Tardive dyskinesia is postulated to result from an increased number of dopamine receptors that are synthesized as a compensatory response to long-term dopamine receptor blockade buy cheap tadacip 20mg on-line impotence with prostate cancer. This makes the neuron supersensitive to the actions of dopamine buy cheap tadacip smoking weed causes erectile dysfunction, and it allows the dopaminergic input to this structure to overpower the cholinergic input order tadacip 20 mg online erectile dysfunction and age, causing excess movement in the patient. These agents cause a decreased uptake of monoamines into synaptic vesicles and depletion of monoamine stores, ideally focused on dopamine, to address the symptoms of tardive dyskinesia. Neuroleptic malignant syndrome This potentially fatal reaction to antipsychotic drugs is characterized by muscle rigidity, fever, altered mental status and stupor, unstable blood pressure, and myoglobinemia. Treatment necessitates discontinuation of the antipsychotic agent and supportive therapy. Those antipsychotics with potent antimuscarinic activity often produce dry mouth, urinary retention, constipation, and loss of visual accommodation. Others may block α-adrenergic receptors, resulting in lowered blood pressure and orthostatic hypotension. The antipsychotics depress the hypothalamus, thereby affecting thermoregulation and causing amenorrhea, galactorrhea, gynecomastia, infertility, and erectile dysfunction. Glucose and lipid profiles should be monitored in patients taking antipsychotics, as the second-generation agents may increase these laboratory parameters and possibly exacerbate preexisting diabetes or hyperlipidemia. Cautions and contraindications All antipsychotics may lower the seizure threshold and should be used cautiously in patients with seizure disorders or those with an increased risk for seizures, such as withdrawal from alcohol. These agents also carry the warning of increased risk for mortality when used in elderly patients with dementia-related behavioral disturbances and psychosis. Antipsychotics used in patients with mood disorders should also be monitored for worsening of mood and suicidal ideation or behaviors. Maintenance treatment Patients who have had two or more psychotic episodes secondary to schizophrenia should receive maintenance therapy for at least 5 years, and some experts prefer indefinite therapy. Which antipsychotic agent may have the best chance to improve his apathy and blunted affect? Risperidone is the only antipsychotic on the list that has some reported benefit in improving the negative symptoms of schizophrenia. All of the agents have the potential to diminish the hallucinations and delusional thought processes (positive symptoms). Brexpiprazole is the only agent listed that acts as a partial agonist at D receptors. He has been having “different-appearing tics,” such as prolonged contraction of the facial muscles, and he experiences opisthotonos (extrapyramidal spasm of the body in which the head and heels are bent backward and the body is bowed forward). The other drugs would have no effect or, in the case of prochlorperazine and risperidone, might increase the adverse symptoms. Olanzapine has significant sedative activity as well as antipsychotic properties and is the drug most likely to alleviate this patient’s report of insomnia. Although other antipsychotics may benefit this patient’s disorder, paliperidone has the indication for this disorder, and if the underlying disorder is improved, then the symptom of insomnia may also improve without risking other unwanted adverse effects, such as the weight gain associated with olanzapine. Quetiapine has strong antihistaminergic effects causing sedation and is sometimes used at low doses as a sedative–hypnotic, even though this use is considered off-label. The other antipsychotic agents listed are weaker at blocking the histamine receptor and therefore are not as sedating. His psychotic symptoms are well managed with haloperidol; however, he is reporting restlessness, the inability to sit still at the dinner table, and his family notices that he frequently paces the hallway. Propranolol, a β-blocker, is considered the drug of choice for the management of antipsychotic-induced akathisia. Bromocriptine is more effective for Parkinson-like symptoms, and dantrolene is a muscle relaxant that is best reserved for managing some symptoms of neuroleptic malignant syndrome. Clozapine is the only antipsychotic medication that has a black box warning and a risk of agranulocytosis in approximately 1% of the patients treated. Although other antipsychotics have case reports of blood dyscrasias, clozapine is considered to have