain,
    adipose tissue, skin, etc). They can present with dull abdominal pain or a mass,
    but they are frequently asymptomatic and found incidentally on imaging due to
    calcification or increased echogenicity. They may be bilateral in 7 percent of
    adolescents. They may also increase the risk of ovarian torsion, and approximately
    1 to 3 percent can rupture. There are numerous other malignancies, and though rare,
    several peak during adolescence, such as immature teratomas, endodermal sinus
    tumors, mixed germ cell tumors, and gonadoblastoma. These usually present with
    pelvic pain, a palpable mass, or abdominal distention. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?5/37/5721?
    source=see_link\">",
    " \"Ovarian germ cell neoplasms: Pathology, clinical manifestations, and
    diagnosis\"",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " <strong>",
    " Vaginal foreign bodies",
    " </strong>",
    " &ndash; Foreign bodies include \"lost\" intrauterine devices, contraceptive
    rings, condoms, tampons, or other objects intentionally placed in the vaginal
    cavity. Pelvic pain",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " purulent vaginal discharge can rarely ensue, especially if significant
    vaginal wall irritation or trauma ensues. Complications, such as abscess formation
    or vaginal or uterine perforation, rarely occur. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?35/49/36633?
    source=see_link\">",
    " \"Approach to women with symptoms of vaginitis\"",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " <strong>",
    " Chemical irritants",
    " </strong>",
    " &ndash; Spermicides, lubricants, douching material, or bath products may
    cause vaginal irritation and pelvic pain. Douching predisposes to bacterial
    vaginosis and is not necessary for good vulvovaginal hygiene. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?35/49/36633?
    source=see_link&amp;anchor=H1860693#H1860693\">",
    " \"Approach to women with symptoms of vaginitis\", section on 'Irritants and
    allergens'",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " <strong>",
    " Sexual assault",
    " </strong>",
    " &ndash; Pelvic pain may indicate vaginal contusions, bruising, laceration or
    perforation in adolescents who have been sexually assaulted. The breasts, external
    genitalia, anus, and rectum should also be carefully examined for signs of injury.
    Detectable trauma is more likely in adolescent females who are virginal or report
    vaginal or anal penetration. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?20/7/20601?
    source=see_link&amp;anchor=H5#H5\">",
    " \"Evaluation and management of adult sexual assault victims\", section on
    'Physical examination'",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " <strong>",
    " Sexual abuse",
    " </strong>",
    " &ndash; The possibility of abuse, recent or past, absolutely must be
    included in any differential of acute or chronic pelvic pain. Previous
    psychological trauma, such as emotional, physical, or sexual abuse, can manifest
    itself as chronic functional pelvic pain. Depression, as a result of abuse or as a
    separate disease in itself, may be associated with chronic pelvic pain as well [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/697/abstract/1,2\">",
    " 1,2",
    " </a>",
    " ].",
    " </li>",
    " <li>",
    " <strong>",
    " Somaticization",
    " </strong>",
    " &ndash; Feigned symptoms",
    " <strong>",
    " </strong>",
    " should be considered in the absence of organic disease and an inconsistent
    historical and clinical picture. Psychosocial issues should be investigated, as
    well as any concern for abuse. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?5/20/5450?
    source=see_link&amp;anchor=H7#H7\">",
    " \"Somatization: Epidemiology, pathogenesis, clinical features, medical
    evaluation, and diagnosis\", section on 'Clinical presentation'",
    " </a>",
    " .)",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H1119600\">",
    " <span class=\"h1\">",
    " EVALUATION",
    " </span>",
    " &nbsp;&mdash;&nbsp;The first goal of the evaluation of the adolescent female
    with pelvic pain is to identify life-threatening conditions that require emergent
    interventions. Once this has been accomplished, other causes of pelvic pain can
    often be identified through deliberate evaluation with careful attention to the
    clinical features of the illness (eg, the pain characteristics, sexual history,
    presence of pregnancy, related symptoms, physical findings, and selected diagnostic
    studies) (",
    " <a class=\"graphic graphic_algorithm graphicRef58054 \" href=\"UTD.htm?
    20/40/21134\">",
    " algorithm 1",
    " </a>",
    " and",
    " <a class=\"graphic graphic_algorithm graphicRef69761 \" href=\"UTD.htm?
    8/28/8654\">",
    " algorithm 2",
    " </a>",
    " and",
    " <a class=\"graphic graphic_algorithm graphicRef63401 \" href=\"UTD.htm?
    2/55/2943\">",
    " algorithm 3",
    " </a>",
    " and",
    " <a class=\"graphic graphic_algorithm graphicRef77147 \" href=\"UTD.htm?
    2/56/2944\">",
    " algorithm 4",
    " </a>",
    " ).",
    " </p>",
    " <p>",
    " The evaluation for gastrointestinal and urologic causes of pelvic pain is
    discussed in greater detail separately. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?21/61/22490?
    source=see_link&amp;anchor=H3#H3\">",
    " \"Emergent evaluation of the child with acute abdominal pain\", section on
    'Evaluation'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H13206162\">",
    " <span class=\"h2\">",
    " History",
    " </span>",
    " &nbsp;&mdash;&nbsp;Pain characteristics, associated symptoms, menstrual
    status, and sexual history help to differentiate among the various gynecologic
    causes of pelvic pain [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/697/abstract/3,4\">",
    " 3,4",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " <strong>",
    " Pain characteristics",
    " </strong>",
    " &ndash; The clinician should determine the pain location, quality,
    radiation, timing, and associated symptoms, including temporal association with the
    menstrual cycle. Suggestive pain patterns include:",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " <ul class=\"hyphen-block\">",
    " <li>",
    " <strong>",
    " Ectopic pregnancy",
    " </strong>",
    " &ndash; Lower abdominal pain, typically six to eight weeks after the last
    menstrual period, often lateralizing, with symptoms of pregnancy, syncope and
    vaginal bleeding; with intraperitoneal bleeding, irritation of the diaphragm with
    referred pain to the shoulder or pooling of blood in the posterior cul-de-sac
    (pouch of Douglas) with an urge to defecate may occur (see",
    " <a class=\"medical medical_review\" href=\"UTD.htm?1/9/1178?
    source=see_link&amp;anchor=H3#H3\">",
    " \"Clinical manifestations, diagnosis, and management of ectopic
    pregnancy\", section on 'History'",
    " </a>",
    " ) &nbsp;",
    " </li>",
    " <li>",
    " <strong>",
    " Ovarian torsion",
    " </strong>",
    " &ndash; Abrupt onset of stabbing pain in the lower abdomen, typically
    lateralizing, with radiation to the back, flank, or groin and associated with
    nausea and vomiting (see",
    " <a class=\"medical medical_review\" href=\"UTD.htm?23/8/23690?
    source=see_link&amp;anchor=H327710#H327710\">",
    " \"Ovarian and fallopian tube torsion\", section on 'Clinical
    presentation'",
    " </a>",
    " )",
    " </li>",
    " <li>",
    " <strong>",
    " Ruptured ovarian cyst",
    " </strong>",
    " &ndash; Sudden onset of lateralizing pain, especially in association with
    exercise or sexual intercourse (see",
    " <a class=\"medical medical_review\" href=\"UTD.htm?9/40/9863?
    source=see_link&amp;anchor=H2#H2\">",
    " \"Evaluation and management of ruptured ovarian cyst\", section on
    'Clinical manifestations'",
    " </a>",
    " )",
    " </li>",
    " <li>",
    " <strong>",
    " Pelvic inflammatory disease",
    " </strong>",
    " &ndash; Bilateral pain commonly occurring during or just after menses that
    is worsened by coitus or jarring movement and occasionally associated with a new
    vaginal discharge, fever, or dysuria (see",
    " <a class=\"medical medical_review\" href=\"UTD.htm?1/0/1032?
    source=see_link&amp;anchor=H2#H2\">",
    " \"Clinical features and diagnosis of pelvic inflammatory disease\", section
    on 'Clinical features'",
    " </a>",
    " )",
    " </li>",
    " <li>",
    " <strong>",
    " Dysmenorrhea",
    " </strong>",
    " &ndash; Midline, cramping or dull pain associated with menstruation and
    often accompanied by back pain, fatigue, headache, nausea, vomiting, or diarrhea
    (see",
    " <a class=\"medical medical_review\" href=\"UTD.htm?30/25/31125?
    source=see_link&amp;anchor=H7#H7\">",
    " \"Primary dysmenorrhea in adolescents\", section on 'Typical symptoms'",
    " </a>",
    " )",
    " </li>",
    " <li>",
    " <strong>",
    " Mittelschmerz",
    " </strong>",
    " &ndash; Mild to moderate constant lateralizing pain occurring midway between
    menstrual periods",
    " </li>",
    " <li>",
    " <strong>",
    " Placental abruption",
    " </strong>",
    " &ndash; Lower abdominal",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " back pain, typically in the second or third trimester of pregnancy with
    vaginal bleeding and high frequency and low amplitude contractions (see",
    " <a class=\"medical medical_review\" href=\"UTD.htm?28/46/29417?
    source=see_link&amp;anchor=H5#H5\">",
    " \"Placental abruption: Clinical features and diagnosis\", section on 'Acute
    abruption'",
    " </a>",
    " )",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " <strong>",
    " Menstrual status",
    " </strong>",
    " &ndash; It must be ascertained early on whether the adolescent in question
    is pre or postmenarchal. In postmenarchal females, the timing of the last menstrual
    period should be determined in relation to the onset of pain and to evaluate for
    possible pregnancy.",
    " </li>",
    " <li>",
    " <strong>",
    " Sexual history",
    " </strong>",
    " &mdash; Sexually active adolescents are at risk for complications of
    pregnancy and pelvic inflammatory disease. It is important to have a nonjudgmental
    approach to obtaining a sexual history from the adolescent patient in order to
    protect her confidentiality and to maximize the likelihood that her responses will
    be truthful:",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " <ul class=\"hyphen-block\">",
    " <li>",
    " Questions about whether an adolescent has had sexual intercourse should only
    be posed when the patient's parent or guardian is not present.",
    " </li>",
    " <li>",
    " The clinician should introduce these questions with both an assurance that
    she or he will protect the teenager's confidentiality and a mention of any
    exceptions to confidentiality. State and federal laws and regulations in the United
    States and in other countries can limit confidentiality in specific circumstances,
    such as pregnancy in a minor, suicidality, and situations in which the teenager is
    in the legal custody of a state agency. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?5/24/5512?
    source=see_link\">",
    " \"Consent in adolescent health care\"",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " For every patient who has had sexual intercourse, questions should focus on
    the use of contraceptive methods and difficulty with contraceptive use (missed
    contraceptive pills, broken or unused condom, etc).",
    " </li>",
    " <li>",
    " Other key information includes the timing of the last intercourse, any
    history of sexually transmitted diseases",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " pelvic inflammatory disease, and any prior pregnancies.",
    " </li>",
    " <li>",
    " Patients who disclose sexual assault should ideally have the remainder of
    the evaluation performed by providers specifically trained to care for such cases.
    (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?20/7/20601?
    source=see_link&amp;anchor=H2#H2\">",
    " \"Evaluation and management of adult sexual assault victims\", section on
    'Evaluation'",
    " </a>",
    " .)",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H13206225\">",
    " <span class=\"h2\">",
    " Physical examination",
    " </span>",
    " &nbsp;&mdash;&nbsp;The adolescent female with pelvic pain warrants a complete
    examination with particular focus on vital signs and examination of the abdomen,
    genitalia, and pelvis. Hemodynamically unstable patients require resuscitation of
    shock prior to a comprehensive physical examination (",
    " <a class=\"graphic graphic_algorithm graphicRef77079 \" href=\"UTD.htm?
