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    Carlos Hernández
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    41.txt

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    858 views206 pages

    41

    Uploaded by

    Carlos Hernández

    Copyright:

    © All Rights Reserved
    Download as TXT, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 206

    var title_f0_41_656="SCFE metaphyseal blurring";

    var content_f0_41_656=[" <div id=\"graphicsToolbar\">",


    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
    " <div id=\"graphicsLinks\">",
    " <a href=\"?imageKey=PEDS
    %2F55393&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\">",
    " <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
    title=\"Print this page\"/>",
    " </a>",
    " <a class=\"icontxt textLink\" href=\"?imageKey=PEDS
    %2F55393&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: 493px\">",
    " <div class=\"ttl\">",
    " Blurring of the metaphyseal-growth plate junction",
    " </div>",
    " <div class=\"cntnt\" style=\"width: 473px; height: 221px; background-image:
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    " </div>",
    " <div class=\"lgnd\">",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Adapted with permission from: Bloomberg, TJ, Nuttall, J, Stoker, DJ. Clin
    Radiol 1978; 29:657. Copyright &copy; 1978 Blackwell Publishing.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
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    var outline_f0_41_656=null;
    var title_f0_41_657="Gastric volvulus on plain chest film";
    var content_f0_41_657=[" <div id=\"graphicsToolbar\">",
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    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
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    " <a class=\"etacLink\" href=\"#\">",
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    " </div>",
    " <div class=\"graphic\">",
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    " Gastric volvulus on plain chest film",
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    " </div>",
    " <div class=\"lgnd\">",
    " The plain radiograph of the chest shows a large central gas bubble in the
    thoracic cavity reminiscent of a large hiatal hernia (between white arrows).",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
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    var outline_f0_41_657=null;
    var title_f0_41_658="Measles, mumps, and rubella vaccines (combined): Patient drug
    information";
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    " <img align=\"right\" alt=\"Wolters Kluwer Health\" height=\"40\"
    src=\"./../images/logoWKH.myextg\" width=\"175\">",
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    " </div>",
    " <div class=\"lgnd\">",
    " Widespread erythema, desquamation, and postinflammatory hyperpigmentation are
    evident in this patient with acute graft-versus-host disease.",
    " <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");
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    var title_f0_41_660="Cartilagenous calcification US";
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    " &copy;2013 UpToDate",
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    " &reg;",
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    " </a>",
    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
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    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 524px\">",
    " <div class=\"ttl\">",
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    " </div>",
    " <div class=\"lgnd\">",
    " This long axis sonogram of the wrist of a 72-year-old woman with
    chondrocalcinosis shows both hypoechoic and hyperechoic areas in the triangular
    fibrocartilage complex. Areas of hyperechogenicity (arrows) are likely to represent
    calcium pyrophosphate dihydrate (CPPD) deposits.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Courtesy of George AW Bruyn, MD, PhD.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
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    var outline_f0_41_660=null;
    var title_f0_41_661="Arterial catheter with continuous flush";
    var content_f0_41_661=[" <div id=\"graphicsToolbar\">",
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    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
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    " <a href=\"?imageKey=EM
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    " <a class=\"icontxt textLink\" href=\"?imageKey=EM
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    " </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: 524px\">",
    " <div class=\"ttl\">",
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    " </div>",
    " <div class=\"lgnd\">",
    " The catheter is secured with suture and a sterile, transparent dressing and
    attached to a system that consists of flushed tubing, a stopcock, and a syringe on
    a pump set at a low rate that provides continuous flushing of the catheter.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Reproduced with permission from: Torrey SB, Saladino RA. Arterial puncture
    and catheterization. In: Textbook of Pediatric Emergency Procedures, 2nd edition,
    King C, Henretig FM (Eds), Lippincott Williams &amp; Wilkins, Philadelphia 2008.
    Copyright &copy; 2008 Lippincott Williams &amp; Wilkins.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_41_661=[""].join("\n");
    var outline_f0_41_661=null;
    var title_f0_41_662="Misoprostol: Drug information";
    var content_f0_41_662=[" <noscript>",
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    " <div id=\"topicContent\">",
    " <div id=\"drugTitle\">",
    " Misoprostol: Drug information",
    " </div>",
    " <div id=\"lexiTitleImg\">",
    " <img height=\"17\" src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\"
    width=\"71\"/>",
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    " Copyright 1978-2013 Lexicomp, Inc. All rights reserved.",
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    " <div id=\"topicText\">",
    " (For additional information",
    " <a class=\"drug drug_patient\" href=\"UTD.htm?11/23/11636?source=see_link\">",
    " see \"Misoprostol: Patient drug information\"",
    " </a>",
    " and",
    " <a class=\"drug drug_pediatric\" href=\"UTD.htm?17/31/17908?
    source=see_link\">",
    " see \"Misoprostol: 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=\"block black-box-warn drugH1Div\" id=\"F5709091\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " ALERT: U.S. Boxed Warning",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " The FDA-approved labeling includes a boxed warning. See Warnings/Precautions
    section for a concise summary of this information. For verbatim wording of the
    boxed warning, consult the product labeling or",
    " <a href=\"file://www.fda.gov\" target=\"_blank\">",
    " www.fda.gov",
    " </a>",
    " .",
    " </p>",
    " </div>",
    " <div class=\"list ubnlist drugH1Div drugBrandNames\" id=\"F197188\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Brand Names: U.S.",
    " </span>",
    " <ul>",
    " <li>",
    " Cytotec&reg;",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"list cbnlist drugH1Div drugBrandNames\" id=\"F197189\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Brand Names: Canada",
    " </span>",
    " <ul>",
    " <li>",
    " Novo-Misoprostol;",
    " </li>",
    " <li>",
    " PMS-Misoprostol",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ex_sect_xr thclist drugH1Div drugBrandNames\" id=\"F197231\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Pharmacologic Category",
    " </span>",
    " <ul>",
    " <li>",
    " Prostaglandin",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"block doa drugH1Div\" id=\"F197192\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Dosing: Adult",
    " </span>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " <b>",
    " Prevention of NSAID-induced gastric ulcers:",
    " </b>",
    " Oral: 200 mcg 4 times daily with food; if not tolerated, may decrease dose to
    100 mcg 4 times daily with food; last dose of the day should be taken at bedtime",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " <b>",
    " Medical termination of pregnancy:",
    " </b>",
    " Oral: Refer to Mifepristone monograph.",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " <b>",
    " Labor induction or cervical ripening (unlabeled uses):",
    " </b>",
    " Intravaginal: 25 mcg (",
    " <sup>",
    " 1",
    " </sup>",
    " /",
    " <sub>",
    " 4",
    " </sub>",
    " of 100 mcg tablet); may repeat at intervals no more frequent than every 3-6
    hours. Do not use in patients with previous cesarean delivery or prior major
    uterine surgery (ACOG, 2009b).",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " <b>",
    " Prevention of postpartum hemorrhage (unlabeled use):",
    " </b>",
    " Oral: 600 mcg as a single dose administered immediately after delivery; to be
    used in settings where oxytocin is not available (FIGO, 2012).",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " <b>",
    " Treatment of postpartum hemorrhage (unlabeled use):",
    " </b>",
    " Sublingual: 800 mcg as a single dose; to be used in settings where oxytocin
    is not available. Use caution if a prophylactic dose was already given, especially
    if adverse events were observed (FIGO, 2012).",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " <b>",
    " Treatment of incomplete abortion (unlabeled use):",
    " </b>",
    " Oral: 600 mcg as a single dose (ACOG, 2009a)",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " <b>",
    " Treatment of missed abortion (unlabeled use):",
    " </b>",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Sublingual: 600 mcg; may repeat every 3 hours for 2 additional doses if
    needed (ACOG, 2009a).",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Intravaginal: 800 mcg; may repeat every 3 hours for 2 additional doses if
    needed (ACOG, 2009a).",
    " </p>",
    " </div>",
    " <div class=\"block doe drugH1Div\" id=\"F15976971\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Dosing: Geriatric",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " <b>",
    " Prevention of NSAID-induced gastric ulcers:",
    " </b>",
    " Refer to adult dosing.",
    " </p>",
    " </div>",
    " <div class=\"block dor drugH1Div\" id=\"F9660726\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Dosing: Renal Impairment",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Dose adjustment is not routinely needed; however, the dose may be reduced if
    the recommended dose is not tolerated. It is not known if misoprostol is removed by
    dialysis.",
    " </p>",
    " </div>",
    " <div class=\"block doh drugH1Div\" id=\"F15976866\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Dosing: Hepatic Impairment",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " No dosage adjustment provided in manufacturer's labeling.",