the highest risk. Although this is a general warning for many antipsychotics, thioridazine has been issued a “black box warning,” suggesting that it is associated with the greatest risk. Overview Approximately 10% of the population has at least one seizure in their lifetime. Globally, epilepsy is the fourth most common neurologic disorder after migraine, cerebrovascular disease (stroke), and Alzheimer’s disease. Epilepsy is not a single entity but an assortment of different seizure types and syndromes originating from several mechanisms that have in common the sudden, excessive, and synchronous discharge of cerebral neurons. This abnormal electrical activity may result in a variety of events, including loss of consciousness, abnormal movements, atypical or odd behavior, and distorted perceptions that are of limited duration but recur if untreated. The site of origin of abnormal neuronal firing determines the symptoms that occur. For example, if the motor cortex is involved, the patient may experience abnormal movements or a generalized convulsion. Seizures originating in the parietal or occipital lobe may include visual, auditory, and olfactory hallucinations. Medications are the most widely used mode of treatment for patients with epilepsy. In general, seizures can be controlled with one medication in approximately 75% of patients. Patients may require more than one medication in order to optimize seizure control, and some patients may never obtain total seizure control. Etiology of Seizures Epilepsy can be due to an underlying genetic, structural, or metabolic cause or an unknown etiology. The neuronal discharge in epilepsy results from firing of a small population of neurons in a specific area of the brain referred to as the “primary focus. A number of causes, such as illicit drug use, tumor, head injury, hypoglycemia, meningeal infection, and the rapid withdrawal of alcohol from an alcoholic, can precipitate seizures. In cases when the source of a seizure can be determined and corrected, medication may not be necessary. For example, a seizure that is caused by a drug reaction is not epilepsy and does not require chronic therapy. In other situations, antiseizure medications may be needed when the primary cause of the seizures cannot be corrected. Though multiple specific epilepsy syndromes that include symptoms other than seizures have been classified, a discussion of these syndromes is beyond the scope of this chapter. Classification of Seizures It is important to correctly classify seizures to determine appropriate treatment. Seizures have been categorized by site of origin, etiology, electrophysiologic correlation, and clinical presentation. Nomenclature developed by the International League Against Epilepsy is considered the standard classification for seizures and epilepsy syndromes (ure 12. The symptoms of each seizure type depend on the site of neuronal discharge and on the extent to which the electrical activity spreads to other neurons in the brain. Generalized Generalized seizures may begin locally and then progress to include abnormal electrical discharges throughout both hemispheres of the brain. Primary generalized seizures may be convulsive or nonconvulsive, and the patient usually has an immediate loss of consciousness.
Pledgets should always cushion the sutures so that they will not cut through the friable annulus and allow paravalvular leaks tadacip 20 mg visa erectile dysfunction viagra doesn't work. Handling of Tissue Valves Tissue valves must be kept moist by intermittently rinsing them with room temperature physiologic saline solution tadacip 20mg amex erectile dysfunction jelly. If this vital precaution is not taken cheap 20mg tadacip with amex erectile dysfunction doctor nyc, the heat of the operating room lights will soon dry and permanently damage the valve tissue. Antibiotics and Tissue Prosthesis Tissue prostheses should never be exposed to antibiotic solutions because of possible tissue-chemical interaction, which may result in premature fibrosis and calcification. Interference with the Occluding Mechanism of Mechanical Prostheses Pledgets on the ventricular aspect may occasionally interfere with the normal function of disc prostheses. Excess Retained Chordal Button Tissue Excess retained chordal and leaflet tissue above the mitral annular plane should be sutured to the atrial wall away from the sewing ring to prevent interference with the prosthetic mechanism. Detached Chords Unattached chords hanging loose can be drawn into the prosthesis and prevent its normal closure, resulting in incompetence of the prosthesis. Obstructive Calcium Deposits Calcium in the ventricular wall that protrudes into