    41/12/42178\">",
    " algorithm 5",
    " </a>",
    " ). (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?26/8/26762?
    source=see_link&amp;anchor=H2#H2\">",
    " \"Initial management of shock in children\", section on 'Early goal-directed
    therapy'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " <strong>",
    " Vital signs",
    " </strong>",
    " &ndash; Fever suggests the presence of appendicitis, pelvic inflammatory
    disease (PID), or rarely, a septic abortion. Tachycardia with poor capillary
    perfusion or hypotension suggests shock in association with acute abruption,
    ectopic pregnancy, uterine rupture, appendicitis, ruptured hemorrhagic ovarian cyst
    (rare), or septic abortion.",
    " </li>",
    " <li>",
    " <strong>",
    " Abdomen",
    " </strong>",
    " &ndash; Right lower quadrant tenderness may arise from appendicitis, pelvic
    inflammatory disease, ovarian torsion, ovarian cyst, ectopic pregnancy, or
    nephrolithiasis. Left lower quadrant tenderness is caused by the same diagnoses,
    although appendicitis occurs rarely on the left side. Bilateral lower quadrant
    tenderness suggests PID. Rebound tenderness is found in patients with appendicitis
    or PID. A midline tender mass may be appreciated in adolescents females with
    imperforate hymen and hydrometrocolpos. Other causes of abdominal pain in the
    adolescent female are discussed in detail separately. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?11/20/11593?
    source=see_link\">",
    " \"Causes of acute abdominal pain in children and adolescents\"",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " <strong>",
    " Pelvic examination",
    " </strong>",
    " &ndash; A pelvic examination is essential in all sexually active adolescent
    females with pelvic pain. A speculum examination is necessary to assess for
    cervical discharge or bleeding and to evaluate for vaginal laceration or abnormal
    discharge. Cervical specimens for N. gonorrhoeae and Chlamydia trachomatis should
    be obtained and a sample of vaginal discharge collected for microscopic
    examination. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?35/49/36633?
    source=see_link&amp;anchor=H6#H6\">",
    " \"Approach to women with symptoms of vaginitis\", section on 'Diagnostic
    studies'",
    " </a>",
    " .)",
    " <br/>",
    " <br/>",
    " Although a vaginal bimanual examination is preferred, a rectal bimanual
    examination may be substituted in virginal patients.",
    " <br/>",
    " <br/>",
    " Important findings on pelvic examination may include:",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " <ul class=\"hyphen-block\">",
    " <li>",
    " Imperforate hymen (hematometrocolpos)",
    " </li>",
    " <li>",
    " Vulvar, anal,",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " vaginal trauma (sexual assault)",
    " </li>",
    " <li>",
    " Vaginal discharge (PID)",
    " </li>",
    " <li>",
    " Vaginal bleeding (ectopic pregnancy, acute abruption, spontaneous abortion,
    normal labor)",
    " </li>",
    " <li>",
    " Cervical motion tenderness (PID)",
    " </li>",
    " <li>",
    " Uterine tenderness (PID, acute abruption, dysmenorrhea, uterine rupture)",
    " </li>",
    " <li>",
    " Adnexal tenderness (PID, ectopic pregnancy, ovarian torsion)",
    " </li>",
    " <li>",
    " Adnexal mass (ovarian mass [cyst, abscess, or tumor], ectopic pregnancy,
    PID, endometriosis)",
    " </li>",
    " <li>",
    " Tenderness of the posterior cul-de-sac, rectovaginal septum, or uterosacral
    ligaments on rectovaginal examination (endometriosis)",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H13206274\">",
    " <span class=\"h2\">",
    " Laboratory",
    " </span>",
    " &nbsp;&mdash;&nbsp;The history and physical examination direct the subsequent
    ancillary testing that should be done.",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " <strong>",
    " Pregnancy test",
    " </strong>",
    " &ndash; Urine pregnancy testing must be done in a menstruating adolescent,
    and may also be appropriate in the ostensibly premenstrual girl in the face of an
    ambiguous history or clinical picture. Urine beta human chorionic gonadotropin
    testing is rapid and sensitive for detecting early pregnancy. If the patient is
    pregnant, quantitative beta hCG testing and Rh(D) typing may be indicated and the
    status of the pregnancy should be determined (eg, ectopic, intrauterine, threatened
    abortion). It is important to keep in mind that a positive pregnancy test does not
    exclude a non-gynecologic cause of pelvic pain. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?43/48/44808?
    source=see_link&amp;anchor=H8967182#H8967182\">",
    " \"Clinical manifestations and diagnosis of early pregnancy\", section on
    'Urine pregnancy test'",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " <strong>",
    " Urine tests",
    " </strong>",
    " &ndash; After cleansing, a rapid urine dipstick that indicates hematuria or
    pyuria helps to identify those patients that should have a microscopic urinalysis",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " urine culture. Of note, bladder catheterization is typically needed in
    patients with vaginal bleeding to avoid contamination of the urine specimen.",
    " </li>",
    " <li>",
    " <strong>",
    " Complete blood count and inflammatory markers",
    " </strong>",
    " &ndash; Patients with pelvic pain who have vaginal bleeding warrant
    assessment for anemia and thrombocytopenia. An elevated white blood cell count with
    immature neutrophil forms on differential is suggestive of appendicitis or pelvic
    inflammatory disease. Erythrocyte sedimentation rates or C-reactive protein levels
    may also be increased in patients with these conditions. &nbsp;",
    " </li>",
    " <li>",
    " <strong>",
    " Blood typing &ndash;",
    " </strong>",
    " Pregnant patients with spontaneous abortion, ectopic pregnancy or placental
    abruption should have blood typing to determine Rh (D or Rhesus antigen) status and
    the potential need for anti-D immune globulin administration to prevent
    alloimmunization. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?39/44/40648?
    source=see_link\">",
    " \"Prevention of Rh(D) alloimmunization\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?39/44/40648?
    source=see_link&amp;anchor=H8#H8\">",
    " \"Prevention of Rh(D) alloimmunization\", section on 'Additional
    indications'",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " <strong>",
    " Detection of sexually transmitted disease",
    " </strong>",
    " &ndash; Depending upon clinical suspicion, cervical culture (gonorrhea,
    chlamydia, genital herpes, Trichomonas), serology (herpes simplex virus type 2,
    syphilis), or cervical nucleic acid amplification tests (N. gonorrhoeae, C.
    trachomatis) or a combination may be obtained. Alternatively, nucleic acid
    amplification tests for C. trachomatis and N. gonorrhoeae may be sent on a
    spontaneously voided urine obtained before external cleansing in patients for whom
    pelvic examination is otherwise unnecessary. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?36/51/37689?
    source=see_link&amp;anchor=H16#H16\">",
    " \"Sexually transmitted diseases: Overview of issues specific to
    adolescents\", section on 'Screening and diagnostic testing'",
    " </a>",
    " .)",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H1120299\">",
    " <span class=\"h2\">",
    " Imaging",
    " </span>",
    " &nbsp;&mdash;&nbsp;Ultrasound (US) is the preferred initial method for
    evaluating pelvic pathology. The ultrasound examination is usually initiated
    transabdominally. The bladder does not have to be full; however, if the ovaries
    cannot be visualized, it may be necessary to have the patient fill her bladder to a
    comfortable capacity. This is especially important for those teenagers who are
    unable to tolerate placement of a transvaginal ultrasound probe. Often in these
    cases, the entire examination can be performed transabdominally. Transabdominal
    scanning is important for evaluating the upper pelvis and abdomen, and can detect
    appendicitis, in some cases, nephrolithiasis, ovarian cysts, tumors, and
    tuboovarian abscess. Doppler flow studies can assist in the urgent diagnosis of
    ovarian torsion. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?35/61/36824?
    source=see_link&amp;anchor=H22#H22\">",
    " \"Ultrasound examination in obstetrics and gynecology\", section on
    'Examination'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?18/61/19416?
    source=see_link&amp;anchor=H2#H2\">",
    " \"Acute appendicitis in children: Diagnostic imaging\", section on
    'Ultrasonography (US)'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Transvaginal sonography is best performed with an empty bladder and is helpful
    in diagnosing ectopic and intrauterine pregnancy and spontaneous abortion.",
    " </p>",
    " <p>",
    " Computed tomography (CT) of the abdomen and pelvis may be helpful in patients
    in whom diagnostic uncertainty persists after laboratory and US evaluation,
    especially those in whom nephrolithiasis or appendicitis is suspected. Contrast
    should not be given to patients undergoing CT for the diagnosis of nephrolithiasis.
    (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?13/19/13623?
    source=see_link&amp;anchor=H14#H14\">",
    " \"Clinical features and diagnosis of nephrolithiasis in children\", section
    on 'Non-contrast helical CT'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?18/61/19416?
    source=see_link&amp;anchor=H9#H9\">",
    " \"Acute appendicitis in children: Diagnostic imaging\", section on 'Computed
    tomography (CT)'",
    " </a>",
    " .) &nbsp;",
    " </p>",
    " <p>",
    " Rarely, magnetic resonance imaging may be helpful in patients with suspected
    malformations of the genitourinary tract.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H1120387\">",
    " <span class=\"h2\">",
    " Laparoscopy",
    " </span>",
    " &nbsp;&mdash;&nbsp;Laparoscopy is sometimes indicated in the evaluation of
    acute pelvic pain, especially when the diagnosis is not clear after less invasive
    evaluations and the differential diagnoses include potentially life-threatening or
    organ-threatening disorders. Examples are appendicitis, pelvic inflammatory
    disease, endometriosis, and ovarian torsion. Laparoscopy also has a role in the
    treatment of many surgical disorders. On the other hand, most adolescent females
    with acute pelvic pain, normal imaging and laboratory studies, and a normal
    physical examination (including absence of",
    " <span class=\"nowrap\">",
    " vaginal/cervical",
    " </span>",
    " discharge and abnormal uterine bleeding) will improve without need for
    intervention. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?16/44/17095?
    source=see_link&amp;anchor=H18#H18\">",
    " \"Evaluation of acute pelvic pain in women\", section on 'Laparoscopy'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H13206372\">",
    " <span class=\"h1\">",
    " ALGORITHMIC APPROACH",
    " </span>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H5587293\">",
    " <span class=\"h2\">",
    " Pregnant",
    " </span>",
    " &nbsp;&mdash;&nbsp;The approach to the pregnant adolescent female with pelvic
    pain is show in the algorithms (",
    " <a class=\"graphic graphic_algorithm graphicRef58054 \" href=\"UTD.htm?
    20/40/21134\">",
    " algorithm 1",
    " </a>",
    " and",
    " <a class=\"graphic graphic_algorithm graphicRef69761 \" href=\"UTD.htm?
    8/28/8654\">",
    " algorithm 2",
    " </a>",
    " ).",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H5587309\">",
    " <span class=\"h3\">",
    " Vaginal bleeding",
    " </span>",
    " &nbsp;&mdash;&nbsp;Pregnant patients with vaginal bleeding first should be
    assessed for hemodynamic stability (",
    " <a class=\"graphic graphic_algorithm graphicRef58054 \" href=\"UTD.htm?
    20/40/21134\">",
    " algorithm 1",
    " </a>",
    " ). Shock is associated with a ruptured ectopic pregnancy, acute abruption, and
    uterine rupture. Patients who are less than 20 weeks gestation and hemodynamically
    stable may have abruptio placenta or a spontaneous abortion. In addition to these
    conditions, those patients with vaginal bleeding during late pregnancy may be in
    normal or premature labor.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H5587317\">",
    " <span class=\"h3\">",
    " No vaginal bleeding",
    " </span>",
    " &nbsp;&mdash;&nbsp;Pregnant patients without vaginal bleeding, but with
    rhythmic contractions may be in normal or premature labor (late pregnancy by
    examination or ultrasound) or may have a threatened abortion (",
    " <a class=\"graphic graphic_algorithm graphicRef69761 \" href=\"UTD.htm?
    8/28/8654\">",
    " algorithm 2",
    " </a>",
    " ). Patients with sacroiliac joint pain with provocative testing (FABERE sign)
    may have pelvic girdle pain of pregnancy. Otherwise, the clinician should evaluate
    for causes unrelated to pregnancy, especially in patients with fever or peritonitis
    (",
    " <a class=\"graphic graphic_algorithm graphicRef69041 \" href=\"UTD.htm?
    1/2/1058\">",
    " algorithm 6",
    " </a>",
    " ).",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H5587301\">",
    " <span class=\"h2\">",
    " Not pregnant",
    " </span>",
    " &nbsp;&mdash;&nbsp;The approach to pelvic pain in the adolescent female who is
    not pregnant is shown in the algorithms and varies according to whether the girl
    has reached normal menstruation or not (",
    " <a class=\"graphic graphic_algorithm graphicRef63401 \" href=\"UTD.htm?
    2/55/2943\">",
    " algorithm 3",
    " </a>",
    " and",
    " <a class=\"graphic graphic_algorithm graphicRef77147 \" href=\"UTD.htm?
    2/56/2944\">",
    " algorithm 4",
    " </a>",
    " ). A careful physical examination with selected ancillary studies helps
    differentiate among the possible causes.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H29078100\">",
    " <span class=\"h3\">",
    " Premenarchal",
    " </span>",
    " &nbsp;&mdash;&nbsp;Key findings for girls who have not yet reached normal
    menstruation include (",
    " <a class=\"graphic graphic_algorithm graphicRef63401 \" href=\"UTD.htm?
    2/55/2943\">",
    " algorithm 3",
    " </a>",
    " ):",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Sexual assault may be determined by history or diagnosed by evidence of
    vulvovaginal trauma.",
    " </li>",
    " <li>",
    " Hydrocolpos with an imperforate hymen is identified on external examination
    of the vulva.",
    " </li>",
    " <li>",
    " Right lower quadrant tenderness with supportive findings on complete blood
    count",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " ultrasound suggests appendicitis.",
    " </li>",
    " <li>",
    " Flank pain radiating to the pelvis with hematuria is found in patients with
    nephrolithiasis.",
    " </li>",
    " <li>",
    " Flank or suprapubic pain with pyuria suggests pyelonephritis or a urinary
    tract infection.",
    " </li>",
    " <li>",
    " Rarely, a previously premenarchal girl may be pregnant",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H29944782\">",
    " <span class=\"h3\">",
    " Postmenarchal",
    " </span>",
    " &nbsp;&mdash;&nbsp;In females who have reached normal menstruation, the
    diagnosis is suggested by the following clinical findings (",
    " <a class=\"graphic graphic_algorithm graphicRef77147 \" href=\"UTD.htm?