    " </p>",
    " </div>",
    " <div class=\"block foc drugH1Div\" id=\"F197165\"
    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;\">",
    " Tablet, oral: 100 mcg, 200 mcg",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Cytotec&reg;: 100 mcg",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Cytotec&reg;: 200 mcg [scored]",
    " </p>",
    " </div>",
    " <div class=\"block geq drugH1Div\" id=\"F197151\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Generic Equivalent Available: U.S.",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Yes",
    " </p>",
    " </div>",
    " <div class=\"block adm drugH1Div\" id=\"F197168\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Administration",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Incidence of diarrhea may be lessened by having patient take dose right after
    meals and avoiding magnesium-containing antacids. When used for the prevention of
    NSAID-induced ulcers, therapy is usually begun on the second or third day of the
    next normal menstrual period in women of childbearing potential.",
    " </p>",
    " </div>",
    " <div class=\"block use drugH1Div\" id=\"F197167\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Use",
    " </span>",
    " <p style=\"text-indent:-2em;margin-left:2em;\">",
    " Prevention of NSAID-induced gastric ulcers",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;\">",
    " Medical termination of pregnancy of &le;49 days in conjunction with
    mifepristone (refer to Mifepristone monograph for details)",
    " </p>",
    " </div>",
    " <div class=\"block usu drugH1Div\" id=\"F197227\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Use - Unlabeled",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Cervical ripening and labor induction (except in women with prior cesarean
    delivery or major uterine surgery); prevention of postpartum hemorrhage; treatment
    of postpartum hemorrhage; treatment of incomplete or missed abortion in women
    &lt;12 weeks gestation",
    " </p>",
    " </div>",
    " <div class=\"block mst drugH1Div\" id=\"F197238\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Medication Safety Issues",
    " </span>",
    " <div class=\"collapsible\">",
    " <span class=\"collapsible-title\">",
    " Sound-alike/look-alike issues:",
    " </span>",
    " <div class=\"collapsible-wrap\">",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Cytotec&reg; may be confused with Cytoxan",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Misoprostol may be confused with metoprolol, mifepristone",
    " </p>",
    " </div>",
    " </div>",
    " </div>",
    " <div class=\"block ars drugH1Div\" id=\"F197229\"
    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%: Gastrointestinal: Diarrhea, abdominal pain",
    " </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;\">",
    " Central nervous system: Headache",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " Gastrointestinal: Constipation, dyspepsia, flatulence, nausea, vomiting",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " &lt;1% (Limited to important or life-threatening): Abnormal taste, abnormal
    vision, alkaline phosphatase increased, alopecia, anaphylaxis, anemia, amylase
    increase, anxiety, arrhythmia, arterial thrombosis, arthralgia, cardiac enzymes
    increased, chest pain, chills, confusion, CVA, deafness, depression, diaphoresis,
    dizziness, drowsiness, dysphagia, dyspnea, dysuria, edema, epistaxis, ESR
    increased, fatigue, fever, GI bleeding, GI inflammation, gingivitis, glycosuria,
    gout; gynecological disorders, hematuria, hepatobiliary function abnormal,
    hyper-/hypotension, impotence, loss of libido, MI, muscle cramps, myalgia,
    neuropathy, neurosis, nitrogen increased, pallor, phlebitis, polyuria, pulmonary
    embolism, purpura, rash, reflux, rigors, stiffness, syncope, thirst,
    thrombocytopenia, tinnitus, uterine rupture, weakness, weight changes",
    " </p>",
    " </div>",
    " <div class=\"block coi drugH1Div\" id=\"F197171\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Contraindications",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Hypersensitivity to prostaglandins; pregnancy (when used to reduce NSAID-
    induced ulcers)",
    " </p>",
    " </div>",
    " <div class=\"block war drugH1Div\" id=\"F197155\"
    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>",
    " Concerns related to adverse effects:",
    " </i>",
    " </b>",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " &bull; Abortifacient:",
    " <b>",
    " [U.S. Boxed Warning]: Due to the abortifacient property of this medication,
    patients must be warned not to give this drug to others.",
    " </b>",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " <b>",
    " <i>",
    " Disease-related concerns:",
    " </i>",
    " </b>",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " &bull; Cardiovascular disease: Use with caution in patients with
    cardiovascular disease.",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " &bull; Renal impairment: Use with caution in patients with renal
    impairment.",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " <b>",
    " <i>",
    " Special populations:",
    " </i>",
    " </b>",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " &bull; Elderly: Use with caution in the elderly.",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " &bull; Pregnancy: Adverse events have been reported when used outside of
    current product labeling (cervical ripening, induction of labor, postpartum
    hemorrhage). Uterine tachysystole may occur and progress to uterine tetany;
    uteroplacental blood flow may be impaired and uterine rupture or amniotic fluid
    embolism may occur. The risk of uterine rupture may be increased with advanced
    gestational age, grand multiparity, or prior uterine surgery. Uterine activity and
    fetal status should be monitored in a hospital setting. Misoprostol should not be
    used in situations where uterotonic drugs are otherwise contraindicated or
    inappropriate.",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " &bull; Women of childbearing potential:",
    " <b>",
    " [U.S. Boxed Warning]: Use of misoprostol during pregnancy may cause
    abortion, birth defects, or premature birth. It is not to be used to reduce NSAID-
    induced ulcers in a woman of childbearing potential unless she is capable of
    complying with effective contraceptive measures and is at high risk of developing
    gastric ulcers and/or their complications.",
    " </b>",
    " If needed, the patient must have a negative pregnancy test within 2 weeks of
    starting therapy, she must use effective contraception during treatment, and
    therapy should begin on the second or third day of next normal menstrual period.
    Women of childbearing potential taking this for reducing the risk of NSAID-induced
    gastric ulcers should be given oral and written warnings of the potential adverse
    events if pregnancy occurs during treatment.",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " <b>",
    " <i>",
    " Other warnings/precautions:",
    " </i>",
    " </b>",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " &bull; Appropriate use: Ulcers: For use only in patients at high risk of
    complications from gastric ulcers (eg, the elderly or patients with concomitant
    diseases) or patients at high risk for developing gastric ulcers (eg, those with a
    history of ulcers) taking NSAIDs. Misoprostol must be taken during the duration of
    NSAID therapy. It is not effective in preventing duodenal ulcers in patients taking
    NSAIDs.",
    " </p>",
    " </div>",
    " <div class=\"block cyt drugH1Div\" id=\"F13299720\"
    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=\"F197160\"
    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:-2em;margin-left:2em;\">",
    " Antacids: May enhance the adverse/toxic effect of Misoprostol. More
    specifically, concomitant use with magnesium-containing antacids may increase the
    risk of diarrhea. Management: Avoid concomitant use of misoprostol and magnesium-
    containing antacids. In patients requiring antacid therapy, employ magnesium-free
    preparations. Monitor for increased adverse effects (e.g., diarrhea,
    dehydration).",
    " <b>",
    " Exceptions:",
    " </b>",
    " Aluminum Hydroxide; Calcium Carbonate; Sodium Bicarbonate.",
    " <i>",
    " Risk D: Consider therapy modification",
    " </i>",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;\">",
    " Carbetocin: Misoprostol may enhance the therapeutic effect of Carbetocin.",
    " <i>",
    " Risk X: Avoid combination",
    " </i>",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;\">",
    " Oxytocin: Misoprostol may enhance the therapeutic effect of Oxytocin.
    Management: The manufacturer of misoprostol recommends avoiding concomitant use
    with oxytocin. Misoprostol may augment effects of oxytocin, particularly when
    given within 4 hours of oxytocin initiation.",
    " <i>",
    " Risk D: Consider therapy modification",
    " </i>",
    " </p>",
    " </div>",
    " <div class=\"block foi drugH1Div\" id=\"F197184\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Ethanol/Nutrition/Herb Interactions",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Food: Misoprostol peak serum concentrations may be decreased if taken with
    food (not clinically significant).",
    " </p>",
    " </div>",
    " <div class=\"block prf drugH1Div\" id=\"F197162\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Pregnancy Risk Factor",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " X (",
    " <a class=\"graphic graphic_table\" href=\"UTD.htm?16/42/17068\">",
    " show table",
    " </a>",
    " )",
    " </p>",
    " </div>",
    " <div class=\"block pri drugH1Div\" id=\"F197174\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Pregnancy Implications",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Teratogenic effects were not observed in animal reproduction studies.
    Congenital anomalies following first trimester exposure have been reported,
    including skull defects, cranial nerve palsies, falcial malformations, and limb
    defects. Misoprostol may produce uterine contractions; fetal death, uterine
    perforation, and abortion may occur.",
    " <b>",
    " [U.S. Boxed Warning]: Use of misoprostol during pregnancy may cause
    abortion, birth defects, or premature birth. It is not to be used to reduce NSAID-
    induced ulcers in a woman of childbearing potential unless she is capable of
    complying with effective contraceptive measures and is at high risk of developing
    gastric ulcers and/or their complications.",
    " </b>",
    " If needed, the patient must have a negative pregnancy test within 2 weeks of
    starting therapy, she must use effective contraception during treatment, and
    therapy should begin on the second or third day of next normal menstrual period.