the ventricular cavity near the annulus can seriously impair normal excursion of the mechanical leaflet mechanism. Every precaution must be taken to prevent these struts from coming into contact with or becoming embedded in the left ventricular wall. This can result in intractable dysrhythmia and can also interfere with normal prosthetic function. Prosthetic Obstruction of the Left Ventricular Outflow Tract A bioprosthesis must be placed in such a way that the struts do not obstruct the adjacent left ventricular outflow tract P. There are markings on the sewing cuff of the bioprosthesis to ensure the optimal alignment of the struts in the left ventricular outflow tract. Strut Entanglement the struts of the prosthesis can become encircled by the sutures or the subvalvular apparatus, which causes distortion of the leaflets and interferes with valve function. It is therefore important to “tighten” the struts of the bioprosthesis, prior to lowering the valve into the left ventricular cavity, to minimize the chance of catching any sutures or part of subvalvular apparatus. Inadvertent placement of sutures into left ventricular musculature will cut through the left ventricular wall. This can cause a hematoma of the left ventricle, which may enlarge and rupture outside the heart after ventricular contraction resumes. Paravalvular Leak Weakness or tearing of the posterior annulus may result in disruption of the prosthetic attachment during the surgery as well as postoperatively; consequent paravalvular leak may ensue. Such a complication must be noted and corrected by reinserting the sutures, now reinforced with pledgets, into a stronger part of the posterior annulus. Exclusion of the Left Atrial Appendage the left atrial appendage can be closed to prevent blood stasis and subsequent possible thromboembolism. Exclusion is accomplished by tying off the auricle or stapling it closed from the outside, or by occluding its orifice from the inside of the left atrium with a purse-string suture. Mitral Valve Replacement in Children Selection of an appropriately sized mitral prosthesis in the very young can be challenging. We have found aortic bileaflet mechanical prostheses satisfactory when implanted upside down in the mitral position. In this manner, the leaflets and occluding mechanism will be well above the mitral annulus, sitting entirely in the left atrium, thereby allowing a larger prosthesis to be implanted safely. Supraannular Bileaflet Aortic Prosthesis This modification of the bileaflet aortic prosthesis must never be used in an upside-down manner in the mitral position because this would result in the entire valve housing and leaflets residing in the left ventricle itself. Regurgitant Fraction of the Bileaflet Valve There is an 8% to 10% regurgitant flow across the bileaflet prosthesis. In young hearts with a small left ventricle, the regurgitant fraction may be significant compared with the stroke volume, and the prosthesis may not therefore provide optimal hemodynamics. Obstruction to Pulmonary Veins the sewing ring must be sewn to the atrial wall well away from the orifices of the pulmonary veins to prevent pulmonary venous obstruction. This kind of injury commonly occurs during leaflet excision or an aggressive removal of annular calcific deposits. The prosthesis is removed so that the edges of the aneurysm can be identified and closed either with horizontal pledgeted mattress sutures or with a Dacron patch. The valve can then be reimplanted placing the posterior annular sutures through the reinforced aneurysm suture closure or the upper edge of the Dacron patch. Paravalvular Leaks In most patients, paravalvular dehiscence resulting in leaks around the mitral prosthesis is due to imperfect surgical technique. Some of the predisposing factors, such as calcified or degenerative annulus (which allows the sutures to cut through the tissues), have been referred to previously. Massive calcification affecting the aortomitral leaflet continuity may obscure the annulus and interfere with correct placement of anchoring stitches. The annulus stitches may be inadvertently placed in the atrial wall or fleshy muscular ventricular wall instead of the annulus. It is therefore important for surgeons to be aware of these fine details so that necessary precautions can be taken. Pledgeted sutures are passed deeply through the tissue margin of the defect and then through the sewing ring of the prosthesis before tying. When the tissue margin of the defect is not satisfactory, sutures are first passed through the sewing ring of the prosthesis before taking a deep bite in the vicinity of the annulus through the full thickness of the atrial wall. Taking