    2/56/2944\">",
    " algorithm 4",
    " </a>",
    " ):",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " A vaginal foreign body is typically evident on pelvic examination.",
    " </li>",
    " <li>",
    " Vaginal bleeding with pain during menstruation is seen in patients with
    dysmenorrhea.",
    " </li>",
    " <li>",
    " Bilateral adnexal tenderness with cervical discharge",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " cervical motion tenderness supports the diagnosis of pelvic inflammatory
    disease.",
    " </li>",
    " <li>",
    " Patients with unilateral stabbing abdominal pain and decreased blood flow by
    Doppler ultrasound (US) have ovarian torsion.",
    " </li>",
    " <li>",
    " An adnexal mass on pelvic examination",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " ultrasound is seen in patients with ovarian tumor, abscess, or cyst.",
    " </li>",
    " <li>",
    " Endometriosis is suggested by recurrent pain, dyspareunia, or typical
    findings on recto-vaginal examination. (See",
    " <a class=\"local\" href=\"#H13206225\">",
    " 'Physical examination'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Patients who are midcycle and have lateral pain without any other
    distinguishing features likely have mittelschmerz.",
    " </li>",
    " <li>",
    " If the evaluation, including pelvic examination, urinalysis, complete blood
    count, and ultrasound fail to establish a diagnosis in a menstruating female, then
    the clinician should observe for additional signs of appendicitis or PID and pursue
    other gastrointestinal or urologic causes (",
    " <a class=\"graphic graphic_algorithm graphicRef69041 \" href=\"UTD.htm?
    1/2/1058\">",
    " algorithm 6",
    " </a>",
    " ).",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H1120584\">",
    " <span class=\"h1\">",
    " SUMMARY",
    " </span>",
    " &nbsp;&mdash;&nbsp;Pelvic pain most often involves the gastrointestinal or the
    urinary systems in prepubertal girls. However, gynecologic conditions become more
    prevalent as etiologies for pelvic pain, especially during late adolescence.",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " The gynecologic causes of acute pelvic pain in adolescent females are listed
    in the table (",
    " <a class=\"graphic graphic_table graphicRef75310 \" href=\"UTD.htm?
    35/5/35931\">",
    " table 1",
    " </a>",
    " ). (See",
    " <a class=\"local\" href=\"#H13206035\">",
    " 'Differential diagnosis'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Pain characteristics, associated symptoms, menstrual status, and sexual
    history help to differentiate among the various gynecologic causes of pelvic pain.
    (See",
    " <a class=\"local\" href=\"#H13206162\">",
    " 'History'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " The adolescent female with pelvic pain warrants a complete examination with
    particular focus on vital signs and examination of the abdomen, genitalia, and
    pelvis. Hemodynamically unstable patients require resuscitation of shock prior to a
    comprehensive physical examination (",
    " <a class=\"graphic graphic_algorithm graphicRef77079 \" href=\"UTD.htm?
    41/12/42178\">",
    " algorithm 5",
    " </a>",
    " ). A pelvic examination is essential in all sexually active adolescent
    females with pelvic pain. (See",
    " <a class=\"local\" href=\"#H13206225\">",
    " 'Physical examination'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Urine pregnancy testing must be done in a menstruating adolescent and may
    also be appropriate in the ostensibly premenstrual girl in the face of an ambiguous
    history or clinical picture. Other ancillary studies are guided by clinical
    findings. (See",
    " <a class=\"local\" href=\"#H13206274\">",
    " 'Laboratory'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H1120299\">",
    " 'Imaging'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " The algorithms provide a suggested approach to adolescent with pelvic pain
    according to the presence of key findings, such as vaginal bleeding, pregnancy, and
    other results of clinical evaluation (",
    " <a class=\"graphic graphic_algorithm graphicRef58054 \" href=\"UTD.htm?
    20/40/21134\">",
    " algorithm 1",
    " </a>",
    " and",
    " <a class=\"graphic graphic_algorithm graphicRef69761 \" href=\"UTD.htm?
    8/28/8654\">",
    " algorithm 2",
    " </a>",
    " and",
    " <a class=\"graphic graphic_algorithm graphicRef63401 \" href=\"UTD.htm?
    2/55/2943\">",
    " algorithm 3",
    " </a>",
    " and",
    " <a class=\"graphic graphic_algorithm graphicRef77147 \" href=\"UTD.htm?
    2/56/2944\">",
    " algorithm 4",
    " </a>",
    " ). (See",
    " <a class=\"local\" href=\"#H13206372\">",
    " 'Algorithmic approach'",
    " </a>",
    " above.)",
    " </li>",
    " </ul>",
    " </p>",
    " </div>",
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    " Use of UpToDate is subject to the",
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    " Subscription and License Agreement",
    " </a>",
    " .",
    " </div>",
    " <div class=\"headingAnchor\" id=\"references\">",
    " <h1>",
    " REFERENCES",
    " </h1>",
    " <ol id=\"reference\">",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/697/abstract/1\">",
    " Berkowitz CD. Medical consequences of child sexual abuse. Child Abuse Negl
    1998; 22:541.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/697/abstract/2\">",
    " Kamm MA. Chronic pelvic pain in women--gastroenterological, gynaecological
    or psychological? Int J Colorectal Dis 1997; 12:57.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/697/abstract/3\">",
    " Kruszka PS, Kruszka SJ. Evaluation of acute pelvic pain in women. Am Fam
    Physician 2010; 82:141.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/697/abstract/4\">",
    " Hewitt GD, Brown RT. Acute and chronic pelvic pain in female adolescents.
    Med Clin North Am 2000; 84:1009.",
    " </a>",
    " </li>",
    " </ol>",
    " </div>",
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    " <h1>",
    " TOPIC OUTLINE",
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    " <span>",
    " SUMMARY",
    " </span>",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H13206028\">",
    " INTRODUCTION",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H13206035\">",
    " DIFFERENTIAL DIAGNOSIS",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H13206042\">",
    " Life-threatening conditions",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H4155804\">",
    " - Ectopic pregnancy",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H4155837\">",
    " - Placental abruption",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H4155912\">",
    " - Uterine rupture",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H13206049\">",
    " - Appendicitis",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H3093327\">",
    " - Ovarian torsion",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H13206084\">",
    " Common conditions",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H4156466\">",
    " - Dysmenorrhea",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H4156418\">",
    " - Mittelschmerz",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H4156366\">",
    " - Pelvic inflammatory disease",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H4156405\">",
    " - Ruptured ovarian cyst",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H4156549\">",
    " - Nephrolithiasis",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H832927\">",
    " - Urinary tract infection",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H13206115\">",
    " Other gynecologic conditions",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H1119600\">",
    " EVALUATION",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H13206162\">",
    " History",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H13206225\">",
    " Physical examination",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H13206274\">",
    " Laboratory",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H1120299\">",
    " Imaging",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H1120387\">",
    " Laparoscopy",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H13206372\">",
    " ALGORITHMIC APPROACH",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H5587293\">",
    " Pregnant",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H5587309\">",
    " - Vaginal bleeding",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H5587317\">",
    " - No vaginal bleeding",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H5587301\">",
    " Not pregnant",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H29078100\">",
    " - Premenarchal",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H29944782\">",
    " - Postmenarchal",
    " </a>",
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    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H1120584\">",
    " SUMMARY",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a href=\"#references\">",
    " REFERENCES",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " <h1>",
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    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_algorithm\" href=\"UTD.htm?20/40/21134\"
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    " Pelvic pain in the pregnant adolescent female with vaginal bleed",
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    " Scoring system for dysmenorrhea",
    " </a>",
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    " </ul>",
    " </div>",
    " <h1>",
    " RELATED TOPICS",
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    var title_f0_43_698="Alcoholic hepatitis: Natural history and management";
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    " <!-- TC:TOPIC_PAGE -->",
    " <div id=\"topicContent\">",
    " <div id=\"topicTitle\">",
    " Alcoholic hepatitis: Natural history and management",
    " </div>",
    " <div id=\"topicContributors\">",
    " <div>",
    " <a id=\"authors\">",
    " </a>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"UTD.htm?0/43/698/contributors\">",
    " Author",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/43/698/contributors\">",
    " Scott L Friedman, MD",
    " </a>",
    " <br/>",
    " </div>",
    " <div>",
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    href=\"UTD.htm?0/43/698/contributors\">",
    " Section Editor",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/43/698/contributors\">",
    " Bruce A Runyon, MD",
    " </a>",
    " <br/>",
    " </div>",
    " <div>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"UTD.htm?0/43/698/contributors\">",
    " Deputy Editor",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/43/698/contributors\">",
    " Anne C Travis, MD, MSc, FACG",
    " </a>",
    " <br/>",
    " </div>",
    " </div>",
    " <div id=\"disclosures\">",
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    " All topics are updated as new evidence becomes available and our",
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    " peer review process",
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    " is complete.",
    " </span>",
    " </div>",
    " <div id=\"literatureReviewDate\">",
    " <span class=\"emphasis\">",
    " Literature review current through:",
    " </span>",
    " Oct 2013.",
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    " |",
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    " <span class=\"emphasis\">",
    " This topic last updated:",
    " </span>",
    " Jan 29, 2013.",
    " </div>",
    " <div id=\"topicText\">",
    " <p class=\"headingAnchor\" id=\"H234083145\">",
    " <span class=\"h1\">",
    " INTRODUCTION",
    " </span>",
    " &nbsp;&mdash;&nbsp;Excessive alcohol consumption is associated with a range of
    hepatic manifestations, including alcoholic fatty liver disease (with or without
    steatohepatitis), alcoholic hepatitis, and cirrhosis. While asymptomatic
    steatohepatitis due to alcohol could be referred to as \"alcoholic hepatitis\", the
    term is typically used to describe the acute onset of symptomatic hepatitis. The
    amount of alcohol intake that puts an individual at risk for alcoholic hepatitis is
    not known, but the majority of patients have a history of heavy alcohol use (more
    than 100",
    " <span class=\"nowrap\">",
    " g/day)",
    " </span>",
    " for two or more decades (",
    " <a class=\"graphic graphic_figure graphicRef68118 \" href=\"UTD.htm?
    4/61/5079\">",
    " figure 1",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/1,2\">",
    " 1,2",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " This topic will review the prognosis and management of patients with alcoholic
    hepatitis. The pathogenesis of alcoholic liver disease, the clinical manifestations
    and diagnosis of alcoholic hepatitis, and the approach to patients with alcoholic
    fatty liver disease or alcoholic cirrhosis are discussed separately. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?30/5/30807?
    source=see_link\">",
    " \"Pathogenesis of alcoholic liver disease\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?28/4/28744?
    source=see_link\">",
    " \"Alcoholic hepatitis: Clinical manifestations and diagnosis\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?20/42/21162?
    source=see_link\">",
    " \"Clinical manifestations and diagnosis of alcoholic fatty liver disease and
    alcoholic cirrhosis\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?21/37/22104?
    source=see_link\">",
    " \"Prognosis and management of alcoholic fatty liver disease and alcoholic
    cirrhosis\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " <a class=\"external\"
    href=\"file://www.aasld.org/practiceguidelines/Documents/Bookmarked Practice
    Guidelines/AlcoholicLiverDisease1-2010.pdf\">",
    " Guidelines",
    " </a>",
    " for the management of patients with alcoholic liver disease were issued in
    2010 by the American Association for the Study of Liver Diseases [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/3\">",
    " 3",
    " </a>",
    " ]. The discussion that follows is generally consistent with those
    guidelines.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H234081660\">",
    " <span class=\"h1\">",
    " NATURAL HISTORY",
    " </span>",
    " &nbsp;&mdash;&nbsp;Mortality rates among patients who do not receive
    pharmacologic therapy (eg,",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/48/33536?source=see_link\">",
    " prednisolone",
    " </a>",
    " ) for alcoholic hepatitis are variable. In patients with severe alcoholic
    hepatitis (typically defined by a Maddrey discriminant function &ge;32 (",
    " <a class=\"calc calc_professional\" href=\"UTD.htm?15/29/15825?
