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To distin- the abdomen guish between masses and free fluid you must examine the patient and sometimes you will need Free See to perform an ultrasound as described in Chapter 1 generic bystolic 2.5 mg without prescription. Table 1 shows the most impor- Hyperstimulation of ovaries 28–30 tant gynecological causes of free fluid in the abdo- men 5 mg bystolic amex. CLASSIFICATION OF ABDOMINAL MASSES Table 2 Anatomical origin of abdominal masses A patient with an abdominal mass may present with Genital mass Extragenital mass symptoms, but the mass might only be detected Uterine Gastrointestinal and pancreatic during physical examination or even only through Tubo-ovarian Hepato-biliary ultrasound. This chapter deals with palpable and Renal and urological sonographically detectable masses as the difference Mesenteric and retroperitoneal between the two may only be in size but not neces- Abdominal wall herniation sarily in treatment. Please refer to Gynecological surgical textbooks for further investigations and Pregnancy-related treatment of other conditions. Normal intrauterine pregnancy Old ruptured extrauterine pregnancy (abdominal, tubal SIGNS AND SYMPTOMS pregnancy); see Chapter 12 Molar pregnancy see Chapter 15 As was said earlier, many women with a pelvic mass Uterine origin will have no symptoms at all. Most symptoms are Uterine fibroids, see Chapter 19 not specific for a specific organ or entity. Patients Advanced uterine carcinoma or sarcoma, see Chapter may present with: 29 Hematometra/pyometra • Feeling of heaviness or fullness in the lower Tubal origin abdomen. Hydro-/pyosalpinx (Chapter 17 on STI) • Acute or chronic pain. Tubo-ovarian abscess (Chapter 17) • Bowel symptoms such as constipation or Advanced cancer of the tube bloating. Ovarian origin • Urogenital symptoms: frequent micturition, Ovarian torsion, see Chapter 5 on acute pelvic pain urge, recurrent urinary tract infection (UTI), Benign cyst retention of urine. Endometrioma, see Chapter 6 on chronic pelvic pain • Increased abdominal circumference. Benign tumor (dermoid, fibroma, cyst-adenoma) Borderline tumor Genital symptoms such as abnormal vaginal bleed- Malignant tumor (carcinoma, granulosa cell or germ ing, amenorrhea, dysmenorrhea or increased vagi- cell tumor; see Chapter 28) nal discharge may point to the reproductive organs A pelvic mass associated with an upper abdominal mass as causative organs. The absence of those symptoms may indicate advanced ovarian cancer with omental however doesn’t exclude a genital origin of the cake especially when associated with ascites patient’s complaints. Surgical causes Menstrual, bladder and bowel symptoms with or Appendicular abscess without pressure symptoms associated with a pelvic Obstructed hernia mass may point to fibroid uterus in women of re- Intussusception productive age, but similar symptoms may manifest Colorectal carcinoma sinister disease in a postmenopausal patient. There- Subacute intestinal obstruction fore each symptom needs further evaluation, i. Diverticular abscess onset, duration of symptoms, character and inten- Large bowel tumor/mesenteric tumor Abdominal aortic aneurism sity of pain or discomfort, loss of weight and Renal tumor: pelvic kidney, bladder carcinoma, urinary appetite and limitations of daily activity etc. Neurological causes DIFFERENTIAL DIAGNOSIS Neuroblastoma It is of utmost importance to identify those patients Hematological causes Hodgkin’s and non-Hodgkin’s lymphoma, pelvic spleen with a potentially life-threatening disease, as well those patients who are already in a critical condi- tion. Table 3 gives an overview of the differential diagnosis. It is important to have a systematic approach for ductive age coming with a pelvic mass. The most assessment in order not to miss a patient with a common benign gynecological mass is a leiomyoma potentially dangerous condition. Note that pelvic masses are also causes of mass arising from the pelvis in a woman of repro- generalized abdominal swellings or acute abdomen ductive age is an intrauterine or old ruptured which may be dealt with initially by general sur- ectopic pregnancy. It is thus important to have a geons in many countries, so sensitization of surgical suspicion for pregnancy in every woman of repro- colleagues is important. Newly experienced dyspareunia can of obtaining a history. See general questions for point to endometrioma in the pouch of Douglas gynecological history taking in Chapter 1. A higher number of partners tions you may want to ask are: with inconsistent condom use makes an STI • Presenting complaints: onset, duration, charac- more likely. Weight loss and increased abdominal cannot be delayed. So after taking her vital signs to circumference can indicate a malignancy. A pel- rule out shock you should assess her abdomen for vic mass with fever can point to an infectious signs of peritonism as described in Chapter 1: assess cause of the mass such as a tubo-ovarian abscess for rebound tenderness and guarding. Don’t forget to check for generalized lymph bleeding, amenorrhea, if yes since when? Irregular bleeding culosis, but also gynecological malignancy in your can point to either a pregnancy or a uterine cause differential diagnosis. Amenorrhea of more than 6 months to- surgery if required; see http://en. The differential diagnosis Systematic examination will be extremely of pre- and postmenopausal patients differ! For example, a patient pre- children, desire for children, current contracep- senting with a 1-day history of nausea and vomit- tion. An ectopic pregnancy in the history makes ing may have an advanced stage ovarian or a recurrence more likely. A pregnancy is likely peritoneal cancer, and vomiting may be due to in a woman who wants