    Written and verbal warnings concerning the hazards of misoprostol should be
    provided.",
    " </p>",
    " <p style=\"text-indent:0em;margin-top:2em;\">",
    " Misoprostol is FDA approved for the medical termination of pregnancy of
    &le;49 days in conjunction with mifepristone.",
    " </p>",
    " <p style=\"text-indent:0em;margin-top:2em;\">",
    " Because misoprostol may induce or augment uterine contractions, it has been
    used off-label as a cervical-ripening agent for induction of labor in women who
    have not had a prior cesarean delivery or major uterine surgery. Hyperstimulation
    of the uterus, uterine rupture, or adverse events in the fetus or mother may occur
    with this use.",
    " </p>",
    " </div>",
    " <div class=\"block lac drugH1Div\" id=\"F197196\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Lactation",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Enters breast milk/use caution",
    " </p>",
    " </div>",
    " <div class=\"block brc drugH1Div\" id=\"F197175\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Breast-Feeding Considerations",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Misoprostol acid (the active metabolite of misoprostol) has been detected in
    breast milk. Concentrations following a single oral dose were 7.6-20.9 pg/mL after
    1 hour and decreased to &lt;1 pg/mL by 5 hours. Adverse events have not been
    reported in nursing infants (FIGO, 2012).",
    " </p>",
    " </div>",
    " <div class=\"block dic drugH1Div\" id=\"F197176\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Dietary Considerations",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Should be taken with food.",
    " </p>",
    " </div>",
    " <div class=\"block fee drugH1Div\" id=\"F197173\"
    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>",
    " Tablets",
    " </b>",
    " (Cytotec Oral)",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " 100 mcg (100): $216.46",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " 200 mcg (100): $300.53",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " <b>",
    " Tablets",
    " </b>",
    " (Misoprostol Oral)",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " 100 mcg (60): $49.45",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
    " 200 mcg (60): $71.95",
    " </p>",
    " </div>",
    " <div class=\"block mop drugH1Div\" id=\"F9660727\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Monitoring Parameters",
    " </span>",
    " <p style=\"text-indent:-2em;margin-left:2em;\">",
    " Prevention of NSAID-induced gastric ulcers: Pregnancy test in women of
    reproductive potential prior to therapy; adequate diagnostic measures in all cases
    of undiagnosed abnormal vaginal bleeding",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;\">",
    " Off-label pregnancy-related uses: Uterine activity and fetal status. When
    used for incomplete or missed abortion, re-evaluate 1-2 weeks after dosing",
    " </p>",
    " </div>",
    " <div class=\"list fbnlist drugH1Div drugBrandNames\" id=\"F197177\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " International Brand Names",
    " </span>",
    " <ul>",
    " <li>",
    " Alsoben (KP);",
    " </li>",
    " <li>",
    " Chromalux (ID);",
    " </li>",
    " <li>",
    " Cyprostol (AT);",
    " </li>",
    " <li>",
    " Cytil (CO);",
    " </li>",
    " <li>",
    " Cytolog (IN);",
    " </li>",
    " <li>",
    " Cytotec (AE, AR, AU, BE, BF, BG, BH, BJ, BR, CH, CI, CL, CO, CR, CY, CZ, DE,
    DK, EC, EE, EG, ES, ET, FI, FR, GB, GH, GM, GN, GR, HK, HN, HU, ID, IE, IL, IQ, IR,
    IT, JO, JP, KE, KP, KW, LB, LR, LU, LY, MA, ML, MR, MT, MU, MW, MX, MY, NE, NG, NI,
    NL, NO, NZ, OM, PA, PE, PL, PT, QA, RU, SA, SC, SD, SE, SG, SK, SL, SN, SV, SY, TH,
    TN, TR, TW, TZ, UG, VE, YE, ZA, ZM, ZW);",
    " </li>",
    " <li>",
    " Gastrul (ID);",
    " </li>",
    " <li>",
    " Gymiso (FR);",
    " </li>",
    " <li>",
    " Invitec (ID);",
    " </li>",
    " <li>",
    " Misel (KP);",
    " </li>",
    " <li>",
    " Misotrol (CN);",
    " </li>",
    " <li>",
    " Noprostol (ID);",
    " </li>",
    " <li>",
    " U-Miso (TW)",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"block pha drugH1Div\" id=\"F197154\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Mechanism of Action",
    " </span>",
    " <p style=\"text-indent:0em;display:inline\">",
    " Misoprostol is a synthetic prostaglandin E",
    " <sub>",
    " 1",
    " </sub>",
    " analog that replaces the protective prostaglandins consumed with
    prostaglandin-inhibiting therapies (eg, NSAIDs); has been shown to induce uterine
    contractions",
    " </p>",
    " </div>",
    " <div class=\"block phk drugH1Div\" id=\"F197170\"
    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: Rapid and extensive",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " Metabolism: Hepatic; rapidly de-esterified to misoprostol acid (active)",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " Protein binding: Misoprostol acid: &lt;90%",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " Half-life elimination: Misoprostol acid: 20-40 minutes",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " Time to peak, serum: Misoprostol acid: Fasting: 6-22 minutes",
    " </p>",
    " <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
    " Excretion: Urine (80%)",
    " </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 class=\"headingAnchor\" id=\"references\">",
    " <h1>",
    " REFERENCES",
    " </h1>",
    " <ol id=\"reference\">",
    " <li>",
    " <div class=\"reference\">",
    " American College of Obstetricians and Gynecologists, \"ACOG Committee
    Opinion No. 427: Misoprostol for Postabortion Care,\"",
    " <i>",
    " Obstet Gynecol",
    " </i>",
    " , 2009a, 113(2 Pt 1):465-8.",
    " <span class=\"pubmed-id\">",
    " [PubMed",
    " <a href=\"UTD.htm?0/41/662/abstract-text/19155922/pubmed\" id=\"19155922\"
    target=\"_blank\">",
    " 19155922",
    " </a>",
    " ]",
    " </span>",
    " </div>",
    " </li>",
    " <li>",
    " <div class=\"reference\">",
    " American College of Obstetricians and Gynecologists, &ldquo;ACOG Practice
    Bulletin No. 107: Induction of Labor,&rdquo;",
    " <i>",
    " Obstet Gynecol",
    " </i>",
    " , 2009b, 114(2 Pt 1):386-97.",
    " <span class=\"pubmed-id\">",
    " [PubMed",
    " <a href=\"UTD.htm?0/41/662/abstract-text/19623003/pubmed\" id=\"19623003\"
    target=\"_blank\">",
    " 19623003",
    " </a>",
    " ]",
    " </span>",
    " </div>",
    " </li>",
    " <li>",
    " <div class=\"reference\">",
    " American College of Obstetricians and Gynecologists, \"ACOG Practice
    Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery,\"",
    " <i>",
    " Obstet Gynecol",
    " </i>",
    " , 2010, 116(2 Pt 1):450-63.",
    " <span class=\"pubmed-id\">",
    " [PubMed",
    " <a href=\"UTD.htm?0/41/662/abstract-text/20664418/pubmed\" id=\"20664418\"
    target=\"_blank\">",
    " 20664418",
    " </a>",
    " ]",
    " </span>",
    " </div>",
    " </li>",
    " <li>",
    " <div class=\"reference\">",
    " Cleghorn GJ, Shepherd RW, and Holt TL, &ldquo;The Use of a Synthetic
    Prostaglandin E1 Analogue (Misoprostol) as an Adjunct to Pancreatic Enzyme
    Replacement in Cystic Fibrosis,&rdquo;",
    " <i>",
    " Scand J Gastroenterol Suppl",
    " </i>",
    " , 1988, 143:142-7.",
    " <span class=\"pubmed-id\">",
    " [PubMed",
    " <a href=\"UTD.htm?0/41/662/abstract-text/3133753/pubmed\" id=\"3133753\"
    target=\"_blank\">",
    " 3133753",
    " </a>",
    " ]",
    " </span>",
    " </div>",
    " </li>",
    " <li>",
    " <div class=\"reference\">",
    " International Federation of Gynecology and Obstetrics (FIGO), \"Prevention
    of Postpartum Hemorrhage With Misoprostol,\"",
    " <i>",
    " Int J Gynaecol Obstet",
    " </i>",
    " ,\" 2012, 119(3):213-4.",
    " <span class=\"pubmed-id\">",
    " [PubMed",
    " <a href=\"UTD.htm?0/41/662/abstract-text/23022109/pubmed\" id=\"23022109\"
    target=\"_blank\">",
    " 23022109",
    " </a>",
    " ]",
    " </span>",
    " </div>",
    " </li>",
    " <li>",
    " <div class=\"reference\">",
    " International Federation of Gynecology and Obstetrics (FIGO), \"Treatment of
    Postpartum Hemorrhage With Misoprostol,\"",
    " <i>",
    " Int J Gynaecol Obstet",
    " </i>",
    " , 2012, 119(3):215-6.",
    " <span class=\"pubmed-id\">",
    " [PubMed",
    " <a href=\"UTD.htm?0/41/662/abstract-text/23036964/pubmed\" id=\"23036964\"
    target=\"_blank\">",
    " 23036964",
    " </a>",
    " ]",
    " </span>",
    " </div>",
    " </li>",
    " <li>",
    " <div class=\"reference\">",
    " Robinson PJ, Smith AL, and Sly PD, &ldquo;Duodenal pH in Cystic Fibrosis and
    Its Relationship to Fat Malabsorption,&rdquo;",
    " <i>",
    " Dig Dis Sci",
    " </i>",
    " , 1990, 35(10):1299-304.",
    " <span class=\"pubmed-id\">",
    " [PubMed",
    " <a href=\"UTD.htm?0/41/662/abstract-text/2120019/pubmed\" id=\"2120019\"
    target=\"_blank\">",
    " 2120019",
    " </a>",
    " ]",
    " </span>",
    " </div>",
    " </li>",
    " <li>",
    " <div class=\"reference\">",
    " Walt RP, &ldquo;Misoprostol for the Treatment of Peptic Ulcer and Anti-