    source=see_link\">",
    " calculator 1",
    " </a>",
    " )), short-term mortality rates are high (approximately 25 to 35 percent at one
    month) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/4-6\">",
    " 4-6",
    " </a>",
    " ], whereas patients with mild to moderate alcoholic hepatitis have low short-
    term mortality rates (&lt;10 percent at one to three months) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/7,8\">",
    " 7,8",
    " </a>",
    " ]. (See",
    " <a class=\"local\" href=\"#H325299748\">",
    " 'Determining disease severity'",
    " </a>",
    " below.)",
    " </p>",
    " <p>",
    " In a pooled analysis of 661 patients with alcoholic hepatitis who had received
    placebo in randomized trials, the overall mortality rate after a median of 160 days
    was 34 percent [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/4\">",
    " 4",
    " </a>",
    " ]. The primary causes of death were hepatic failure (55 percent),
    gastrointestinal bleeding (21 percent), and sepsis (7 percent). When mortality
    rates were examined based on study inclusion criteria, one-month mortality rates
    were higher in trials that included only patients with severe alcoholic hepatitis
    compared with trials that included patients with both moderate and severe alcoholic
    hepatitis or trials that did not specify severity (23 versus 21 and 11 percent,
    respectively).",
    " </p>",
    " <p>",
    " A high mortality rate for patients with severe alcoholic hepatitis was also
    seen in a meta-analysis of five randomized trials [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/6\">",
    " 6",
    " </a>",
    " ]. Among 197 patients with severe alcoholic hepatitis who did not receive
    corticosteroids, the mortality rate at 28 days was 34 percent.",
    " </p>",
    " <p>",
    " Mortality rates for patients with mild to moderate alcoholic hepatitis have
    been reported in small trials:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " In a trial of nutritional support, 12 patients had moderate alcoholic
    hepatitis. There were no deaths at 28 days among the patients with moderate
    alcoholic hepatitis, regardless of the treatment arm (whereas the mortality rate
    was 32 percent among those with severe alcoholic hepatitis) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/7\">",
    " 7",
    " </a>",
    " ].",
    " </li>",
    " <li>",
    " In a trial that included 26 patients with mild to moderate alcoholic
    hepatitis who did not receive treatment, 2 patients (8 percent) died [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/8\">",
    " 8",
    " </a>",
    " ].",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " Multiple factors have been associated with increased mortality in patients
    with alcoholic hepatitis, some of which have been incorporated into prognostic
    models. (See",
    " <a class=\"local\" href=\"#H325299748\">",
    " 'Determining disease severity'",
    " </a>",
    " below.)",
    " </p>",
    " <p>",
    " Factors associated with increased mortality include [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/9-14\">",
    " 9-14",
    " </a>",
    " ]:",
    " </p>",
    " <p>",
    " <ul class=\"bulletCompact-block\">",
    " <li>",
    " Older age",
    " </li>",
    " <li>",
    " Acute kidney injury",
    " </li>",
    " <li>",
    " Elevated bilirubin level",
    " </li>",
    " <li>",
    " Elevated INR",
    " </li>",
    " <li>",
    " Leukocytosis",
    " </li>",
    " <li>",
    " Alcohol consumption &gt;120",
    " <span class=\"nowrap\">",
    " g/day",
    " </span>",
    " </li>",
    " <li>",
    " Presence of infection (sepsis, spontaneous bacterial peritonitis, pneumonia,
    urinary tract infection)",
    " </li>",
    " <li>",
    " Hepatic encephalopathy",
    " </li>",
    " <li>",
    " Upper gastrointestinal bleeding",
    " </li>",
    " <li>",
    " A bilirubin to gamma glutamyl transferase ratio &gt;1",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " Rarely, extremely high white blood cell counts (a leukemoid reaction) are seen
    and are associated with very high mortality rates. In a review of 10 cases of
    patients with alcoholic hepatitis and a leukemoid reaction, the white blood cell
    counts ranged from",
    " <span class=\"nowrap\">",
    " 57,000/microL",
    " </span>",
    " to",
    " <span class=\"nowrap\">",
    " 129,000/microL,",
    " </span>",
    " and only one patient survived [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/15\">",
    " 15",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H325299748\">",
    " <span class=\"h1\">",
    " DETERMINING DISEASE SEVERITY",
    " </span>",
    " &nbsp;&mdash;&nbsp;Several models have been proposed to determine the severity
    of a patient's alcoholic hepatitis [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/13\">",
    " 13",
    " </a>",
    " ]. The Maddrey discriminant function and the Model for End-stage Liver Disease
    (MELD) score are the most commonly used to help identify patients who are more
    likely to benefit from pharmacologic therapy. Other validated scores include the
    Glasgow alcoholic hepatitis score, the ABIC score (which includes age, serum
    bilirubin, international normalized ratio, and serum creatinine), and the Lille
    score (which is used to determine if a patients is responding to treatment) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/13,16,17\">",
    " 13,16,17",
    " </a>",
    " ]. (See",
    " <a class=\"local\" href=\"#H234081695\">",
    " 'Glucocorticoids'",
    " </a>",
    " below.)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H251272027\">",
    " <span class=\"h2\">",
    " Maddrey discriminant function",
    " </span>",
    " &nbsp;&mdash;&nbsp;Disease severity and mortality risk in patients with
    alcoholic hepatitis may be estimated using the Maddrey discriminant function (DF,
    also known as the Maddrey score), which is calculated as follows (",
    " <a class=\"calc calc_professional\" href=\"UTD.htm?15/29/15825?
    source=see_link\">",
    " calculator 1",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/5,18\">",
    " 5,18",
    " </a>",
    " ]:",
    " </p>",
    " <p>",
    " For bilirubin in conventional units",
    " <span class=\"nowrap\">",
    " (mg/dL):",
    " </span>",
    " </p>",
    " <p>",
    " DF = (4.6 x [prothrombin time (sec) - control prothrombin time (sec)]) +
    (serum bilirubin)",
    " </p>",
    " <p>",
    " For bilirubin in syst&egrave;me international (SI) units",
    " <span class=\"nowrap\">",
    " (micromol/L):",
    " </span>",
    " </p>",
    " <p>",
    " DF = (4.6 x [prothrombin time (sec) - control prothrombin time (sec)]) +
    (serum",
    " <span class=\"nowrap\">",
    " bilirubin/17.1)",
    " </span>",
    " </p>",
    " <p>",
    " Patients with a DF value &ge;32 have high short-term mortality and may benefit
    from treatment with glucocorticoids, whereas those with lower scores have low
    short-term mortality and do not appear to benefit from glucocorticoids. (See",
    " <a class=\"local\" href=\"#H234081660\">",
    " 'Natural history'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H234081695\">",
    " 'Glucocorticoids'",
    " </a>",
    " below.)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H251272037\">",
    " <span class=\"h2\">",
    " Meld score",
    " </span>",
    " &nbsp;&mdash;&nbsp;The Model for End-stage Liver Disease (MELD) score is a
    statistical model developed to predict survival in patients with cirrhosis that has
    also been used to predict mortality in patients hospitalized for alcoholic
    hepatitis [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/19-21\">",
    " 19-21",
    " </a>",
    " ]. The score ranges from 6 to 40 and is based on the serum bilirubin,
    creatinine, and INR (",
    " <a class=\"calc calc_professional\" href=\"UTD.htm?21/23/21874?
    source=see_link\">",
    " calculator 2",
    " </a>",
    " and",
    " <a class=\"calc calc_professional\" href=\"UTD.htm?18/2/18466?
    source=see_link\">",
    " calculator 3",
    " </a>",
    " ). (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?15/25/15770?
    source=see_link\">",
    " \"Model for End-stage Liver Disease (MELD)\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " In one report, a MELD score &gt;11 performed as well as the DF in predicting
    30-day mortality [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/19\">",
    " 19",
    " </a>",
    " ]. The sensitivity and specificity of MELD for predicting 30-day mortality
    were 86 and 81 percent, respectively, and for the DF were 86 and 48 percent,
    respectively. In a second study, a MELD score of &ge;21 had a sensitivity of 75
    percent and a specificity of 75 percent for predicting 90-day mortality [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/20\">",
    " 20",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " In addition, an increase in the MELD score of &ge;2 points in the first week
    of hospitalization may independently predict in-hospital mortality [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/21\">",
    " 21",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H251272046\">",
    " <span class=\"h2\">",
    " Glasgow alcoholic hepatitis score",
    " </span>",
    " &nbsp;&mdash;&nbsp;The Glasgow alcoholic hepatitis score (GAH) predicts
    mortality in alcoholic hepatitis and is based on a multivariable model that
    includes age, serum bilirubin, blood urea nitrogen, prothrombin time, and
    peripheral white blood cell count (",
    " <a class=\"calc calc_professional\" href=\"UTD.htm?42/9/43152?
    source=see_link\">",
    " calculator 4",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/22,23\">",
    " 22,23",
    " </a>",
    " ]. An initial validation study with 195 patients with alcoholic hepatitis
    found that a GAH score &ge;9 had lower sensitivity but higher specificity for
    predicting 28-day mortality than a DF of &ge;32 (81 versus 96 percent and 61 versus
    27 percent, respectively) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/23\">",
    " 23",
    " </a>",
    " ]. Similar results were seen when it was compared with the MELD score (using a
    MELD cutoff of 11).",
    " </p>",
    " <p>",
    " A subsequent validation study with 225 patients with a DF &ge;32 found that
    patients with a GAH score &ge;9 who received glucocorticoids had higher survival
    rates compared with those who did not receive glucocorticoids (78 versus 52 percent
    survival at 28 days and 59 versus 38 percent survival at 84 days) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/22\">",
    " 22",
    " </a>",
    " ]. However, no survival benefit with glucocorticoids was seen among the
    patients with a GAH score &lt;9.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H234081667\">",
    " <span class=\"h1\">",
    " MANAGEMENT",
    " </span>",
    " &nbsp;&mdash;&nbsp;The management of alcoholic hepatitis includes treatment
    for alcohol withdrawal, providing hemodynamic and nutritional support, and in those
    with severe alcoholic hepatitis (discriminant function [DF] &ge;32 (",
    " <a class=\"calc calc_professional\" href=\"UTD.htm?15/29/15825?
    source=see_link\">",
    " calculator 1",
    " </a>",
    " )), treating with either a glucocorticoid or",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?source=see_link\">",
    " pentoxifylline",
    " </a>",
    " . Patients with alcoholic hepatitis usually need to be admitted to the
    hospital for management. Admission to an intensive care unit (ICU) should be
    considered in patients who are unstable or combative. In addition, patients who are
    inebriated or encephalopathic should have their airway protected. In patients not
    being managed in an ICU, hospitalization should be continued if there is evidence
    of infection, renal failure, severe coagulopathy",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " liver failure, alcohol withdrawal, delirium tremens, or other serious
    complications. Once these have been excluded and the patient is hemodynamically
    stable (with or without ongoing steroid usage), discharge can be considered,
    provided that there is sufficient social support and patient insight to ensure good
    compliance with medications, abstinence from alcohol, and close medical follow-up.
    Consultation with a gastroenterologist or hepatologist is recommended to assist
    with management, especially for patients who fail to respond to pharmacologic
    treatment.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H234081674\">",
    " <span class=\"h2\">",
    " General management for all patients",
    " </span>",
    " &nbsp;&mdash;&nbsp;Patients with alcoholic hepatitis require general
    supportive care, including:",
    " </p>",
    " <p>",
    " <ul class=\"bulletCompact-block\">",
    " <li>",
    " Alcohol abstinence",
    " </li>",
    " <li>",
    " Prevention and treatment of alcohol withdrawal",
    " </li>",
    " <li>",
    " Fluid management",
    " </li>",
    " <li>",
    " Nutritional support",
    " </li>",
    " <li>",
    " Infection surveillance",
    " </li>",
    " <li>",
    " Prophylaxis against gastric mucosal bleeding",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H251271990\">",
    " <span class=\"h3\">",
    " Alcohol abstinence",
    " </span>",
    " &nbsp;&mdash;&nbsp;All patients with alcoholic hepatitis should abstain from
    alcohol. Pharmacologic therapy with agents such as",
    " <a class=\"drug drug_general\" href=\"UTD.htm?35/31/36342?source=see_link\">",
    " baclofen",
    " </a>",
    " may aid with abstinence [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/24-27\">",
    " 24-27",
    " </a>",
    " ]. Since many have a long history of heavy alcohol use, they are at risk for
    alcohol withdrawal. Therefore, the prevention and treatment of alcohol withdrawal
    is an important part of a patient's management. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?19/61/20441?
    source=see_link&amp;anchor=H24#H24\">",
    " \"Management of moderate and severe alcohol withdrawal syndromes\", section
    on 'Prophylaxis'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?19/61/20441?
    source=see_link&amp;anchor=H13#H13\">",
    " \"Management of moderate and severe alcohol withdrawal syndromes\", section
    on 'Management'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?18/48/19209?
    source=see_link&amp;anchor=H22#H22\">",
    " \"Pharmacotherapy for alcohol abuse and dependence\", section on 'Baclofen'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/55/41847?