all the aforementioned precautions into consideration, the surgeon must implant a new prosthesis. For a secure closure, the interatrial groove tissue should be included for its buttressing effect. To ensure adequate hemostasis, a bite of tissue beyond the ends of the incision should be taken before continuing the closure. Whenever the left atriotomy is extended inferiorly behind the heart, the closure is facilitated if the sewing is begun from the inside of the atrium under direct vision. Atriotomy Closure Although a single-layer closure is adequate, a second over-and-over suture provides a more secure atriotomy closure. Transatrial Oblique Approach the divided interatrial septum is approximated with a continuous suture of 4-0 Prolene, starting at the far (anterior) end of the incision and progressing toward the right superior pulmonary vein. Injury to the Right Phrenic Nerve Caution must be exercised in closing the right superior pulmonary vein to avoid incorporating the phrenic nerve in the suture line. Depth of Sutures in the Septum the septum is quite thick at times; the sutures should incorporate the whole thickness, including the endocardium on both sides of the septum. Buttressing the Sutures At times, fossa ovalis tissue can be friable and may not hold sutures well. Transatrial Longitudinal Septal Approach After completion of the procedure, the septum is reapproximated with a continuous 4-0 Prolene suture. Functional or secondary tricuspid insufficiency occurs frequently in patients with advanced mitral valve disease and pulmonary hypertension. The insufficiency may disappear or improve significantly when successful mitral valve repair or replacement is accomplished. The current approach is to be more aggressive with secondary tricuspid disease and to perform an annuloplasty in patients with dilated annuli or more than mild tricuspid insufficiency. With rare exceptions, it is associated with mitral and, in many patients, aortic valve disease as well.
The pipette allows 1–2mL of normal local host defence deficiency due to the lack of an innate saline to be expelled into the lower part of the vagina cheap tadacip 20 mg with mastercard ginkgo biloba erectile dysfunction treatment, the local protective response from neutrophils buy cheap tadacip 20 mg on line leading causes erectile dysfunction. If a diagnosis of pinworms is to be excluded order 20 mg tadacip with amex erectile dysfunction remedy, then specific bacterial contamination, which in the majority a piece of sticky tape over the anus early in the morning of cases is due to poor hygiene. If a specific pathogen before the child gets out of bed will reveal the presence of is isolated, for example Streptococcus pneumoniae, eggs on microscopy. The vast majority of children do not have a pathological Candidal infection in children is extremely rare, organism. The primary treatment in this group is advice although as a common cause of vulvovaginitis in the about perineal hygiene. All parents of children with chronic adult, it is a common misdiagnosis in children. Candida vaginal disease are extremely worried that this may cause in children is usually associated with diabetes mellitus or long‐term detrimental effects to their daughters, particu- immunodeficiency and almost entirely related to these larly the fear of sexual dysfunction or subsequent infertility. The presence of viral infections, There is no evidence that this is the case and therefore par- for example herpes simplex or condylomata acuminata, ents should be reassured that this is a local problem only. Management of these children is directed towards diligent Vulval skin disease is not uncommon in children, par- hygiene of the perineum. The child must be taught to clean ticularly atopic dermatitis in those children who also her vulva, particularly after defecation, from front to back, have eczema. Referral to a dermatologist is appropriate as this avoids the transfer of enterobacteria to the vulval in these circumstances. After micturition the mother and child should be children and may cause persistent vulval itching. The instructed to clean the vulva completely and not to leave skin undergoes atrophy and fissuring and is very suscep- the vulval skin wet, as this damp warm environment is an tible to secondary infection. Sexual abuse in children may present with vaginal dis- the mother must also be informed that vulval hygiene charge. Any child who has recurrent attacks of vaginal through daily washing should be performed, but that the discharge should alert the clinician to this possibility. Excessive washing However, as non‐specific bacterial infection is a com- of the vulva must be avoided as this leads