    inflammatory Drug-Induced Gastroduodenal Ulceration,&rdquo;",
    " <i>",
    " N Engl J Med",
    " </i>",
    " , 1992, 327(22):1575-80.",
    " <span class=\"pubmed-id\">",
    " [PubMed",
    " <a href=\"UTD.htm?0/41/662/abstract-text/1435885/pubmed\" id=\"1435885\"
    target=\"_blank\">",
    " 1435885",
    " </a>",
    " ]",
    " </span>",
    " </div>",
    " </li>",
    " <li>",
    " <div class=\"reference\">",
    " Wing, DA, &ldquo;Labor Induction With Misoprostol,&rdquo;",
    " <i>",
    " Am J Obstet Gynecol",
    " </i>",
    " , 1999, 181(2):339-45.",
    " <span class=\"pubmed-id\">",
    " [PubMed",
    " <a href=\"UTD.htm?0/41/662/abstract-text/10454679/pubmed\" id=\"10454679\"
    target=\"_blank\">",
    " 10454679",
    " </a>",
    " ]",
    " </span>",
    " </div>",
    " </li>",
    " </ol>",
    " </div>",
    " <div id=\"topicVersionRevision\">",
    " Topic 9657 Version 40.0",
    " </div>",
    " </div>",
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    " <h1>",
    " TOPIC OUTLINE",
    " </h1>",
    " <div id=\"outline\">",
    " <ul>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F5709091\">",
    " ALERT: U.S. Boxed Warning",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197188\">",
    " Brand Names: U.S.",
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    " <a class=\"outlineLink\" href=\"#F197189\">",
    " Brand Names: Canada",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197231\">",
    " Pharmacologic Category",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197192\">",
    " Dosing: Adult",
    " </a>",
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    " <a class=\"outlineLink\" href=\"#F15976971\">",
    " Dosing: Geriatric",
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    " <a class=\"outlineLink\" href=\"#F9660726\">",
    " Dosing: Renal Impairment",
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    " Dosing: Hepatic Impairment",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197165\">",
    " Dosage Forms: U.S.",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197151\">",
    " Generic Equivalent Available: U.S.",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197168\">",
    " Administration",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197167\">",
    " Use",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197227\">",
    " Use - Unlabeled",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197238\">",
    " Medication Safety Issues",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197229\">",
    " Adverse Reactions Significant",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197171\">",
    " Contraindications",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197155\">",
    " Warnings/Precautions",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F13299720\">",
    " Metabolism/Transport Effects",
    " </a>",
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    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197160\">",
    " Drug Interactions",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197184\">",
    " Ethanol/Nutrition/Herb Interactions",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197162\">",
    " Pregnancy Risk Factor",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197174\">",
    " Pregnancy Implications",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197196\">",
    " Lactation",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197175\">",
    " Breast-Feeding Considerations",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197176\">",
    " Dietary Considerations",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
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    " Pricing: U.S. (Medi-Span&reg;)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F9660727\">",
    " Monitoring Parameters",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197177\">",
    " International Brand Names",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F197154\">",
    " Mechanism of Action",
    " </a>",
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    " Pharmacodynamics/Kinetics",
    " </a>",
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    " <a href=\"#references\">",
    " REFERENCES",
    " </a>",
    " </li>",
    " </ul>",
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    " <h1>",
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    " GRAPHICS",
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    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_table\" href=\"UTD.htm?23/39/24183\"
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    " </ul>",
    " </div>",
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    " RELATED TOPICS",
    " </h1>",
    " <div id=\"relatedTopics\">",
    " <ul>",
    " <li class=\"plainItem\">",
    " <a class=\"drug drug_patient\" href=\"UTD.htm?11/23/11636?
    source=related_link\">",
    " Misoprostol: Patient drug information",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"drug drug_pediatric\" href=\"UTD.htm?17/31/17908?
    source=related_link\">",
    " Misoprostol: Pediatric drug information",
    " </a>",
    " </li>",
    " </ul>",
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    " </div>"].join("\n");
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    " </div>",
    " <div class=\"lgnd\">",
    " A) Physiologic jaundice. B) Pressing the color from the skin allows better
    recognition of the yellow of jaundice. Infant with bilirubin level of 13 mg/d. C)
    Infant with no appreciable jaundice at chest level.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " A) Reproduced with permission from: O'Doherty N. Atlas of the Newborn.
    Philadelphia: JB Lippincott, 1979. Copyright &copy; 1979 Lippincott Williams &amp;
    Wilkins.",
    " <br>",
    " B and C) Reproduced with permission from: Fletcher M: Physical Diagnosis in
    Neonatology, Philadelphia, Lippincott-Raven Publishers, 1998. Copyright &copy; 1998
    Lippincott Williams &amp; Wilkins.",
    " </br>",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_41_663=[""].join("\n");
    var outline_f0_41_663=null;
    var title_f0_41_664="Clinical features of autism spectrum disorders";
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    " <!-- TC:TOPIC_PAGE -->",
    " <div id=\"topicContent\">",
    " <div id=\"topicTitle\">",
    " Clinical features of autism spectrum disorders",
    " </div>",
    " <div id=\"topicContributors\">",
    " <div>",
    " <a id=\"authors\">",
    " </a>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"UTD.htm?0/41/664/contributors\">",
    " Author",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/41/664/contributors\">",
    " Marilyn Augustyn, MD",
    " </a>",
    " <br/>",
    " </div>",
    " <div>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"UTD.htm?0/41/664/contributors\">",
    " Section Editors",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/41/664/contributors\">",
    " Marc C Patterson, MD, FRACP",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/41/664/contributors\">",
    " Carolyn Bridgemohan, MD",
    " </a>",
    " <br/>",
    " </div>",
    " <div>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"UTD.htm?0/41/664/contributors\">",
    " Deputy Editor",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/41/664/contributors\">",
    " Mary M Torchia, MD",
    " </a>",
    " <br/>",
    " </div>",
    " </div>",
    " <div id=\"disclosures\">",
    " <a href=\"UTD.htm?0/41/664/contributor-disclosure\" target=\"_blank\">",
    " Disclosures",
    " </a>",
    " </div>",
    " <div id=\"reviewProcess\">",
    " <span>",
    " All topics are updated as new evidence becomes available and our",
    " </span>",
    " <a href=\"/home/editorial-policy\" target=\"_blank\">",
    " peer review process",
    " </a>",
    " <span>",
    " is complete.",
    " </span>",
    " </div>",
    " <div id=\"literatureReviewDate\">",
    " <span class=\"emphasis\">",
    " Literature review current through:",
    " </span>",
    " Oct 2013.",
    " <span class=\"pipeSpace\">",
    " |",
    " </span>",
    " <span class=\"emphasis\">",
    " This topic last updated:",
    " </span>",
    " Dec 20, 2012.",
    " </div>",
    " <div id=\"topicText\">",
    " <p class=\"headingAnchor\" id=\"H1\">",
    " <span class=\"h1\">",
    " INTRODUCTION",
    " </span>",
    " &nbsp;&mdash;&nbsp;Autism spectrum disorders (ASD) are a group of biologically
    based neurodevelopmental disorders characterized by impairments in three major
    domains: socialization, communication, and behavior. The Diagnostic and Statistical
    Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) categorizes
    these disorders under \"pervasive developmental disorders\" (PDD) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ]. These disorders include autistic disorder (classic autism, sometimes called
    early infantile autism, childhood autism, or Kanner's autism), childhood
    disintegrative disorder, Rett disorder, Asperger disorder (also known as Asperger
    syndrome), and pervasive developmental disorder-not otherwise specified (PDD-NOS),
    including atypical autism.",
    " </p>",
    " <p>",
    " The clinical features of autism spectrum disorders will be reviewed here.