    source=see_link\">",
    " \"Psychosocial treatment of alcohol abuse and dependence\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H251272000\">",
    " <span class=\"h3\">",
    " Hydration and nutritional support",
    " </span>",
    " &nbsp;&mdash;&nbsp;Other supportive measures include ensuring appropriate
    hydration and nutritional support. Poor oral intake prior to presentation may
    result in dehydration, so many patients require fluid resuscitation. However,
    overhydration should be avoided, particularly in patients with stigmata of chronic
    liver disease suggestive of cirrhosis, since it may increase the degree of ascites,
    lower the plasma sodium concentration, and occasionally precipitate
    gastrointestinal hemorrhage from varices. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?34/7/34935?
    source=see_link\">",
    " \"Maintenance and replacement fluid therapy in adults\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Most patients with severe alcoholic hepatitis are malnourished and require
    nutritional support. High rates of malnourishment among patients with severe
    alcoholic hepatitis were demonstrated in a Veterans Administration Cooperative
    Study that included 284 patients with alcoholic hepatitis who underwent a complete
    nutritional assessment [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/28\">",
    " 28",
    " </a>",
    " ]. The study found that:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Signs of tissue wasting and severe protein-calorie malnutrition (eg,
    hypoalbuminemia, edema) were evident in almost all patients",
    " </li>",
    " <li>",
    " Indices of malnutrition correlated closely with the clinical severity of
    liver disease",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " Nutritional support includes providing adequate calories and protein, as well
    as vitamin (eg, thiamine, folate, and pyridoxine) and mineral (eg, phosphate,
    magnesium) repletion [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/29\">",
    " 29",
    " </a>",
    " ]. Vitamin K is usually given to patients with a prolonged prothrombin time,
    even though this regimen is often ineffective because the coagulopathy is more a
    reflection of underlying liver failure than vitamin K deficiency. Correction of the
    coagulopathy with fresh frozen plasma is",
    " <strong>",
    " not",
    " </strong>",
    " recommended unless there is active hemorrhage or the need to perform an
    invasive procedure. In theory, the volume expansion from fresh frozen plasma
    administration might increase the risk of variceal hemorrhage in a patient with
    portal hypertension. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?17/8/17544?
    source=see_link&amp;anchor=H430163212#H430163212\">",
    " \"Nutritional status in alcohol dependence\", section on 'Supplementation'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?15/37/15960?
    source=see_link&amp;anchor=H18#H18\">",
    " \"Overview of vitamin K\", section on 'Treatment of coagulopathy'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " The efficacy of nutritional therapy in alcoholic hepatitis has been evaluated
    in multiple clinical trials, although there have been few studies in recent years
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/7,30-33\">",
    " 7,30-33",
    " </a>",
    " ]. The majority of studies have demonstrated improvement in liver function and
    histology with nutritional therapy, though they have not consistently found
    reductions in mortality. In addition, a pilot, open-label study suggested that
    combining nutritional therapy with glucocorticoids might allow for a reduced course
    of glucocorticoids, but further studies are needed [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/34\">",
    " 34",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Given the evidence suggesting a possible benefit with nutritional therapy, we
    suggest nutritional support for patients with alcoholic hepatitis. In general,
    enteral feeding is preferred over intravenous nutrition. Although protein ingestion
    is a theoretical risk factor for the development of hepatic encephalopathy, protein
    feeding is well tolerated in patients with alcoholic hepatitis, and protein should
    NOT be routinely restricted in such patients. In patients who develop
    encephalopathy associated with protein feeding, use of branched-chain amino acids
    may be helpful. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?6/46/6889?
    source=see_link&amp;anchor=H74885353#H74885353\">",
    " \"Nutritional assessment in chronic liver disease\", section on 'Alcoholic
    steatohepatitis'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H251272009\">",
    " <span class=\"h3\">",
    " Infection surveillance",
    " </span>",
    " &nbsp;&mdash;&nbsp;Patients with evidence of possible infection (eg, fever,
    worsening mental status, hemodynamic instability) should have blood and urine
    cultures obtained. In addition, sputum cultures should be obtained if the patient
    has a productive cough or is intubated, and cerebrospinal fluid should be examined
    and cultured in those patients with fever and neurologic signs or symptoms that
    suggest CNS infection rather than typical hepatic encephalopathy (eg, headache with
    fever, nuchal rigidity, or lateralizing neurologic deficits). In addition, if
    present, ascitic fluid should be obtained for culture, cell count with
    differential, total protein, and albumin level. For patients with typical symptoms
    of hepatic encephalopathy, a trial of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/34/33316?source=see_link\">",
    " lactulose",
    " </a>",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " <a class=\"drug drug_general\" href=\"UTD.htm?36/17/37140?source=see_link\">",
    " rifaximin",
    " </a>",
    " should be considered first, with further evaluation (including head imaging)
    to exclude other diagnoses if the patient does not improve. Cultures are required
    because it is often impossible to distinguish between the fever of hepatitis and
    that of infection based solely on clinical criteria. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?28/4/28744?
    source=see_link&amp;anchor=H428430251#H428430251\">",
    " \"Alcoholic hepatitis: Clinical manifestations and diagnosis\", section on
    'Signs and symptoms'",
    " </a>",
    " .)",
    " <br/>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H251272018\">",
    " <span class=\"h3\">",
    " Acid suppression",
    " </span>",
    " &nbsp;&mdash;&nbsp;We suggest prophylaxis against gastric mucosal bleeding
    with a proton pump inhibitor, H2-blocker, or",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/29/29141?source=see_link\">",
    " sucralfate",
    " </a>",
    " , particularly if the patient is in an intensive care unit, is receiving
    glucocorticoids, or has occult blood detected in the stool. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?18/21/18776?
    source=see_link&amp;anchor=H7#H7\">",
    " \"Stress ulcer prophylaxis in the intensive care unit\", section on
    'Prophylaxis'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?11/4/11336?
    source=see_link&amp;anchor=H3#H3\">",
    " \"Evaluation of occult gastrointestinal bleeding\", section on 'Testing for
    occult blood'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H234081681\">",
    " <span class=\"h2\">",
    " Patients with mild to moderate alcoholic hepatitis",
    " </span>",
    " &nbsp;&mdash;&nbsp;The mainstay of treatment in patients with mild to moderate
    alcoholic hepatitis is abstinence from alcohol. In addition, general supportive
    care (eg, nutritional support and hydration) should be provided, but pharmacologic
    treatment with glucocorticoids is not recommended as it does not appear to be
    beneficial in patients with mild to moderate alcoholic hepatitis (Maddrey
    discriminant function [DF] &lt;32) (",
    " <a class=\"calc calc_professional\" href=\"UTD.htm?15/29/15825?
    source=see_link\">",
    " calculator 1",
    " </a>",
    " ).",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?source=see_link\">",
    " Pentoxifylline",
    " </a>",
    " has only been studied in patients with severe alcoholic hepatitis and not in
    patients with mild to moderate alcoholic hepatitis. (See",
    " <a class=\"local\" href=\"#H234081674\">",
    " 'General management for all patients'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H234081695\">",
    " 'Glucocorticoids'",
    " </a>",
    " below.)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H234081688\">",
    " <span class=\"h2\">",
    " Patients with severe alcoholic hepatitis",
    " </span>",
    " &nbsp;&mdash;&nbsp;In addition to general supportive care, pharmacologic
    treatment is indicated for patients with severe alcoholic hepatitis (DF &ge;32 (",
    " <a class=\"calc calc_professional\" href=\"UTD.htm?15/29/15825?
    source=see_link\">",
    " calculator 1",
    " </a>",
    " )).",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/48/33536?source=see_link\">",
    " Prednisolone",
    " </a>",
    " has traditionally been used, though some studies suggest that",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?source=see_link\">",
    " pentoxifylline",
    " </a>",
    " is effective and it lacks the side effects seen with glucocorticoids. (See",
    " <a class=\"local\" href=\"#H234081674\">",
    " 'General management for all patients'",
    " </a>",
    " above.)",
    " </p>",
    " <p>",
    " We recommend treating patients with severe alcoholic hepatitis with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/48/33536?source=see_link\">",
    " prednisolone",
    " </a>",
    " 40 mg per day, provided there are no contraindications to its use (eg, active
    infection). We prefer prednisolone to",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?source=see_link\">",
    " pentoxifylline",
    " </a>",
    " because of the larger body of research supporting its use. Pentoxifylline 400
    mg three times per day is an alternative in patients who are at risk for sepsis,
    but there are no data to support this approach. Treatment is continued for 28 days,
    though we stop therapy in patients who fail to show signs of improvement after a
    week of therapy (ie, those who fail to have improvement in their bilirubin or DF).
    For those who receive 28 days of prednisolone, we finish therapy with a 16-day
    prednisolone taper (we decrease the dose by 10",
    " <span class=\"nowrap\">",
    " mg/day",
    " </span>",
    " every four days until a dose of 10",
    " <span class=\"nowrap\">",
    " mg/day",
    " </span>",
    " is reached, at which point we decrease it by 5",
    " <span class=\"nowrap\">",
    " mg/day",
    " </span>",
    " every three days).",
    " </p>",
    " <p>",
    " The Lille score is one method to determine if patients with alcoholic
    hepatitis are responding to glucocorticoid therapy. The score was derived using a
    cohort of 295 patients with alcoholic hepatitis who were treated with
    glucocorticoids [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/16\">",
    " 16",
    " </a>",
    " ]. It combines six variables: age, renal insufficiency (Cr &gt;1.3 or
    creatinine clearance &lt;40",
    " <span class=\"nowrap\">",
    " mL/min),",
    " </span>",
    " albumin, prothrombin time, bilirubin, and evolution of bilirubin at day seven
    (bilirubin at day 7 &ndash; bilirubin at day 0). Online",
    " <a class=\"external\" href=\"file://www.lillemodel.com/score.asp?
    score=lillept\">",
    " calculators",
    " </a>",
    " are available for the calculating the Lille score.",
    " </p>",
    " <p>",
    " A score &gt;0.45 suggests that a patient is not responding to glucocorticoid
    therapy. In a validation cohort of 118 patients, 40 percent of patients had a Lille
    score &gt;0.45. Mortality at six months was higher among patients with a score
    &gt;0.45 compared with those who had a lower score (75 versus 15 percent) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/16\">",
    " 16",
    " </a>",
    " ]. In addition, the Lille score performed better than the DF, Child-Pugh
    score, or GAH score in predicting survival at six months. Similarly, glucocorticoid
    treatment was not beneficial for patients with a high Lille score in a study that
    used a cutoff of &ge;0.56 [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/6\">",
    " 6",
    " </a>",
    " ]. We do not use the Lille score when deciding whether to continue treatment,
    but since it incorporates a bilirubin decrease in response to steroids, it may also
    be used. (See",
    " <a class=\"local\" href=\"#H234081695\">",
    " 'Glucocorticoids'",
    " </a>",
    " below.)",
    " </p>",
    " <p>",
    " Patients who fail to respond to medical therapy may require liver
    transplantation, though many are not considered candidates due to recent alcohol
    abuse. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?5/2/5160?
    source=see_link&amp;anchor=H4#H4\">",
    " \"Liver transplantation in alcoholic liver disease\", section on 'Alcohol
    abstinence and psychosocial factors'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H234081695\">",
    " <span class=\"h3\">",
    " Glucocorticoids",
    " </span>",
    " &nbsp;&mdash;&nbsp;Glucocorticoid therapy for severe alcoholic hepatitis
    typically consists of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/48/33536?source=see_link\">",
    " prednisolone",
    " </a>",
    " 40 mg per day for 28 days, followed by a taper over two to four weeks.