to recurrent exfo- mon problem in children, the clinician must proceed liation and vulval dermatitis. During acute attacks of non‐ with considerable caution in raising the possibility of specific recurrent vulvovaginitis, children often complain sexual abuse. Only those bacterial infections related to of burning during micturition due to the passage of urine venereal disease, for example gonorrhoea, may be cited across the inflamed vulva. There is no evi- It is important that the clinician remembers that many dence that topical oestrogen and antibiotic creams are of girls suffer from urinary incontinence, particularly at any benefit and should not be prescribed. In patients who have per- at this stage may help to prevent further adhesion forma- sistent vaginal discharge despite treatment, an ultra- tion. Finally, in taking a history it is important to estab- sound scan may detect a foreign body or, if a history of a lish that there has not been any trauma to the vulva, as foreign body is forthcoming, it is probably best to carry very rarely labial adhesions may be the result of sexual out an examination under anaesthetic and remove any abuse. Treatment should be appro- priate but if trauma is suspected, sexual abuse must always be considered with referral to the appropriate Adolescence team. The adolescent gynaecological patient usually presents with one of three disorders: (i) problems associated with Labial adhesions the menstrual cycle and menstrual dysfunction, (ii) pri- Labial adhesions are usually an innocent finding and a mary amenorrhoea (see Chapter 38); and (iii) teenage trivial problem, but its importance is that it is frequently hirsutism. They occur most frequently in children aged between 3 Menstrual problems months and 3 years, with a prevalence of about 3%. It As can be seen in the description of puberty (Chapter 38), is believed that labial adhesions result from vulvar menstrual cycles are rarely established as normal ovula- inflammation in a hypo‐oestrogenic environment. It is usual for labia minora stick together in the midline, usually from cycles to be irregular and bleeding sometimes prolonged posterior to anterior until only a small opening is left initially, and it can take some girls several years to achieve through which urine is passed. It may be difficult to distin- the gynaecologist understands this phenomenon, as the guish the opening at all. The vulva has the appearance of management of these cases is usually not active treat- being flat, and there are no normal tissues beyond the ment but support and explanation to the mother and clitoris evident. There are usually Trying to establish a history of heavy menstrual bleeding no symptoms associated with this condition, although can be challenging in this age group. The patients have older children may complain that there is some spraying little experience and may well not understand normality. As late childhood ensues and ovar- Expectation from maternal influence is also a contribu- ian activity begins, there is spontaneous resolution of the tory factor and so efforts should be made to interview problem in 80% of children. Normal menstrual loss treatment is required and the parents should be reas- should not exceed 80 mL during a period, although in 5% sured that their daughters are entirely normal. In those of individuals it is heavier than this and causes no trou- children in whom there are some clinical problems, local ble. Getting some idea from frequency of pad change or oestrogen cream can be applied for about 2 weeks. If a history of pro- is complete resolution of the labial adhesions in 90% of longed bleeding during surgical or dental procedures is cases. In the case of failure of oestrogen treatment, topi- obtained, screening for a coagulopathy is appropriate. Gynaecological Disorders of Childhood and Adolescence 555 the clinician is faced with attempting to assess whether 12 weeks. Amenorrhoea rates of 60% at 1 year and 70% the child truly has menstrual loss that is medically seri- at 2 years can be achieved. The newer alternative is the ous or menstrual loss that is irritating and distressing levonorgestrel intrauterine system which has similar without being medically harmful. It requires a skilled physician to fit lish which of these is the case is by measuring the hae- and in some cases this may require sedation. Oral progestogens are sel- mother and child of the normal physiology of menstrual dom used for long‐term use and have significantly higher establishment, that the manifestation of the menstrual side‐effect rates. Progesterone‐only pills and etonorg- loss is normal and that it may take some time for the estrel implants are not