    Related topics are presented separately:",
    " </p>",
    " <p>",
    " <ul class=\"bulletCompact-block\">",
    " <li>",
    " (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?34/17/35097?
    source=see_link\">",
    " \"Surveillance and screening for autism spectrum disorders in primary
    care\"",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?4/37/4698?
    source=see_link\">",
    " \"Terminology, epidemiology, and pathogenesis of autism spectrum
    disorders\"",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?38/3/38969?
    source=see_link\">",
    " \"Diagnosis of autism spectrum disorders\"",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?0/54/872?
    source=see_link\">",
    " \"Autism spectrum disorders in children and adolescents: Overview of
    management\"",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?4/1/4122?
    source=see_link\">",
    " \"Autism spectrum disorders in children and adolescents: Behavioral and
    educational interventions\"",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?34/46/35562?
    source=see_link\">",
    " \"Autism spectrum disorders in children and adolescents: Pharmacologic
    interventions\"",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?15/54/16234?
    source=see_link\">",
    " \"Autism spectrum disorders in children and adolescents: Compleme",
    "1ff8",
    "ntary and alternative therapies\"",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/52/41801?
    source=see_link\">",
    " \"Asperger disorder: Management and prognosis in children and
    adolescents\"",
    " </a>",
    " .)",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H2\">",
    " <span class=\"h1\">",
    " OVERVIEW",
    " </span>",
    " &nbsp;&mdash;&nbsp;Autism spectrum disorders are characterized by
    abnormalities in social interaction, communication, and behavior. Symptoms of
    autism most commonly are recognized in the second year of life [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/2-6\">",
    " 2-6",
    " </a>",
    " ], but may be present earlier [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/7-9\">",
    " 7-9",
    " </a>",
    " ]. By definition, symptoms of autistic disorder must be present by three years
    of age [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ]. Early symptoms of Asperger disorder may not be apparent to parents or
    teachers until four to six years of age [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/10\">",
    " 10",
    " </a>",
    " ]. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?15/20/15689?
    source=see_link&amp;anchor=H5#H5\">",
    " \"Asperger disorder: Clinical features and diagnosis in children and
    adolescents\", section on 'Clinical features'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " As the term &ldquo;spectrum&rdquo; is applied clinically to this cohort of
    children, the broad array of potential presentations has increased: from children
    who may present in the first year of life with delays in the three core areas, to
    children who may develop typically and then plateau, to children who may show signs
    of frank regression after typical development [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/6,11\">",
    " 6,11",
    " </a>",
    " ]. Approximately two-thirds of patients with autism present with lack of
    acquisition of communication skills during the first two years of life.
    Approximately one-fourth to one-third of children with ASD achieve early language
    milestones, but have regression of language, communication,",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " social skills between 15 to 24 months of age [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/2,11-17\">",
    " 2,11-17",
    " </a>",
    " ]. The regression of skills can be gradual or sudden, and may occur in the
    context of preexisting developmental delays or atypical development [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/12\">",
    " 12",
    " </a>",
    " ]. Regression of skills is an important characteristic of ASD; attribution of
    regression to stressors, such as the birth of a new sibling or moving to a new
    home, may delay the diagnosis of ASD [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/12\">",
    " 12",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H3\">",
    " <span class=\"h1\">",
    " AUTISTIC DISORDER",
    " </span>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H4\">",
    " <span class=\"h2\">",
    " Social interaction",
    " </span>",
    " &nbsp;&mdash;&nbsp;Impaired social interaction is a hallmark of ASD. The DSM-
    IV-TR criteria for autistic disorder are listed in Table 1 (",
    " <a class=\"graphic graphic_table graphicRef72403 \" href=\"UTD.htm?
    29/6/29804\">",
    " table 1",
    " </a>",
    " )&nbsp;[",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H5\">",
    " <span class=\"h3\">",
    " Nonverbal behaviors",
    " </span>",
    " &nbsp;&mdash;&nbsp;Individuals with ASD have impaired ability to use and
    interpret nonverbal behaviors such as eye-to-eye gaze, facial expression, gestures,
    and body postures. They are unable to read nonverbal emotional cues. During
    infancy, parents may notice that the baby resists cuddling, avoids eye contact, or
    fails to spread the arms in anticipation of being picked up, although these
    behaviors are not universal [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/18\">",
    " 18",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H6\">",
    " <span class=\"h3\">",
    " Peer relationships",
    " </span>",
    " &nbsp;&mdash;&nbsp;Individuals with ASD fail to develop peer relationships
    appropriate to their developmental level. Younger children may have little or no
    interest in developing friendships. They may prefer solitary play to social play,
    involving others in activities only as tools or \"mechanical\" aids (ie, using the
    hand of a parent to obtain a desired object without making eye contact) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ]. Older children may become more interested in social interaction, but lack
    understanding of social conventions or the needs of others (eg, having little sense
    of boundaries, repeating memorized information regardless of its appropriateness)
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Few children with ASD are so socially isolated that they fail to interact with
    a loved family member, but purposeful social interaction is usually subdued or
    intermittent, without the expected joy and reciprocity [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/2\">",
    " 2",
    " </a>",
    " ]. Parents of such children may describe them as independent rather than
    aloof, and may be proud of their apparent self-sufficiency [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/2\">",
    " 2",
    " </a>",
    " ]. Parents seem to feel the lack of interactive initiative and responsiveness
    of their babies and increasingly try to supply soliciting behaviors as early as 18
    months [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/19\">",
    " 19",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H7\">",
    " <span class=\"h3\">",
    " Joint attention",
    " </span>",
    " &nbsp;&mdash;&nbsp;Individuals with ASD lack the spontaneous seeking to share
    enjoyment, interests, or achievements with other people (ie, impaired joint
    attention or social referencing) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/12\">",
    " 12",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Joint attention is a spontaneous behavior in which an infant or toddler tries
    to share interest, amusement, or apprehension about an object with a caretaker or
    playmate [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/20\">",
    " 20",
    " </a>",
    " ]. The child does this by purposefully looking back and forth between the
    object of interest and the eyes of the caretaker or playmate (usually by 8 to 10
    months of age), or by pointing to the object (protodeclarative pointing, usually by
    14 to 16 months of age). Protodeclarative pointing is distinguished from
    protoimperative pointing, in which the infant points to an object, usually out of
    reach, in order to obtain it [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/12\">",
    " 12",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Children with autism lack joint attention (but not protoimperative pointing).
    They are content with passive play, often described by their parents as \"good\"
    infants and toddlers, undemanding of attention [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/21\">",
    " 21",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H8\">",
    " <span class=\"h3\">",
    " Social reciprocity/referencing",
    " </span>",
    " &nbsp;&mdash;&nbsp;Individuals with ASD lack social or emotional reciprocity.
    The impairment in reciprocal social interaction is profound and sustained [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ]. Younger children may be unaware of other children (including siblings) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/18\">",
    " 18",
    " </a>",
    " ]. They may lack empathy for another's emotional perspective (eg, unable to
    sense that another is in pain). They are not interested in imitating others or in
    bringing a novel object to a trusted individual to show.",
    " </p>",
    " <p class=\"h 1ff8 eadingAnchor\" id=\"H9\">",
    " <span class=\"h2\">",
    " Communication",
    " </span>",
    " &nbsp;&mdash;&nbsp;Marked and sustained impairment of communication is the
    second hallmark of ASD [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ]. Delays and deviations in language development are the most common
    presenting complaints of parents of children with ASD [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/22,23\">",
    " 22,23",
    " </a>",
    " ]. In addition to delayed or deviant language skills, children with ASD often
    lack even the intent to communicate [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/18\">",
    " 18",
    " </a>",
    " ]. The DSM-IV-TR criteria for qualitative impairments in communication are
    listed in the table (",
    " <a class=\"graphic graphic_table graphicRef72403 \" href=\"UTD.htm?
    29/6/29804\">",
    " table 1",
    " </a>",
    " )&nbsp;[",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H10\">",
    " <span class=\"h3\">",
    " Language",
    " </span>",
    " &nbsp;&mdash;&nbsp;Delay in, or total lack of, the development of spoken
    language (not accompanied by an attempt to compensate through alternative modes of
    communication such as gesture or mime) is a characteristic feature of autism [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ]. In most individuals, receptive language is delayed even more than
    expressive language [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ]. Children may not respond to the calling of their names; concerns regarding
    hearing impairment may be the presenting complaint [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/12,24\">",
    " 12,24",
    " </a>",
    " ]. Children with autism may be unable to understand simple questions or
    directions. They do not engage in simple imitation games of infancy and early
    childhood, or do so only out of context or in a mechanical way.",
    " </p>",
    " <p>",
    " There is wide variability in the severity and quality of language dysfunction
    in children with autism, reflecting the heterogeneity of the disorder [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/12\">",
    " 12",
    " </a>",
    " ]. Less than one-half fail to use speech as the primary mode of communication
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/18,25\">",
    " 18,25",
    " </a>",
    " ]. In some, verbal language develops but is not used as a tool for
    communication (eg, it consists of repeating words [echolalia] or rote imitation of
    words or dialogue). Individuals with adequate speech may have difficulty initiating
    or sustaining a conversation with others (ie, pragmatics), or the language may have
    meaning only to people who are familiar with the autistic individual's
    communication style (ie, idiosyncratic language). At the far end of the spectrum,
    subtle deviations of stress, pitch, or intonation (eg, sing-song or monotone) may
    be the only manifestation [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/20\">",
    " 20",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Higher-functioning individuals do communicate and have relatively normal
    understanding and use of phonologic aspects, grammar, and some aspects of the
    meaning of language [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/20\">",
    " 20",
    " </a>",
    " ]. However, they may have difficulty gaining their listener's perspective,
    realizing meaningful implications of what is said, and understanding and conveying
    shades of meaning. They may have difficulty appreciating humor or sarcasm [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/20,26\">",
    " 20,26",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H12\">",
    " <span class=\"h2\">",
    " Behavior",
    " </span>",
    " &nbsp;&mdash;&nbsp;Restricted and repetitive and stereotyped patterns of
    behavior are the third core symptom of ASD. The DSM-IV-TR criteria for qualitative
    impairments in behavior in autistic disorder are listed in the table (",
    " <a class=\"graphic graphic_table graphicRef72403 \" href=\"UTD.htm?