    Prednisolone is preferred over",
    " <a class=\"drug drug_general\" href=\"UTD.htm?37/43/38585?source=see_link\">",
    " prednisone",
    " </a>",
    " because the latter requires conversion to prednisolone (the active form) in
    the liver, a process that may be impaired in alcoholic hepatitis.",
    " </p>",
    " <p>",
    " The efficacy of glucocorticoids in alcoholic hepatitis has been evaluated in
    multiple randomized trials and meta-analyses, with mixed results [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/5,6,35-49\">",
    " 5,6,35-49",
    " </a>",
    " ]. Mortality rates after one to six months among patients treated with
    glucocorticoids in these trials ranged from 15 to 63 percent. Some of the
    variability may be related to differences in disease severity among the trials. The
    preponderance of evidence suggests that the benefit of glucocorticoids is most
    evident in patients who have severe alcoholic hepatitis (see",
    " <a class=\"local\" href=\"#H325299748\">",
    " 'Determining disease severity'",
    " </a>",
    " above):",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " In a meta-analysis that included 15 randomized trials with 721 patients, 40
    percent of the patients died [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/46\">",
    " 46",
    " </a>",
    " ]. While glucocorticoids did not reduce mortality overall, when the analysis
    was restricted to trials with patients with severe alcoholic hepatitis (DF &ge;32
    or hepatic encephalopathy), there was a reduction in mortality (relative risk [RR]
    0.37, 95% CI 0.16-0.86).",
    " </li>",
    " <li>",
    " Similarly, a meta-analysis that examined patient-level data from five
    randomized trials with 221 patients found that patients with severe alcoholic
    hepatitis treated with glucocorticoids had lower 28-day mortality rates than those
    treated with placebo (20 versus 34 percent) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/6\">",
    " 6",
    " </a>",
    " ].",
    " <br/>",
    " <br/>",
    " The survival benefit was only statistically significant in those with a
    Lille score &lt;0.56. The Lille score assesses improvement after one week of
    treatment, with lower scores indicating more improvement. Among patients with a
    Lille score &le;0.16, those who received glucocorticoids were less likely to die
    than those who received placebo (hazard ratio [HR] 0.18, 95% CI 0.05-0.71). A
    survival benefit with glucocorticoid treatment was also seen among patients with a
    Lille score &gt;0.16 and &lt;0.56 (HR 0.38, 95% CI 0.17-0.87). However, among
    patients with a Lille score &ge;0.56, the survival benefit with glucocorticoid
    treatment was not statistically significant (HR 0.81, 95% CI 0.45-1.45), though if
    true, a 19 percent reduction in mortality would be clinically significant.",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " Among patients who fail to respond to glucocorticoid therapy, substituting",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?source=see_link\">",
    " pentoxifylline",
    " </a>",
    " for",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/48/33536?source=see_link\">",
    " prednisolone",
    " </a>",
    " does not appear to be effective [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/50\">",
    " 50",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Careful monitoring for evidence of infection, gastrointestinal bleeding, or
    glucose intolerance is essential while the patient is on",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/48/33536?source=see_link\">",
    " prednisolone",
    " </a>",
    " therapy. In one report, infection developed in 24 percent of 57 patients who
    received glucocorticoids and was more likely to develop in those who did not
    respond to glucocorticoids (43 versus 11 percent) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/51\">",
    " 51",
    " </a>",
    " ]. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?26/47/27386?
    source=see_link\">",
    " \"Major side effects of systemic glucocorticoids\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Glucocorticoids have not been evaluated in patients with concomitant
    pancreatitis, gastrointestinal bleeding, renal failure, or active infection, as
    these conditions were exclusion criteria in many of the clinical trials. Our
    approach is to use glucocorticoids only in patients who qualify based on published
    criteria, and we do not treat with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?source=see_link\">",
    " pentoxifylline",
    " </a>",
    " given the lack of efficacy data. However, other groups, including the American
    Association for the Study of Liver Diseases and the European Association for the
    Study of the Liver, do recommend pentoxifylline in patients who cannot receive
    glucocorticoids [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/3,13\">",
    " 3,13",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H234081702\">",
    " <span class=\"h3\">",
    " Pentoxifylline",
    " </span>",
    " &nbsp;&mdash;&nbsp;",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?source=see_link\">",
    " Pentoxifylline",
    " </a>",
    " inhibits tumor necrosis factor (TNF) synthesis, which is increased in patients
    with alcoholic hepatitis. Pentoxifylline (400 mg three times daily for 28 days) has
    been considered as an alternative to glucocorticoids in patients with severe
    alcoholic hepatitis (DF &ge;32), yet the data supporting its use are weak.
    Pentoxifylline may prevent hepatorenal syndrome, but a meta-analysis as well as
    preliminary results from a subsequent randomized trial suggest that it may not
    improve survival [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/52,53\">",
    " 52,53",
    " </a>",
    " ]. The meta-analysis included five trials with 336 patients. The initial
    analysis found that pentoxifylline was associated with reduced mortality compared
    with placebo (RR 0.64, 95% IC 0.46-0.89), but the benefit was not statistically
    significant after adjustment for multiple testing [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/53\">",
    " 53",
    " </a>",
    " ]. In addition, some of the individual trials were considered to be at risk
    for bias that may have overestimated the treatment effect. The meta-analysis did
    find a lower risk of death from hepatorenal syndrome with pentoxifylline, but with
    similar methodological concerns. Finally, one of the studies included in the
    analysis found an increased risk of serious and non-serious adverse events with
    pentoxifylline.",
    " </p>",
    " <p>",
    " A subsequent randomized trial of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?source=see_link\">",
    " pentoxifylline",
    " </a>",
    " for patients with severe alcoholic hepatitis has been reported in preliminary
    form. The trial included 270 patients with a DF &ge;32 who were assigned to
    receive",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/48/33536?source=see_link\">",
    " prednisolone",
    " </a>",
    " plus pentoxifylline or prednisolone plus placebo [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/52\">",
    " 52",
    " </a>",
    " ]. There was no difference in mortality at six months between those who
    received pentoxifylline and those who did not (32 versus 31 percent, respectively).
    In addition, there was no difference in the rate of hepatorenal syndrome (9 versus
    10 percent, respectively). Similarly, a trial with 70 patients failed to show a
    difference in six-month survival between patients treated with prednisolone plus
    pentoxifylline and those treated with prednisolone alone [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/54\">",
    " 54",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Despite low quality evidence supporting its use,",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?source=see_link\">",
    " pentoxifylline",
    " </a>",
    " is commonly used for the treatment of patients with severe alcoholic
    hepatitis. This is likely due in part to its good safety profile and the lack of
    alternatives to glucocorticoids. In one study investigating clinician preferences
    for the treatment of severe alcoholic hepatitis, 29 percent of patients were
    treated with pentoxifylline, 25 percent were treated with glucocorticoids, and 6
    percent were treated with both [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/55\">",
    " 55",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " A large randomized trial (STOPAH) is being conducted in the United Kingdom
    comparing",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?source=see_link\">",
    " pentoxifylline",
    " </a>",
    " with corticosteroids or a combination of both in patients with severe
    alcoholic hepatitis [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/56,57\">",
    " 56,57",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H164407366\">",
    " <span class=\"h3\">",
    " Possibly effective treatments",
    " </span>",
    " &nbsp;&mdash;&nbsp;Several other medical therapies have been investigated for
    the treatment of severe alcoholic hepatitis, though whether they will have a role
    in the routine treatment of alcoholic hepatitis is unclear [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/13\">",
    " 13",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " <strong>",
    " Enteral nutrition",
    " </strong>",
    " &ndash; In addition to its role in the general management of patients with
    alcoholic hepatitis, nutritional therapy may have a role as an alternative to
    glucocorticoids in patients with severe alcoholic hepatitis, though additional
    trials are needed. A randomized trial with 71 patients with severe alcoholic
    hepatitis assigned patients to",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/48/33536?
    source=see_link\">",
    " prednisolone",
    " </a>",
    " or enteral tube feeding for 28 days and then followed the patients for one
    year [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/58\">",
    " 58",
    " </a>",
    " ]. Early mortality during treatment was similar in patients who received
    prednisolone and those who received enteral tube feeding (25 versus 31 percent,
    respectively), although deaths occurred later in those who received prednisolone
    (median 23 versus 7 days). Among the 51 patients who were discharged from the
    hospital, mortality over the long-term was higher in the prednisolone group (37
    versus 8 percent).",
    " </li>",
    " <li>",
    " <strong>",
    " N-acetylcysteine &ndash;",
    " </strong>",
    " The combination of N-acetylcysteine (NAC), an antioxidant, with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/48/33536?
    source=see_link\">",
    " prednisolone",
    " </a>",
    " has been studied for the treatment of severe alcoholic hepatitis, but it may
    not be more effective than prednisolone alone. A randomized trial with 174 patients
    compared treatment with either four weeks of prednisolone or four weeks of
    prednisolone plus NAC given on days one through five [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/59\">",
    " 59",
    " </a>",
    " ]. There was no difference in six-month mortality (the primary endpoint)
    between those who received prednisolone and those who received prednisolone plus
    NAC (38 versus 27 percent, p = 0.07). While mortality was higher among those
    treated with prednisolone alone at one month (24 versus 8 percent, p&lt;0.01), the
    difference was no longer statistically significant at three months (34 versus 22
    percent, p = 0.06). However, given the trend toward increased survival in those
    treated with NAC, additional study is warranted.",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H234081709\">",
    " <span class=\"h3\">",
    " Ineffective treatments",
    " </span>",
    " &nbsp;&mdash;&nbsp;Ineffective treatments for alcoholic hepatitis that have
    been studied include anti-tumor necrosis factor (TNF) antibodies, anabolic
    steroids, and hepatic regeneration therapy.",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " <strong>",
    " Anti-TNF antibodies &ndash;",
    " </strong>",
    " TNF-alpha is believed to play a role in the pathogenesis of acholic
    hepatitis, but trials using anti-TNF antibodies have had disappointing results.
    (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?30/5/30807?
    source=see_link&amp;anchor=H10#H10\">",
    " \"Pathogenesis of alcoholic liver disease\", section on 'Injurious
    cytokines'",
    " </a>",
    " .)",
    " <br/>",
    " <br/>",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/31/28151?
    source=see_link\">",
    " Etanercept",
    " </a>",
    " is a soluble TNF receptor:FC fusion protein that binds to and neutralizes
    soluble TNF. While initial observational studies of etanercept showed a possible
    benefit [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/60\">",
    " 60",
    " </a>",
    " ], a randomized controlled trial in patients with moderate to severe
    alcoholic hepatitis did not [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/61\">",
    " 61",
    " </a>",
    " ]. Compared with placebo, etanercept was associated with significantly
    higher mortality (mainly due to infection) after six months (58 versus 23
    percent).",
    " <br/>",
    " <br/>",
    " Another anti-TNF antibody,",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/6/28776?
    source=see_link\">",
    " infliximab",
    " </a>",
    " , has also been studied for the treatment of severe alcoholic hepatitis.
    Infliximab is a chimeric mouse-human anti-TNF monoclonal antibody that was
    associated with clinical improvement in open-label trials [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/62,63\">",
    " 62,63",
    " </a>",
    " ]. Infliximab was then studied in a randomized trial with 36 patients with
    severe alcoholic hepatitis [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/64\">",
    " 64",
    " </a>",
    " ]. The patients were assigned to infliximab (10",
    " <span class=\"nowrap\">",
    " mg/kg",
    " </span>",
    " at days 0, 14, and 28) or placebo. All patients also received",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/48/33536?
    source=see_link\">",
    " prednisolone",
    " </a>",
    " (40 mg daily) for 28 days. The study was stopped early due higher mortality
    at two months in the infliximab group (39 versus 18 percent), though the increase
    was not statistically significant. Infections were more common in the infliximab
    group (72 versus 17 percent, p = 0.002), with severe infections accounting for half
    of the deaths. The study was criticized because high doses of infliximab were used
    (10",
    " <span class=\"nowrap\">",
    " mg/kg",
    " </span>",
    " at days 0, 14, and 28), though the open-label studies that used lower doses
    also found high infection rates [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/62,63\">",
    " 62,63",
    " </a>",
    " ]. In addition, it is not known if the increased infection rate in the
    infliximab group was due to the infliximab alone or due to the combined effects of
    infliximab plus prednisolone.",
    " </li>",
    " <li>",
    " <strong>",
    " Anabolic steroids &ndash;",
    " </strong>",
    " Androgens have been used in an attempt to improve nutritional status in
    patients with alcoholic hepatitis, but they are likely ineffective. Promising
    results were seen in a subset of patents from a multicenter Veterans Administration
    trial of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?38/28/39364?
    source=see_link\">",
    " oxandrolone",
    " </a>",
    " that included 263 patients with moderate or severe alcoholic hepatitis [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/38\">",
    " 38",
    " </a>",
    " ]. While there was no benefit in short-term survival, there was some benefit
    in long-term survival among patients who survived for at least one month. However,
    no benefit could be demonstrated in a systematic review of five randomized trials
    of patients with alcoholic hepatitis",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " cirrhosis [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/65\">",
    " 65",
    " </a>",
    " ].",
    " </li>",
    " <li>",
    " <strong>",
    " Hepatic regeneration therapy &ndash;",
    " </strong>",
    " Several growth factors have been identified that influence hepatocyte
    regeneration, though their role in the treatment of patients with alcoholic
    hepatitis has yet to be established. The best studied in humans are insulin and
    glucagon, which have been evaluated in several randomized trials [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/66-69\">",
    " 66-69",
    " </a>",
    " ]. A treatment benefit has not been consistently demonstrated, and
    complications (including hypoglycemic deaths) have occurred.",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H234081716\">",
    " <span class=\"h3\">",
    " Liver transplantation",
    " </span>",
    " &nbsp;&mdash;&nbsp;Patients with severe alcoholic hepatitis who fail to
    respond to treatment with glucocorticoids or",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?source=see_link\">",
    " pentoxifylline",
    " </a>",
    " may require liver transplantation. However, because alcoholic hepatitis
    implies recent alcohol abuse, such patients rarely receive transplantations. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?5/2/5160?
    source=see_link&amp;anchor=H3#H3\">",
    " \"Liver transplantation in alcoholic liver disease\", section on 'Patient
    selection'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H164407509\">",
    " <span class=\"h2\">",
    " Patients with hepatorenal syndrome",
    " </span>",
    " &nbsp;&mdash;&nbsp;Patients with severe alcoholic hepatitis often develop
    renal failure, which is associated with increased mortality [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/9,70\">",
    " 9,70",
    " </a>",
    " ]. Hepatorenal syndrome should be considered in patients with a rising
    creatinine despite fluid resuscitation and discontinuation of diuretics. The
    approach to the diagnosis and treatment of hepatorenal syndrome is discussed in
    detail elsewhere. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?28/50/29482?