used, as menstrual suppression is cycle to be established. However, it is imperative that the child is fol- pill is also used and the 30‐µg pills are best. Continuous lowed up at 6‐monthly intervals until the pattern of men- use can achieve amenorrhoea rates of 30–50%, although struation is established, as reassurance is the most breakthrough bleeding is a common problem. Again, an explanation is required so that the ● Menstrual disorders in adolescents are usually a reflec- mother and daughter understand the cause of the prob- tion of normal physiology. It would be unusual Primary dysmenorrhoea for either of these therapies to be unsuccessful in con- Primary dysmenorrhoea is defined as pain which begins trolling the menstrual loss. The manage- they should be stopped on an annual basis so that assess- ment of dysmenorrhoea in the teenager is no different ment may be made about whether or not the normal pat- from that in the adult (see Chapter 34). The use of both tern of menstruation has been established by maturation non‐steroidal anti‐inflammatory drugs and the oral con- of the hypothalamic–pituitary–ovarian axis.
Genitourinary Dysfunction Inadvertent injury to the sacral splanchnic and hypogastric nerves during rectal mobilization may lead to urinary and sexual dysfunction following rectal surgery purchase online tadacip erectile dysfunction drugs staxyn. More than 50% of patients will have a reduced sexual function and about one-third will have alterations in urinary function buy tadacip 20mg mastercard erectile dysfunction treatment at gnc. In men order online tadacip erectile dysfunction 40s, sexual dysfunction may manifest as impotence and difficulties with ejaculation; women may experience dyspareunia and vaginal dryness. These known complications carry with them a significant reduction in psychosocial well-being and quality of life . It remains unclear if laparoscopic resection offers any benefits compared to open surgery regarding these complications. If urinary dysfunction is a concern, particularly if there is involvement of the membranous urethra, Foley catheterization should be continued for an extended duration in the perioperative period. Patients may be discharged with a Foley catheter in place, to be discontinued later in the postoperative period. Buchler M, Friess H, Klempa I, et al: Role of octreotide in the prevention of postoperative complications following pancreatic resection. Montorsi M, Zago M, Mosca F, et al: Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial. Pederzoli P, Bassi C, Falconi M, et al: Efficacy of octreotide in the prevention of complications of elective pancreatic surgery. Bassi C, Falconi M, Molinari E, et al: Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Suc B, Msika S, Fingerhut A, et al: Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial. Tran K, Van Eijck C, Di Carlo V, et al: Occlusion of the pancreatic duct versus pancreaticojejunostomy: a prospective randomized trial. Riediger H, Adam U, Fischer E, et al: Long-term outcome after resection for chronic pancreatitis in 224 patients. Aurello P, Sirimarco D, Magistri P, et al: Management of duodenal stump fistula after gastrectomy for gastric cancer: systematic review. Cozzaglio L, Coladonato M, Biffi R, et al: Duodenal fistula after elective gastrectomy for malignant disease: an italian retrospective multicenter study. Under ideal circumstances, a detailed history (including comorbid illness and prior surgeries), a thorough physical examination, ordering appropriate laboratories, and targeted imaging would reveal the source of the symptoms. The challenge for the intensive care physician begins with the many potential obstacles to early diagnosis, including altered patient sensorium, limited ability to communicate due to mechanical ventilation, concurrent antibiotic therapy, and the masking of reliable physical examination signs. An acute abdomen of an already critically ill patient portends high mortality, especially for patients meeting criteria of severe sepsis, often with derangements of more than one organ system associated with widespread cellular dysfunction. Successful management of the acute abdomen of a critically ill adult has traditionally relied upon clinician-dependent factors such as sharp clinical acumen, early collaborative efforts, and diagnostic expediency, as much as evidence- based algorithms. Despite improvements in data collection and the integration of dedicated specialists into patient care plans, high-quality evidence and specific clinical guidelines are still inadequate . Mesenteric ischemia was associated with both early and late mortality in a single-center, retrospective study of 543 