more children and intestinal obstruction or this may be acute gastro- doesn’t use any contraception. So evaluation of symptoms and indivi- • Past history: past sexually transmitted infection dualization will help you to diagnose each condition (STI) symptoms, abdominal and vaginal opera- accurately. A history of STIs may indi- cate an infectious origin of a pelvic mass, e. See Chapter 1 on how to do an abdominal exami- tubo-ovarian abscess or pyosalpinx. It is important abdominal operations can lead to acute bowel that she empties her bladder before examination obstruction or may point to recurrent diverticu- and that you make her feel safe and at ease. Patients with breast cancer have a higher for surgical scars and obvious distentions. Assess the for urogenital tuberculosis, pelvic abscess, cervi- whole abdomen systematically in order not to miss cal carcinoma and non-Hodgkin lymphoma. Start with the area of the abdomen where 102 Abdominal Masses in Gynecology the patient doesn’t experience any pain. Start palpating the cervix, then have found a pelvic mass, the focus of examination the uterus, then the adnexal regions and then the is to identify the origin of the pelvic mass, i. For this you should try to Cervix Palpate the surface of the cervix for irregu- assess its mobility by moving it gently in all direc- larities, its size, mobility and tenderness.

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Dosage: one tablet daily in the evening discount 2.5 mg bystolic otc, unchewed order 2.5mg bystolic fast delivery, on an empty stomach. Nausea (mild), diarrhea (slightly more frequently than with raltegravir), ALT elevation (less than with raltegravir). Do not use in patients with renal impairment (CrCl <70 ml/min). Routine monitoring of estimated creatinine clearance, urine glucose, and urine protein should be performed in all patients. Comments: The third complete ART in one single tablet per day (STR = single tablet regimen), the first including an integrase inhibitor. For side effects, see also sections on tenofovir (caution with renal function) and cobicistat. A new formulation with tenofovir-alafenamide (TAF) is expected for the end of 2015. For detailed information see page: 193 Sulfadiazine Manufacturer: Heyl, among many others. Indications and trade name: treatment and prophylaxis of cerebral toxoplasmosis, only in combination with pyrimethamine. Renal insufficiency: creatinine clearance 10–50 ml/min: halve dose, <10 ml/min: one third of the dose. Side effects: very frequently allergies with pruritus, fever and urticaria, often treat- ment-limiting. Renal problems with renal failure, crystalluria, nephrolithiasis in up to 7%. Interactions, warnings: sulfadiazine is contraindicated in sulfonamide hypersensi- tivity in G6PD deficiency, renal failure, severe hepatic disease or dysfunction (e. Sulfadiazine can increase the effect of sulfonylurea urea (oral antidiabetics), antico- agulants, diphenylhydantoin. Concurrent use of antacids reduces absorption of sulfadiazine (separate administration by 1–2 hours). Ensure sufficient intake of fluids (at least 2 l daily). Initially, monitor blood count, ALT, creatinine, and BUN at least weekly. Indications and trade name: treatment of patients with evidence of HIV replica- tion despite ongoing ART with at least one PI, any NRTI or NNRTI. However, almost all patients have local injec- tion site reactions: erythema, inflammation, induration, rash. It is important to be particularly vigilant in patients with risk factors for pneumonia (low baseline CD4 counts, high viral load, IV drug users, smokers, history of pulmonary disease). Drug Profiles 713 Hypersensitivity reactions with rash, fever, nausea, chills, hypotension or elevated transaminases are rare (<1%). Injection sites – upper arm, ventral hip, and abdomen. Do not inject at sites with inflammatory signs from previous injections. Do not inject at sites with birth marks, scars or disrupted skin integrity. Comments: T-20 is an entry inhibitor used for heavily treatment-experienced patients. For detailed information see page: 113 Telaprevir Manufacturer: Janssen-Cilag/Vertex. Indications and trade name: in combination therapy with peg-interferon alfa and ribavirin for patients with chronic hepatitis C, genotype 1. Response-guided regimen, depending on viral response and prior response status. Side effects: Nausea (try haloperidol), vomiting, fatigue, diarrhea, pruritus, anemia. Mild skin rashes are common, leading to discontinuation of the drug in up to 7%. Comments: Released to much fanfare in 2011, this HCV NS34A protease inhibitor had a rapid rise and fall. Facing new and better options for hepatitis C, Vertex announced in 2014 the discontinuation of development and sales of telaprevir. Indications and trade names: HIV infection, chronic hepatitis B. Dose adjustments in patients with renal impairment are required. Double dosage interval (every 48 hours) at moderate kidney dysfunction (creatinine clearance 30–49 ml/min, below 30 ml/min it should be avoided). In hemodialysis patients, every 7 days following completion of hemodialysis. Rarely, renal side effects (renal tubulopathies including Fanconi’s syndrome, nephrogenic diabetes insipidus). CK rises observed in up to 48% (macro CK, relevance is unclear). Check creatinine clearance and serum phosphate before starting therapy, during the first year of treatment every four weeks and thereafter every three months. Simultaneous determination of blood glucose and potassium, as well as glucose in the urine. Interruption of therapy may be necessary, if creatinine clear- ance is <50 ml/min or serum phosphate is <1. Creatinine clearance in ml/min is calculated as follows: Women: (1. Do not combine with ddI, comedication with tenofovir increases the AUC of ddI by 44%.