    source=see_link\">",
    " \"Hepatorenal syndrome\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H234081730\">",
    " <span class=\"h2\">",
    " Course after recovery",
    " </span>",
    " &nbsp;&mdash;&nbsp;Patients who recover from alcoholic hepatitis remain at
    risk for progressive liver disease, even if they abstain from alcohol [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/71,72\">",
    " 71,72",
    " </a>",
    " ]. In one series of 61 patients, 18 percent of those who initially had
    alcoholic hepatitis without cirrhosis progressed to cirrhosis despite alcohol
    abstinence [",
    " <a class=\"abstract\" href=\"UTD.htm?0/43/698/abstract/71\">",
    " 71",
    " </a>",
    " ]. In addition, histologic features of alcoholic hepatitis persisted for up to
    14 months after discontinuing alcohol, suggesting that resolution of inflammation
    is slow. Thus, even patients who abstain from alcohol require ongoing evaluation
    for the development of cirrhosis. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/41/23194?
    source=see_link&amp;anchor=H2#H2\">",
    " \"Diagnostic approach to the patient with cirrhosis\", section on 'Clinical
    manifestations'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " It has been our observation that a marked elevation in serum bilirubin with
    slow normalization of aminotransferases that remain in an alcoholic pattern
    (aspartate aminotransferase &gt; alanine aminotransferase) may be seen for many
    months following an episode of alcoholic hepatitis, even in patients who abstain
    from alcohol, perhaps reflecting the persistent histologic changes. Thus, the
    presence of persistently abnormal serum aminotransferases does not necessarily
    indicate that a patient is continuing to drink alcohol.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H234083008\">",
    " <span class=\"h1\">",
    " SUMMARY AND RECOMMENDATIONS",
    " </span>",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " In patients with severe alcoholic hepatitis, short-term mortality rates are
    high (approximately 25 to 35 percent at one month), whereas patients with mild to
    moderate alcoholic hepatitis have low short-term mortality rates (&lt;10 percent at
    one to three months). (See",
    " <a class=\"local\" href=\"#H234081660\">",
    " 'Natural history'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Several prognostic models have been proposed to determine the severity of a
    patient's alcoholic hepatitis. The Maddrey discriminant function (DF) (",
    " <a class=\"calc calc_professional\" href=\"UTD.htm?15/29/15825?
    source=see_link\">",
    " calculator 1",
    " </a>",
    " ) and Model for End-stage Liver Disease (MELD) are the most commonly used to
    identify patients with severe alcoholic hepatitis (DF &ge;32) who are more likely
    to benefit from pharmacologic therapy. (See",
    " <a class=\"local\" href=\"#H325299748\">",
    " 'Determining disease severity'",
    " </a>",
    " above.) The Lille score has also been well validated.",
    " </li>",
    " <li>",
    " Patients with alcoholic hepatitis require general supportive care, including
    (see",
    " <a class=\"local\" href=\"#H234081674\">",
    " 'General management for all patients'",
    " </a>",
    " above):",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " <ul class=\"hyphen-block\">",
    " <li>",
    " Alcohol abstinence",
    " </li>",
    " <li>",
    " Prevention and treatment of alcohol withdrawal",
    " </li>",
    " <li>",
    " Fluid management",
    " </li>",
    " <li>",
    " Nutritional support",
    " </li>",
    " <li>",
    " Infection surveillance",
    " </li>",
    " <li>",
    " Prophylaxis against gastric mucosal bleeding",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " In patients with mild to moderate alcoholic hepatitis (DF &lt;32), we
    recommend",
    " <strong>",
    " against",
    " </strong>",
    " pharmacologic therapy with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/48/33536?
    source=see_link\">",
    " prednisolone",
    " </a>",
    " (",
    " <a class=\"grade\" href=\"._grade_2?title=Grade 1B\">",
    " Grade 1B",
    " </a>",
    " ). Prednisolone does not appear to be beneficial in such patients. In
    addition, we suggest",
    " <strong>",
    " against",
    " </strong>",
    " pharmacologic therapy with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?
    source=see_link\">",
    " pentoxifylline",
    " </a>",
    " (",
    " <a class=\"grade\" href=\"._grade_6?title=Grade 2C\">",
    " Grade 2C",
    " </a>",
    " ). Pentoxifylline has not been studied in this population, and its efficacy
    in patients with more severe alcoholic hepatitis is not clear. The mainstay of
    treatment for patients with mild to moderate alcoholic hepatitis is abstinence from
    alcohol and supportive care. (See",
    " <a class=\"local\" href=\"#H234081681\">",
    " 'Patients with mild to moderate alcoholic hepatitis'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " In patients with severe alcoholic hepatitis (DF &ge;32), we recommend
    pharmacologic therapy plus supportive care rather than supportive care alone (",
    " <a class=\"grade\" href=\"._grade_2?title=Grade 1B\">",
    " Grade 1B",
    " </a>",
    " ). (See",
    " <a class=\"local\" href=\"#H234081688\">",
    " 'Patients with severe alcoholic hepatitis'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Among patients receiving pharmacologic therapy, we recommend treating with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/48/33536?
    source=see_link\">",
    " prednisolone",
    " </a>",
    " rather than",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?
    source=see_link\">",
    " pentoxifylline",
    " </a>",
    " , provided there are no contraindications to glucocorticoids (",
    " <a class=\"grade\" href=\"._grade_2?title=Grade 1B\">",
    " Grade 1B",
    " </a>",
    " ). We prefer prednisolone (40 mg per day for 28 days) to pentoxifylline
    because of the larger body of research supporting its use. After the 28-day course
    of therapy is complete, we taper the prednisolone over 16 days. (See",
    " <a class=\"local\" href=\"#H234081688\">",
    " 'Patients with severe alcoholic hepatitis'",
    " </a>",
    " above.)",
    " <br/>",
    " <br/>",
    " If there are contraindications to the use of glucocorticoids, pentoxifylline
    can be considered, but the evidence of efficacy is weak, and it is not clear if it
    improves survival. Pentoxifylline is given as 400 mg three times per day for 28
    days. (See",
    " <a class=\"local\" href=\"#H234081702\">",
    " 'Pentoxifylline'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " In patients being treated with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?32/48/33536?
    source=see_link\">",
    " prednisolone",
    " </a>",
    " or",
    " <a class=\"drug drug_general\" href=\"UTD.htm?13/28/13765?
    source=see_link\">",
    " pentoxifylline",
    " </a>",
    " , we suggest stopping the medication if there is no sign of improvement (ie,
    decreasing bilirubin or DF) after a week of therapy (",
    " <a class=\"grade\" href=\"._grade_6?title=Grade 2C\">",
    " Grade 2C",
    " </a>",
    " ). Since the Lille score incorporates a bilirubin decrease in response to
    steroids, it may also be used to determine if steroids should be continued. (See",
    " <a class=\"local\" href=\"#H234081688\">",
    " 'Patients with severe alcoholic hepatitis'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Patients who fail to respond to medical therapy may require liver
    transplantation before a six-month waiting period. However, such patients must be
    very carefully selected to ensure a minimal risk of recidivism after transplant.
    (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?5/2/5160?
    source=see_link&amp;anchor=H4#H4\">",
    " \"Liver transplantation in alcoholic liver disease\", section on 'Alcohol
    abstinence and psychosocial factors'",
    " </a>",
    " .)",
    " </li>",
    " </ul>",
    " </p>",
    " </div>",
    " <div id=\"topicAgreement\">",
    " Use of UpToDate is subject to the",
    " <a class=\"licenseLink\" href=\"./license\" id=\"sla_in_page\"
    target=\"_blank\">",
    " Subscription and License Agreement",
    " </a>",
    " .",
    " </div>",
    " <div class=\"headingAnchor\" id=\"references\">",
    " <h1>",
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    " <li>",
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    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/51\">",
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    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/52\">",
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    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/53\">",
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    " </a>",
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    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/54\">",
    " Sidhu SS, Goyal O, Singla P, et al. Corticosteroid plus pentoxifylline is
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    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/55\">",
    " O'Shea R, Kinnard MF, Umar N, et al. Treatment of alcoholic hepatitis (AH)
    in clinical practice. Gastroenterology 2009; 136:A830.",
    " </a>",
    " </li>",
    " <li>",
    " file://www.controlled-trials.com/ISRCTN88782125 (Accessed on January 29,
    2013).",
    " </li>",
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    " www.stopah.com (Accessed on January 29, 2013).",
    " </li>",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/58\">",
    " Cabr&eacute; E, Rodr&iacute;guez-Iglesias P, Caballer&iacute;a J, et al.
    Short- and long-term outcome of severe alcohol-induced hepatitis treated with
    steroids or enteral nutrition: a multicenter randomized trial. Hepatology 2000;
    32:36.",
    " </a>",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/59\">",
    " Nguyen-Khac E, Thevenot T, Piquet MA, et al. Glucocorticoids plus N-
    acetylcysteine in severe alcoholic hepatitis. N Engl J Med 2011; 365:1781.",
    " </a>",
    " </li>",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/60\">",
    " Menon KV, Stadheim L, Kamath PS, et al. A pilot study of the safety and
    tolerability of etanercept in patients with alcoholic hepatitis. Am J Gastroenterol
    2004; 99:255.",
    " </a>",
    " </li>",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/61\">",
    " Boetticher NC, Peine CJ, Kwo P, et al. A randomized, double-blinded,
    placebo-controlled multicenter trial of etanercept in the treatment of alcoholic
    hepatitis. Gastroenterology 2008; 135:1953.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/62\">",
    " Tilg H, Jalan R, Kaser A, et al. Anti-tumor necrosis factor-alpha monoclonal
    antibody therapy in severe alcoholic hepatitis. J Hepatol 2003; 38:419.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/63\">",
    " Sharma P, Kumar A, Sharma BC, Sarin SK. Infliximab monotherapy for severe
    alcoholic hepatitis and predictors of survival: an open label trial. J Hepatol
    2009; 50:584.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/64\">",
    " Naveau S, Chollet-Martin S, Dharancy S, et al. A double-blind randomized
    controlled trial of infliximab associated with prednisolone in acute alcoholic
    hepatitis. Hepatology 2004; 39:1390.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/65\">",
    " Rambaldi A, Gluud C. Anabolic-androgenic steroids for alcoholic liver
    disease. Cochrane Database Syst Rev 2006; :CD003045.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/66\">",
    " Baker AL, Jaspan JB, Haines NW, et al. A randomized clinical trial of
    insulin and glucagon infusion for treatment of alcoholic hepatitis: progress report
    in 50 patients. Gastroenterology 1981; 80:1410.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/67\">",
    " Feh&eacute;r J, Cornides A, Rom&aacute;ny A, et al. A prospective
    multicenter study of insulin and glucagon infusion therapy in acute alcoholic
    hepatitis. J Hepatol 1987; 5:224.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/68\">",
    " Bird G, Lau JY, Koskinas J, et al. Insulin and glucagon infusion in acute
    alcoholic hepatitis: a prospective randomized controlled trial. Hepatology 1991;
    14:1097.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/69\">",
    " Trinchet JC, Balkau B, Poupon RE, et al. Treatment of severe alcoholic
    hepatitis by infusion of insulin and glucagon: a multicenter sequential trial.