    29/6/29804\">",
    " table 1",
    " </a>",
    " )&nbsp;[",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H13\">",
    " <span class=\"h3\">",
    " Preoccupations",
    " </span>",
    " &nbsp;&mdash;&nbsp;Encompassing preoccupation with one or more stereotyped and
    restricted patterns of interest that is abnormal in either intensity or focus and
    persistent preoccupation with parts of objects are two of the DSM-IV-TR criteria
    for autism [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " In younger children, preoccupations may center on peculiar sensory or
    perceptual arousal, as described below [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/20\">",
    " 20",
    " </a>",
    " ]. (See",
    " <a class=\"local\" href=\"#H17\">",
    " 'Sensory perception'",
    " </a>",
    " below.) The preoccupations of older children and those who are more
    cognitively able may include weather, dates, schedules, phone numbers, license
    plates, Thomas the Tank Engine, Pok&eacute;mon, or subtypes of any classification
    (eg, dinosaurs, dogs, planes) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1,20\">",
    " 1,20",
    " </a>",
    " ]. Often, it may be difficult to differentiate primary ASD from secondary
    obsessive compulsive disorder.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H14\">",
    " <span class=\"h3\">",
    " Rituals",
    " </span>",
    " &nbsp;&mdash;&nbsp;Apparently inflexible adherence to specific, nonfunctional
    routines or rituals is another characteristic feature of autism. These may manifest
    during various aspects of daily life, such as the need to always eat particular
    foods in a specific order, or to follow the same route from one place to another
    without deviation. Rituals may also manifest as repetitive ordering of toys, or
    mimicking the actions or dialogue from television or video [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H15\">",
    " <span class=\"h3\">",
    " Motor mannerisms",
    " </span>",
    " &nbsp;&mdash;&nbsp;Stereotyped and repetitive motor mannerisms or complex
    whole-body movements (eg, hand or finger flapping or twisting, rocking, swaying,
    dipping, walking on tip-toe (toe walking)) are another feature of autism [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/27-29\">",
    " 27-29",
    " </a>",
    " ]. Motor mannerisms are reported in 37 to 95 percent of individuals with ASD
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/30\">",
    " 30",
    " </a>",
    " ]. Motor mannerisms often manifest during the preschool years. Stereotyped
    motor mannerisms appear to be self-stimulating and may also be self-injurious [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/20\">",
    " 20",
    " </a>",
    " ]. Self-injurious behaviors are more common among ASD patients with cognitive
    disability and include head-banging, face or body slapping, self-biting, or self-
    pinching. The triggers for these behaviors may be predictable (frustration,
    anxiety, excitement) or seemingly random.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H7859978\">",
    " <span class=\"h3\">",
    " Play",
    " </span>",
    " &nbsp;&mdash;&nbsp;Lack of varied, spontaneous make-believe play or social
    imitative is a characteristic feature of autism [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ]. Children with ASD may line up an exact number of playthings in the same
    manner in a stereotyped ritual, without apparent awareness of what the toys
    represent [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1,2,31\">",
    " 1,2,31",
    " </a>",
    " ]. They may focus on parts of toys rather than the function of the toy [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/20\">",
    " 20",
    " </a>",
    " ]. They may not engage in pretend play, which usually develops by two years of
    age",
    "1ff8",
    ". Even if pretend play develops, it often appears scripted, mimicking of what the
    child may have seen on television or in books.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H16\">",
    " <span class=\"h2\">",
    " Cognitive skills",
    " </span>",
    " &nbsp;&mdash;&nbsp;Cognitive skills of individuals with ASD are usually
    uneven, regardless of the general level of intelligence [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1,22,32\">",
    " 1,22,32",
    " </a>",
    " ]. Verbal skills are usually weaker than nonverbal skills [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/30\">",
    " 30",
    " </a>",
    " ]. Performance on tasks that require rote, mechanical, visuospatial, or
    perceptual processes is usually better than on tasks that require higher-order
    conceptual processes, reasoning, interpretation, integration, or abstraction [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/32-35\">",
    " 32-35",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Some individuals have special skills (ie, \"savant\" skills) in memory,
    mathematics, music, art, or puzzles, despite profound deficiencies in other domains
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1,2,20\">",
    " 1,2,20",
    " </a>",
    " ]. Other special skills include calendar calculation (determining the day of
    the week for a given date) and hyperlexia (spontaneous and precocious mastery of
    single-word reading) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1,36,37\">",
    " 1,36,37",
    " </a>",
    " ]. The reading is usually concrete, with little comprehension or understanding
    of the purpose of reading [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/20\">",
    " 20",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H17\">",
    " <span class=\"h2\">",
    " Sensory perception",
    " </span>",
    " &nbsp;&mdash;&nbsp;Sensory processing abilities are aberrant in 42 to 99
    percent of individuals with ASD [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/30\">",
    " 30",
    " </a>",
    " ]. Aberrant responses may include over-responsiveness, under-responsiveness,
    and paradoxical responses to environmental stimuli [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/38\">",
    " 38",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Examples include [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/20\">",
    " 20",
    " </a>",
    " ]:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Visual inspection of objects out of the corner of the eyes.",
    " </li>",
    " <li>",
    " Preoccupation with edges, spinning objects, or shiny surfaces, lights, or
    odors.",
    " </li>",
    " <li>",
    " Refusal to eat foods with certain tastes or textures, or eating only foods
    with certain tastes and textures; dietary obsessions may be associated with
    gastrointestinal symptoms (eg, weight abnormalities, abnormal stool patterns).",
    " </li>",
    " <li>",
    " Preoccupation with sniffing or licking nonfood objects.",
    " </li>",
    " <li>",
    " Resistance to being touched or increased sensitivity to certain kinds of
    touch; light touch may be experienced as painful, whereas deep pressure may provide
    a sense of calm. This may include resistance to the feel of certain clothing
    textures or colors next to the skin.",
    " </li>",
    " <li>",
    " Apparent indifference to pain.",
    " </li>",
    " <li>",
    " Strong preferences for",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " compulsive touching of certain textures and strong aversions to others.",
    " </li>",
    " <li>",
    " Hypersensitivity to certain frequencies or types of sound (eg, distant fire
    engines) with lack of response to sounds close-by or sounds that would startle
    other children.",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H18\">",
    " <span class=\"h2\">",
    " Macrocephaly",
    " </span>",
    " &nbsp;&mdash;&nbsp;Approximately one-fourth of children with isolated ASD have
    head circumference greater than the 97",
    " <sup>",
    " th",
    " </sup>",
    " percentile [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/39,40\">",
    " 39,40",
    " </a>",
    " ]. An increased rate of head growth is found in up to 70 percent of children
    with autism during the first year of life, but not all of these children become
    macrocephalic [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/41-44\">",
    " 41-44",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Accelerated head growth may be related to abnormalities in the processes of
    early brain development that contribute to the clinical manifestations of ASD [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/41\">",
    " 41",
    " </a>",
    " ]. By two to four years of age, mean brain volume is increased, and
    megalencephaly is present in some children [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/45,46\">",
    " 45,46",
    " </a>",
    " ]. However, in a longitudinal, nationally representative cohort of
    approximately 9000 children, the mean head circumference of children with and
    without ASD was similar at 9 months, 24 months, and 36 months [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/47\">",
    " 47",
    " </a>",
    " ]. Thus, although macrocephaly occurs in some children with ASD, it is not
    required for the diagnosis.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H19\">",
    " <span class=\"h1\">",
    " ASPERGER DISORDER",
    " </span>",
    " &nbsp;&mdash;&nbsp;The DSM-IV-TR provides specific criteria to diagnose
    Asperger disorder (",
    " <a class=\"graphic graphic_table graphicRef60599 \" href=\"UTD.htm?