Long-term efficacy and safety of raltegravir in the management of HIV infection Infect Drug Resist bystolic 2.5mg online. Skin rash related to once-daily boosted darunavir-containing antiretroviral therapy in HIV-infected Taiwanese: incidence and associated factor J Infect Chemother 2014;20:465-70 cheap bystolic 2.5 mg on line. Low-dose physiological growth hormone in patients with HIV and abdominal fat accumulation: a randomized controlled trial. Effects of low-dose growth hormone withdrawal in patients with HIV. Glomerular filtration rate esti- mated using creatinine, cystatin C or both markers and the risk of clinical events in HIV-infected individuals. Clinical Pharmacokinetic, Pharmacodynamic and Drug-Interaction Profile of the Integrase Inhibitor Dolutegravir. Clin Pharmacokinetics 2013, 52: 981-994 Madruga JV, Cahn P, Grinsztejn B, et al. Efficacy and safety of TMC125 (etravirine) in treatment-experienced HIV- 1-infected patients in DUET-1: 24-week results from a randomised, double-blind, placebo-controlled trial. HLA B5701 Screening for hypersensitivity to abacavir. Nevirapine-associated hepatotoxicity in virologically suppressed patients—role of gender and CD4+ cell counts. Prospective evaluation of the effects of antiretroviral therapy on body composition in HIV-1-infected men starting therapy. Nevirapine versus efavirenz in 742 patients: no link of liver toxicity with female sex, and a baseline CD4 cell count greater than 250 cells/microl. Marcos Bravo MC, Ocampo Hermida A, Martinez Vilela J, et al. Hypersensitivity reaction to darunavir and desen- sitization protocol. Efavirenz plasma levels can predict treatment failure and central nervous system side effects in HIV-1-infected patients. Alendronate with calcium and vitamin D supplementation is safe and effective for the treatment of decreased bone mineral density in HIV. Hepatotoxicity associated with long- versus short-course HIV-pro- phylactic nevirapine use: a systematic review and meta-analysis from the Research on Adverse Drug events And Reports (RADAR) project. Safety and efficacy of intradermal poly-L-lactic acid (SculptraTM) injections in patients with HIV-associated facial lipoatrophy. High prevalence of osteonecrosis of the femoral head in HIV-infected adults. Molina JM, Cahn P, Grinsztejn B et al on behalf of the ECHO study group. Rilpivirine versus efavirenz with teno- fovir and emtricitabine in treatment-naive adults infected with HIV-1 (ECHO): a phase 3 randomised double- blind active-controlled trial. Emerging bone problems in patients infected with HIV. Randomized, controlled study of the effects of a short course of prednisone on the incidence of rash associated with nevirapine in patients infected with HIV-1. The incidence and natural history of osteonecrosis in HIV-infected adults. Changes in sleep quality and brain wave patterns following initiation of an efavirenz-containing triple antiretroviral regimen. Effects of Emtricitabine/Tenofovir on Bone Mineral Density in HIV- Negative Persons in a Randomized, Double-Blind, Placebo-Controlled Trial. Effects of Metformin and Rosiglitazone in HIV-infected Patients with Hyperinsulinemia and Elevated Waist/Hip Ratio. Impact of antiretroviral therapy on serum lipoprotein levels and dyslipi- demias: A systematic review and meta-analysis Int J Cardiol 2015;199:307-318. Switching from tenofovir to abacavir in HIV-1-infected patients with low bone mineral density: changes in bone turnover markers and circulating sclerostin levels. The safety of tenofovir disoproxil fumarate for the treatment of HIV infection in adults: the first 4 years. Renal function declines more in tenofovir- than abacavir-based anti- retroviral therapy in low-body weight treatment-naïve patients with HIV infection. Skin rash induced by ritonavir-boosted darunavir is common, but gen- erally tolerable in an observational setting. Hepatotoxicity of antiretrovirals: incidence, mechanisms and management. Clinical Syndromes and Consequences of Antiretroviral-Related Hepatotoxicity. An epidemiologic study to determine the prevalence of the HLA-B*5701 allele among HIV-positive patients in Europe. Protease inhibitors and avascular necrosis: a systematic review and meta-analysis. Nevirapine-associated hepatotoxicity was not predicted by CD4 count 250 cells/µL among women in Zambia, Thailand and Kenya. Rates of cardiovascular disease following smoking cessation in patients with HIV infection: results from the D:A:D study. 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