    Hepatology 1992; 15:76.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/70\">",
    " Verma S, Ajudia K, Mendler M, Redeker A. Prevalence of septic events, type 1
    hepatorenal syndrome, and mortality in severe alcoholic hepatitis and utility of
    discriminant function and MELD score in predicting these adverse events. Dig Dis
    Sci 2006; 51:1637.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/71\">",
    " Galambos JT. Natural history of alcoholic hepatitis. 3. Histological
    changes. Gastroenterology 1972; 63:1026.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/43/698/abstract/72\">",
    " Marbet UA, Bianchi L, Meury U, Stalder GA. Long-term histological evaluation
    of the natural history and prognostic factors of alcoholic liver disease. J Hepatol
    1987; 4:364.",
    " </a>",
    " </li>",
    " </ol>",
    " </div>",
    " <div id=\"topicVersionRevision\">",
    " Topic 87052 Version 4.0",
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    var outline_f0_43_698=[" <div id=\"toggleOutline\">",
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    " <img alt=\"\" src=\"./../images/orange_arrow_left.myextg\"/>",
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    " <div id=\"innerOutline\">",
    " <h1>",
    " TOPIC OUTLINE",
    " </h1>",
    " <div id=\"outline\">",
    " <ul>",
    " <li>",
    " <a class=\"sr_button\" href=\"#H234083008\" id=\"summRecButton\">",
    " <span>",
    " SUMMARY &amp; RECOMMENDATIONS",
    " </span>",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H234083145\">",
    " INTRODUCTION",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H234081660\">",
    " NATURAL HISTORY",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H325299748\">",
    " DETERMINING DISEASE SEVERITY",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H251272027\">",
    " Maddrey discriminant function",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H251272037\">",
    " Meld score",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H251272046\">",
    " Glasgow alcoholic hepatitis score",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H234081667\">",
    " MANAGEMENT",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H234081674\">",
    " General management for all patients",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H251271990\">",
    " - Alcohol abstinence",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H251272000\">",
    " - Hydration and nutritional support",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H251272009\">",
    " - Infection surveillance",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H251272018\">",
    " - Acid suppression",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H234081681\">",
    " Patients with mild to moderate alcoholic hepatitis",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H234081688\">",
    " Patients with severe alcoholic hepatitis",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H234081695\">",
    " - Glucocorticoids",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H234081702\">",
    " - Pentoxifylline",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H164407366\">",
    " - Possibly effective treatments",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H234081709\">",
    " - Ineffective treatments",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H234081716\">",
    " - Liver transplantation",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H164407509\">",
    " Patients with hepatorenal syndrome",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H234081730\">",
    " Course after recovery",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H234083008\">",
    " SUMMARY AND RECOMMENDATIONS",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a href=\"#references\">",
    " REFERENCES",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " <h1>",
    " <div class=\"openRelatedGraphics\" id=\"GAST/87052\" rel=\"outline_link\">",
    " GRAPHICS",
    " <a class=\"graphics_icon\" href=\"#\" title=\"View All Related Graphics\">",
    " View All",
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    " </div>",
    " </h1>",
    " <div id=\"relatedGraphics\">",
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    " FIGURES",
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    " <a class=\"graphic graphic_figure\" href=\"UTD.htm?4/61/5079\" title=\"figure
    1\">",
    " Definition standard drink",
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    " </ul>",
    " </div>",
    " <h1>",
    " CALCULATORS",
    " </h1>",
    " <div id=\"relatedCalculators\">",
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    " <li class=\"plainItem\">",
    " <a class=\"calc calc_professional\" href=\"UTD.htm?15/29/15825?
    source=related_link\" title=\"calculator 1\">",
    " Calculator: Hepatitis discriminant function for corticosteroid therapy in
    alcoholic hepatitis",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"calc calc_professional\" href=\"UTD.htm?21/23/21874?
    source=related_link\" title=\"calculator 2\">",
    " Calculator: MELD score for end-stage liver disease (not appropriate for
    patients under the age of 12)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"calc calc_professional\" href=\"UTD.htm?18/2/18466?
    source=related_link\" title=\"calculator 3\">",
    " Calculator: MELD score for end-stage liver disease (not appropriate for
    patients under the age of 12) (SI units)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"calc calc_professional\" href=\"UTD.htm?42/9/43152?
    source=related_link\" title=\"calculator 4\">",
    " Calculator: Glasgow alcoholic hepatitis score",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " <h1>",
    " RELATED TOPICS",
    " </h1>",
    " <div id=\"relatedTopics\">",
    " <ul>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?28/4/28744?
    source=related_link\">",
    " Alcoholic hepatitis: Clinical manifestations and diagnosis",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?20/42/21162?
    source=related_link\">",
    " Clinical manifestations and diagnosis of alcoholic fatty liver disease and
    alcoholic cirrhosis",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/41/23194?
    source=related_link\">",
    " Diagnostic approach to the patient with cirrhosis",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?11/4/11336?
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    " Evaluation of occult gastrointestinal bleeding",
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    " <a class=\"medical medical_review\" href=\"UTD.htm?28/50/29482?
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    " Hepatorenal syndrome",
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    " <a class=\"medical medical_review\" href=\"UTD.htm?34/7/34935?
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    " Maintenance and replacement fluid therapy in adults",
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    " <a class=\"medical medical_review\" href=\"UTD.htm?26/47/27386?
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    " <a class=\"medical medical_review\" href=\"UTD.htm?15/25/15770?
    source=related_link\">",
    " Model for End-stage Liver Disease (MELD)",
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    " <a class=\"medical medical_review\" href=\"UTD.htm?6/46/6889?
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    " Nutritional assessment in chronic liver disease",
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    " <a class=\"medical medical_review\" href=\"UTD.htm?17/8/17544?
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    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/55/41847?
    source=related_link\">",
    " Psychosocial treatment of alcohol abuse and dependence",
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    " <a class=\"medical medical_review\" href=\"UTD.htm?18/21/18776?
    source=related_link\">",
    " Stress ulcer prophylaxis in the intensive care unit",
    " </a>",
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    " </ul>",
    " </div>",
    " </div>"].join("\n");
    var title_f0_43_699="Suspicion for vestbulodynia";
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    " <div class=\"graphic\">",
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    " Patient comments that should raise suspicion of vestibulodynia",
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    " <td>",
    " I can't use tampons because they hurt.",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " You need to use your smallest speculum when you examine me.",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " My last doctor told me to relax more.",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " I always have a yeast infection, but therapy doesn't help.",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " My episiotomy stitches still hurt.",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " I'm too tight down there.",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Sex has been painful since menopause.",
    " </td>",
    " </tr>",
    " </tbody>",
    " </table>",
    " </div>",
    " <div class=\"lgnd\">",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " </div>",
    " </div>",
    " </div>",
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    var title_f0_43_700="Sample heat acclimatization program for American football";
    var content_f0_43_700=[" <div id=\"graphicsToolbar\">",
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    " Print",
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    " Email",
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    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\">",
    " <div class=\"ttl\">",
    " Sample heat acclimatization program for American footbball",
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    " Modification",
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    " <td class=\"subtitle1\" colspan=\"2\">",
    " Practices 1-5",
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    " <td>",
    " 1",
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    " <td>",
    " 1",
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    " 2 (only every other day)",
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    " Equipment",
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    " <td>",
    " Helmets only",
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    " <td>",
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    " Maximum duration of practice session",
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    " 3 hours",
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    " 3 hours (maximum of 5 hours total on double session days)",
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    " Permitted walk through time (in addition to regular practice session)",
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    " Contact",
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    " <td>",
    " No contact",
    " </td>",
    " <td>",
    " Contact only with blocking sleds/dummies",
    " </td>",
    " <td>",
    " Full contact drills",
    " </td>",
    " </tr>",
    " </tbody>",
    " </table>",
    " </div>",
    " <div class=\"lgnd\">",
    " NOTE: Warm-up, stretching, cool-down, conditioning, and weight-room activities
    are all included as part of practice time.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " References:",
    " <br>",
    " <ol>",
    " <li>",
    " Preseason Heat-Acclimatization Guidelines for Secondary School
    Athletics.&nbsp;Journal of Athletic Training 2009; 44:332.",
    " </li>",
    " </ol>",
    " </br>",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
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    var title_f0_43_701="Comparison of pneumococcal conjugate and polysaccharide
    vaccines";
    var content_f0_43_701=[" <div id=\"graphicsToolbar\">",
    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
    " <div id=\"graphicsLinks\">",
    " <a href=\"?imageKey=PEDS
    %2F71746&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=2\" onclick=\"\">",
    " <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
    title=\"Print this page\"/>",
    " </a>",
    " <a class=\"icontxt textLink\" href=\"?imageKey=PEDS
    %2F71746&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=2\" onclick=\"\"
    title=\"Print this page\">",
    " Print",
    " </a>",
    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
    title=\"Email graphic(s)\"/>",
    " </a>",
    " <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
    " Email",
    " </a>",
    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\">",
    " <div class=\"ttl\">",
    " Comparison of pneumococcal conjugate and pneumococcal polysaccharide vaccines
    used in children in the United States",
    " </div>",
    " <div class=\"cntnt\">",
    " <table cellspacing=\"0\">",
    " <colgroup width=\"20%\">",
    " </colgroup>",
    " <colgroup span=\"2\" width=\"40%\">",
    " </colgroup>",
    " <tbody>",
    " <tr>",
    " <td class=\"subtitle1\">",
    " &nbsp;",
    " </td>",
    " <td class=\"subtitle1\">",
    " 13-valent pneumococcal conjugate vaccine",
    " <br/>",
    " (PCV13)",
    " </td>",
    " <td class=\"subtitle1\">",
    " Pneumococcal polysaccharide vaccine",
    " <br/>",
    " (PPSV23)",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " <strong>",
    " Trade name",
    " </strong>",
    " </td>",
    " <td>",
    " Prevnar 13&trade;",
    " </td>",
    " <td>",
    " Pneumovax",
    " <sup>",
    " &reg;",
    " </sup>",
    " 23",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " <strong>",
    " Serotypes contained",
    " </strong>",
    " </td>",
    " <td>",
    " 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F",
    " </td>",
    " <td>",
    " 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19A,
    19F, 20, 22F, 23F, 33F",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " <strong>",
    " Protein carrier",
    " </strong>",
    " </td>",
    " <td>",
    " CRM197 (a nontoxic mutant of diphtheria toxin)",
    " </td>",
    " <td>",
    " None",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " <strong>",
    " Adjuvant",
    " </strong>",
    " </td>",
    " <td>",
    " Aluminum phosphate",
    " </td>",
    " <td>",
    " None",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " <strong>",
    " Contains thimerosal?",
    " </strong>",
    " </td>",
    " <td>",
    " No",
    " </td>",
    " <td>",
    " May contain thimerosal as a preservative",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " <strong>",
    " Dose",
    " </strong>",
    " </td>",
    " <td>",
    " 0.5 mL",
    " </td>",
    " <td>",
    " 0.5 mL",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " <strong>",
    " Route",
    " </strong>",
    " </td>",
    " <td>",
    " Intramuscular",
    " </td>",
    " <td>",
    " Intramuscular or subcutaneous",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " <strong>",
    " Target groups",
    " </strong>",
    " </td>",
    " <td>",
    " All infants and children younger than five years",
    " </td>",
    " <td>",
    " Individuals &ge;2 years at increased risk for pneumococcal disease",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " <strong>",
    " Approved age groups",
    " </strong>",
    " </td>",
    " <td>",
    " <p>",
    " 6 weeks through 17 years;",
    " </p>",
    " &ge;50 years",
    " </td>",
    " <td>",
    " &ge;2 years",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " <strong>",
    " Number of doses",
    " </strong>",
    " </td>",
    " <td>",
    " Varies depending on age when series is initiated",
    " </td>",
    " <td>",
    " One or two depending upon risk group",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " <strong>",
    " Recommended schedule",
    " </strong>",
    " </td>",
    " <td>",
    " 2, 4, 6, and 12 to 15 months",
    " </td>",
    " <td>",
    " <p>",
    " One dose of PPSV23 at age &ge;2 years and &ge;8 weeks after the last
    indicated dose of PCV13.",
    " </p>",
    " <p>",
    " A second dose (five years after the first) is recommended for children
    who are immunocompromised, have sickle cell disease, or functional or anatomic
    asplenia.",
    " </p>",
    " A second dose is",
    " <strong>",
    " not",
    " </strong>",
    " recommended for immunocompetent children with cochlear implants or chronic
    illness, including chronic heart disease, chronic lung disease, diabetes mellitus,
    and cerebrospinal fluid leaks.",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " <strong>",
    " May be administered with other vaccines?",
    " </strong>",
    " </td>",
    " <td>",
    " Yes",
    " </td>",
    " <td>",
    " Yes",
    " </td>",
    " </tr>",
    " </tbody>",
    " </table>",
    " </div>",
    " <div class=\"lgnd\">",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
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    var outline_f0_43_701=null;
    var title_f0_43_702="AR postoperative outcome";
    var content_f0_43_702=[" <div id=\"graphicsToolbar\">",
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    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 502px\">",
    " <div class=\"ttl\">",
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    ",
    " </div>",
    " <div class=\"lgnd\">",
    " Patients with aortic regurgitation who are in functional class I or II before
    surgery have a survival after surgery that is similar to that expected in an age
    and gender matched normal population. In contrast, the outcome among patients who
    are in functional class III or IV before surgery is worse than for those with
    functional class I and II (p",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Data from Klodas, E, Enriquez-Sarano, M, Tajik, AJ, et al, J Am Coll Cardiol
    1997; 30:746.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_43_702=[""].join("\n");
    var outline_f0_43_702=null;
    var title_f0_43_703="Hydrocarbon ingestion management";
    var content_f0_43_703=[" <div id=\"graphicsToolbar\">",
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    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
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    " <a class=\"icontxt textLink\" href=\"?imageKey=EM
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    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
    title=\"Email graphic(s)\"/>",
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    " <div class=\"graphic\">",
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    " </div>",
    " <div class=\"lgnd\">",
    " <div class=\"footnotes\">",
    " NPO: nothing by mouth; IV: intravenous; CXR: chest radiograph.",
    " </div>",
    " <div class=\"reference\">",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_43_703=[""].join("\n");
    var outline_f0_43_703=null;

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