    12/57/13212\">",
    " table 2",
    " </a>",
    " )&nbsp;[",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1\">",
    " 1",
    " </a>",
    " ]. In contrast to autistic disorder, individuals with Asperger disorder have
    better facility with the mechanics of verbal expression, higher levels of cognitive
    function, and greater interest in interpersonal social activity (often around their
    current obsessive preoccupation) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/12,18\">",
    " 12,18",
    " </a>",
    " ]. There is some controversy regarding whether Asperger disorder is a form of
    high-functioning autism or a separate disorder.",
    " </p>",
    " <p>",
    " Several features distinguish children with Asperger disorder from those with
    high-functioning autism. In contrast to children with high-functioning autism, in
    the first three years of life, children with Asperger disorder:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Do not have clinically significant delays or deviance in language
    acquisition, although subtle aspects of social communication may be affected; they
    may use single non-echoed words communicatively by age two years and communicative
    phrases by age three years, but have difficulty with the typical give-and-take in
    conversation.",
    " </li>",
    " <li>",
    " Do not have clinically significant delays in cognitive development.",
    " </li>",
    " <li>",
    " Do not have clinically significant delays in the acquisition of age-
    appropriate learning skills and adaptive behaviors (other than social
    interaction).",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " The clinical features of Asperger disorder are discussed separately. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?15/20/15689?
    source=see_link\">",
    " \"Asperger disorder: Clinical features and diagnosis in children and
    adolescents\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20\">",
    " <span class=\"h1\">",
    " PERVASIVE DEVELOPMENTAL DISORDER-NOT OTHERWISE SPECIFIED",
    " </span>",
    " &nbsp;&mdash;&nbsp;The term \"pervasive developmental disorder-not otherwise
    specified\" (PDD-NOS) is used to describe individuals who meet some, but not all,
    of the DSM-IV-TR criteria for autistic disorder (ie, atypical autism) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/664/abstract/1,12\">",
    " 1,12",
    " </a>",
    " ]. Individuals may fall into this category because of late age of
    presentation, atypical symptoms, or subthreshold symptoms. In addition, some
    clinicians make an initial diagnosis of PDD-NOS in children younger than 36 months
    regardless of the number or severity of symptoms because diagnostic accuracy is
    lower in younger children.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"PATIENT_INFORMATION\">",
    " <span class=\"h1\">",
    " INFORMATION FOR PATIENTS",
    " </span>",
    " &nbsp;&mdash;&nbsp;UpToDate offers two types of patient education materials,
    &ldquo;The Basics&rdquo; and &ldquo;Beyond the Basics.&rdquo; The Basics patient
    education pi",
    "1ff8",
    "eces are written in plain language, at the 5",
    " <sup>",
    " th",
    " </sup>",
    " to 6",
    " <sup>",
    " th",
    " </sup>",
    " grade reading level, and they answer the four or five key questions a patient
    might have about a given condition. These articles are best for patients who want a
    general overview and who prefer short, easy-to-read materials. Beyond the Basics
    patient education pieces are longer, more sophisticated, and more detailed. These
    articles are written at the 10",
    " <sup>",
    " th",
    " </sup>",
    " to 12",
    " <sup>",
    " th",
    " </sup>",
    " grade reading level and are best for patients who want in-depth information
    and are comfortable with some medical jargon.",
    " </p>",
    " <p>",
    " Here are the patient education articles that are relevant to this topic. We
    encourage you to print or e-mail these topics to your patients. (You can also
    locate patient education articles on a variety of subjects by searching on
    &ldquo;patient info&rdquo; and the keyword(s) of interest.)",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Basics topics (see",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?37/37/38481?
    source=see_link\">",
    " \"Patient information: Autism (The Basics)\"",
    " </a>",
    " )",
    " </li>",
    " <li>",
    " Beyond the Basics topics (see",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?40/46/41699?
    source=see_link\">",
    " \"Patient information: Autism spectrum disorders (Beyond the Basics)\"",
    " </a>",
    " )",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H22\">",
    " <span class=\"h1\">",
    " SUMMARY",
    " </span>",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Symptoms of autism most commonly are recognized in the second year of life,
    but may be present earlier. (See",
    " <a class=\"local\" href=\"#H2\">",
    " 'Overview'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Impaired social interaction may manifest as impaired use of nonverbal
    behaviors to regulate social interaction (eg, eye gaze, facial expression,
    gestures), failure to develop age-appropriate peer relationships, lack of seeking
    to share enjoyment, interests, or achievement, and lack of social or emotional
    reciprocity (",
    " <a class=\"graphic graphic_table graphicRef72403 \" href=\"UTD.htm?
    29/6/29804\">",
    " table 1",
    " </a>",
    " ). (See",
    " <a class=\"local\" href=\"#H4\">",
    " 'Social interaction'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Impaired communication may manifest as absent or delayed verbal language,
    impaired ability to initiate or sustain a conversation, stereotyped or repetitive
    use of language, or lack of pretend or social imitative play (",
    " <a class=\"graphic graphic_table graphicRef72403 \" href=\"UTD.htm?
    29/6/29804\">",
    " table 1",
    " </a>",
    " ). (See",
    " <a class=\"local\" href=\"#H9\">",
    " 'Communication'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Behavioral manifestations include preoccupation with stereotyped or
    restricted patterns of interest, inflexible adherence to nonfunctional routines or
    rituals, stereotyped and repetitive motor mannerisms, and preoccupation with parts
    of objects (",
    " <a class=\"graphic graphic_table graphicRef72403 \" href=\"UTD.htm?
    29/6/29804\">",
    " table 1",
    " </a>",
    " ). (See",
    " <a class=\"local\" href=\"#H12\">",
    " 'Behavior'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Criteria for Asperger disorder are listed in the table (",
    " <a class=\"graphic graphic_table graphicRef60599 \" href=\"UTD.htm?
    12/57/13212\">",
    " table 2",
    " </a>",
    " ). (See",
    " <a class=\"local\" href=\"#H19\">",
    " 'Asperger disorder'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " The term \"pervasive developmental disorder-not otherwise specified\" is
    used to describe individuals who meet some, but not all, of the criteria for
    autistic disorder or Asperger syndrome. (See",
    " <a class=\"local\" href=\"#H20\">",
    " 'Pervasive developmental disorder-not otherwise specified'",
    " </a>",
    " above.)",
    " </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>",
    " REFERENCES",
    " </h1>",
    " <ol id=\"reference\">",
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    " Bailey A, Luthert P, Bolton P, et al. Autism and megalencephaly. Lancet
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    " Lainhart JE, Piven J, Wzorek M, et al. Macrocephaly in children and adults
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    " Lainhart JE. Advances in autism neuroimaging research for the clinician and
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    " Courchesne E, Carper R, Akshoomoff N. Evidence of brain overgrowth in the
    first year of life in autism. JAMA 2003; 290:337.",
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    " Webb SJ, Nalty T, Munson J, et al. Rate of head circumference growth as a
    function of autism diagnosis and history of autistic regression. J Child Neurol
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/41/664/abstract/44\">",
    " Davidovitch M, Golan D, Vardi O, et al. Israeli children with autism
    spectrum disorder are not macrocephalic. J Child Neurol 2011; 26:580.",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/41/664/abstract/45\">",
    " Courchesne E, Karns CM, Davis HR, et al. Unusual brain growth patterns in
    early life in patients with autistic disorder: an MRI study. Neurology 2001;
    57:245.",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/41/664/abstract/46\">",
    " Sparks BF, Friedman SD, Shaw DW, et al. Brain structural abnormalities in
    young children with autism spectrum disorder. Neurology 2002; 59:184.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"./clinical",
    "1ff8",
    "-features-of-autism-spectrum-disorders/abstract/47\">",
    " Barnard-Brak L, Sulak T, Hatz JK. Macrocephaly in children with autism
    spectrum disorders. Pediatr Neurol 2011; 44:97.",
    " </a>",
    " </li>",
    " </ol>",
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    " <h1>",
    " TOPIC OUTLINE",
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    " <div id=\"outline\">",
    " <ul>",
    " <li>",
    " <a class=\"sr_button\" href=\"#H22\" id=\"summRecButton\">",
    " <span>",
    " SUMMARY",
    " </span>",
    " </a>",
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    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H1\">",
    " INTRODUCTION",
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    " OVERVIEW",
    " </a>",
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    " AUTISTIC DISORDER",
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    " Social interaction",
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    " - Nonverbal behaviors",
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    " - Language",
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    " Behavior",
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    " - Preoccupations",
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    " - Rituals",
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    " Macrocephaly",
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    " ASPERGER DISORDER",
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    " SUMMARY",
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    " REFERENCES",
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    " DSM IV criteria autism",
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    " DSM IV criteria Asperger disorder",
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    " RELATED TOPICS",
    " </h1>",
    " <div id=\"relatedTopics\">",
    " <ul>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?15/20/15689?
    source=related_link\">",
    " Asperger disorder: Clinical features and diagnosis in children and
    adolescents",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/52/41801?
    source=related_link\">",
    " Asperger disorder: Management and prognosis in children and adolescents",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?4/1/4122?
    source=related_link\">",
    " Autism spectrum disorders in children and adolescents: Behavioral and
    educational interventions",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?15/54/16234?
    source=related_link\">",
    " Autism spectrum disorders in children and adolescents: Complementary and
    alternative therapies",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?0/54/872?
    source=related_link\">",
    " Autism spectrum disorders in children and adolescents: Overview of
    management",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?34/46/35562?
    source=related_link\">",
    " Autism spectrum disorders in children and adolescents: Pharmacologic
    interventions",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?38/3/38969?
    source=related_link\">",
    " Diagnosis of autism spectrum disorders",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_basics\" href=\"UTD.htm?37/37/38481?