patients over 6 years, causing 6. Diagnoses included severe acute pancreatitis, intestinal or gastric perforation, bowel obstruction, and biliary infection, all of which were associated with high hospital mortality (33. Beyond typical historical elements (onset, quality, severity, location, radiation, exacerbating and alleviating symptoms), additional information about constitutional symptoms, gastrointestinal, and gynecologic symptoms should be obtained. Special attention should be paid to prior medical and surgery history, medications, and social history. However, the information obtained from the patient may be used to identify risk factors for particular intraabdominal processes (see Table 51. Long regarded an essential part of the abdominal examination, auscultation is neither specific nor sensitive . Patients with focal pain or obstructive symptoms should be carefully examined for evidence of inguinal or incisional hernias. Comorbid conditions such as diabetes and chronic immunosuppression may blunt examination findings associated with intraabdominal pathologies. Diagnostic imaging provides critical clinical data during the evaluation, particularly when physical examination findings are unreliable secondary to sedation, obtundation, delirium, or immunosuppression. Plain Radiographs Abdominal radiographs are rapidly and widely available, inexpensive studies that are frequently obtained for patients with abdominal pain. After an intraabdominal exploration or procedure, free air should not persist for more than 48 to 72 hours. Contrast- enhanced X-rays can be used to confirm the placement of gastrostomy and jejunostomy tubes, or to evaluate bowel motility. Ultrasound Ultrasound offers distinct advantages for evaluating abdominal pathologies of the critically ill care. Bedside ultrasound can be used to assess a variety of acute findings, including free fluid, pneumothorax, pericardial effusions, gallbladder disease, aortic aneurysm, intrauterine pregnancy, hydronephrosis, bladder volume, and inferior vena cava diameter (as a marker of volume resuscitation). There are several settings in which technical limitations to ultrasound arise, including morbid obesity and the presence of bowel gas. Acute mesenteric ischemia and acalculous cholecystitis are discussed in detail here, as these are common reasons for surgical consultation for critically ill adults. Abdominal compartment syndrome, surgical infections, and necrotizing fasciitis (Fournier’s gangrene) are separately covered within this section. Acute Mesenteric Ischemia Acute mesenteric ischemia can be a difficult diagnosis to make, and clinicians must maintain a high degree of suspicion particularly for elderly patients with severe abdominal pain. With bacterial translocation occurring 6 hours after disruption of ischemic mucosal barrier, correcting the subsequent physiologic insults is challenging, because the diagnosis takes an average of 8 hours and treatment can take another 2. Even with prompt initiation of anticoagulation for thromboembolic events with intravenous heparin (5,000 International Units bolus followed by 20,000 International Units over 24 hours), morbidity and mortality are substantial. Among patients for whom the diagnosis is delayed by 24 hours, mortality nearly doubles from 36% to 69% . Cholecystitis Acalculous cholecystitis is more frequent among the critically ill than typical stone-based disease. Acalculous cholecystitis reflects ischemic or inflammatory changes to the gallbladder secondary to obstruction of the cystic duct, bile stasis, or distention . Acute acalculous cholecystitis is frequently diagnosed among patients with an admission diagnosis of sepsis . The most common modality for the evaluation of acalculous cholecystitis is ultrasound; however, the absence of stones can decrease the sensitivity of this test . Definitive therapy with open or laparoscopic cholecystectomy is associated with increased perioperative mortality among critically ill patients, leading to alternatives (percutaneous cholecystostomy tube placement) . A retrospective observational study of 56 patients treated for acalculous cholecystitis with percutaneous cholecystostomy demonstrated an efficacy of over 80%, with low rates of associated complications, mortality, or need for subsequent cholecystectomy . Often representing a further progression of multisystem organ failure, acute acalculous cholecystitis requires prompt intervention with low-risk surgical interventions available that can accommodate patients unfit for anesthesia or transport . Clinicians must remain vigilant for extraabdominal sources of pain, particularly when abdominal imaging is unremarkable or equivocal.