    source=related_link\">",
    " Patient information: Autism (The Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?40/46/41699?
    source=related_link\">",
    " Patient information: Autism spectrum disorders (Beyond the Basics)",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?34/17/35097?
    source=related_link\">",
    " Surveillance and screening for autism spectrum disorders in primary care",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?4/37/4698?
    source=related_link\">",
    " Terminology, epidemiology, and pathogenesis of autism spectrum disorders",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " </div>"].join("\n");
    var title_f0_41_665="Stiff-person syndrome";
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    " <div id=\"topicContent\">",
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    " Stiff-person syndrome",
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    " <div id=\"topicContributors\">",
    " <div>",
    " <a id=\"authors\">",
    " </a>",
    " <a class=\"contributor contributor_credentials contributorType\"
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    " Author",
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    0/41/665/contributors\">",
    " Simon M Helfgott, MD",
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    " <br/>",
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    " Ira N Targoff, MD",
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    0/41/665/contributors\">",
    " Jeremy M Shefner, MD, PhD",
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    " Deputy Editor",
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    " Paul L Romain, MD",
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    " Jun 12, 2012.",
    " </div>",
    " <div id=\"topicText\">",
    " <p class=\"headingAnchor\" id=\"H1\">",
    " <span class=\"h1\">",
    " INTRODUCTION",
    " </span>",
    " &nbsp;&mdash;&nbsp;Stiff-person syndrome (SPS, formerly called stiff-man
    syndrome) is an uncommon disorder characterized by progressive muscle stiffness,
    rigidity, and spasm involving the axial muscles, resulting in severely impaired
    ambulation [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/1,2\">",
    " 1,2",
    " </a>",
    " ]. SPS is often associated with type 1 diabetes mellitus, which is a
    reflection of shared pathogenetic features.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H2\">",
    " <span class=\"h1\">",
    " PATHOGENESIS",
    " </span>",
    " &nbsp;&mdash;&nbsp;An autoimmune process was originally postulated to underlie
    SPS since the disorder often occurred in conjunction with a variety of autoimmune
    diseases. These include thyroiditis, vitiligo, pernicious anemia, and,
    particularly, type 1 diabetes mellitus [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/1,3-6\">",
    " 1,3-6",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Additional insight into an autoimmune mechanism was provided by the
    observation of polyclonal and oligoclonal IgG antibody elevations in the
    cerebrospinal fluid of the majority of patients with SPS [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/6,7\">",
    " 6,7",
    " </a>",
    " ]. These antibodies were found to target GABA-ergic (gamma amino butyric acid)
    neurons and their nerve terminals. The dominant antigen recognized by these
    antibodies is the GABA-synthesizing enzyme, glutamic acid decarboxylase (GAD) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/8\">",
    " 8",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Outside the central nervous system, a high concentration of anti-GAD
    antibodies also recognizes pancreatic beta cells; this may explain the link between
    SPS and type 1 diabetes [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/9\">",
    " 9",
    " </a>",
    " ]. (See",
    " <a class=\"local\" href=\"#H17\">",
    " 'Type 1 diabetes mellitus'",
    " </a>",
    " below and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/42/23210?
    source=see_link\">",
    " \"Pathogenesis of type 1 diabetes mellitus\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H3\">",
    " <span class=\"h2\">",
    " Anti-GAD antibodies",
    " </span>",
    " &nbsp;&mdash;&nbsp;Circulating anti-GAD antibodies are present in
    approximately 60 percent of patients with SPS [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/6,10\">",
    " 6,10",
    " </a>",
    " ]. These antibodies can be reliably detected using a commercially available
    radioimmunoassay [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/11,12\">",
    " 11,12",
    " </a>",
    " ]. The relevance of these antibodies to the pathogenesis of SPS is supported
    by the following observations:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Sera and cerebrospinal fluid from a patient with SPS, epilepsy, and type 1
    diabetes were incubated with a formaldehyde-fixed cat brain, which was subsequently
    stained using anti-human IgG antibodies [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/7\">",
    " 7",
    " </a>",
    " ]. The areas of brain that stained corresponded to the distribution of GABA-
    ergic terminals. In addition, the staining patterns were strikingly similar to the
    patterns produced by antibodies to GAD [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/13\">",
    " 13",
    " </a>",
    " ].",
    " </li>",
    " <li>",
    " The concentration of anti-GAD antibodies is increased in the cerebrospinal
    fluid compared with that in sera in patients with SPS [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/6\">",
    " 6",
    " </a>",
    " ].",
    " </li>",
    " <li>",
    " In an in vitro study, the incubation of crude rat cerebellar extracts with
    the sera from 21 of 25 SPS patients with anti-GAD antibodies reduced GABA
    production from these brain cells [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/10\">",
    " 10",
    " </a>",
    " ]. By comparison, monoclonal anti-GAD-antibody purified from patients with
    type 1 diabetes did not affect GABA production, suggesting that a specific epitope
    recognized by some, but not all, anti-GAD-antibodies mediates the inhibition of
    GAD.",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " One study of 18 patients with SPS demonstrated a marked intrathecal antibody
    response against neuronal GAD-65 epitopes, indicating a clonal B cell activation in
    the CNS [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/14\">",
    " 14",
    " </a>",
    " ]. These anti-GAD-65 (or anti GAD65) antibodies, when present in high titers
    and when confirmed by immunoblotting, are highly specific for SPS and appear to be
    pathophysiologically important with an ability to impair GABA synthesis [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/15\">",
    " 15",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H4\">",
    " <span class=\"h3\">",
    " Relationship between SPS and diabetes mellitus",
    " </span>",
    " &nbsp;&mdash;&nbsp;Autoantibodies to GAD are present in the sera of
    approximately 70 to 80 percent of new-onset type 1 diabetic patients and may be
    present long before the onset of clinical disease [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/16-18\">",
    " 16-18",
    " </a>",
    " ]. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/42/23210?
    source=see_link\">",
    " \"Pathogenesis of type 1 diabetes mellitus\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Despite the frequent occurrence of anti-GAD antibodies in patients with type 1
    diabetes, SPS is an extremely rare occurrence in these patients. This finding may
    be explained by the following observations:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " The titer of anti-GAD autoantibodies in those with SPS is far higher than
    that observed in patients with type 1 diabetes, occasionally differing by 100- to
    500-fold [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/19,20\">",
    " 19,20",
    " </a>",
    " ].",
    " </li>",
    " <li>",
    " As previously mentioned, sera from patients with SPS appear to recognize
    different GAD epitopes than those with IDDM. The sera from approximately 70 percent
    of patients with SPS and anti-GAD antibodies, but not from diabetics, recognize a
    linear NH2-terminal epitope residing within the first eight amino acids of GAD [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/19\">",
    " 19",
    " </a>",
    " ]. In addition, sera from patients with type 1 diabetes recognize
    conformational epitopes of GAD, whereas sera from those with SPS recognize a
    combination of linear and conformational epitopes [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/19\">",
    " 19",
    " </a>",
    " ].",
    " </li>",
    " <li>",
    " T-cells appear to respond to different epitopes as well. Two regions of the
    GAD molecule (amino acids 81 to 171, and 331 to 403) produced T-cell proliferative
    responses in six of eight patients with SPS but in only 1 of 17 with type 1
    diabetes [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/21\">",
    " 21",
    " </a>",
    " ]. Conversely, two different regions of GAD (161 to 243, and 473 to 555)
    provoked responses in 10 of 17 diabetics but in none of those with SPS.",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H5\">",
    " <span class=\"h2\">",
    " Genetics",
    " </span>",
    " &nbsp;&mdash;&nbsp;Since SPS appears to be an autoimmune disorder with links
    to type 1 diabetes, it is not surprising that the inheritance of certain HLA
    alleles, particularly those implicated in type 1 diabetes, may increase the risk of
    developing SPS. In one study of 18 patients with SPS, for example, 13 carried the
    DQB1*0201 allele (72 versus 38 percent for controls, p = 0.02) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/22\">",
    " 22",
    " </a>",
    " ]. In addition, other DQB1 alleles rarely found in type I diabetes (such as
    *0602 and sequence-related *06 alleles) were found at the same prevalence in
    patients with SPS and the control group. The last finding suggests that *06 alleles
    may be associated with a reduced prevalence of diabetes in patients with SPS.
    (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?22/42/23210?
    source=see_link\">",
    " \"Pathogenesis of type 1 diabetes mellitus\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H6\">",
    " <span class=\"h1\">",
    " SUBSETS OF SPS",
    " </span>",
    " &nbsp;&mdash;&nbsp;Based upon the presence or absence of specific antibodies,
    as well as other diseases, patients with SPS have been subdivided into the
    following three categories:",
    " </p>",
    " <p>",
    " <ul class=\"bulletCompact-block\">",
    " <li>",
    " Autoimmune variant",
    " </li>",
    " <li>",
    " Paraneoplastic variant",
    " </li>",
    " <li>",
    " Idiopathic variant.",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " There appear to be no clinical differences in the neurologic findings between
    those with or without autoantibodies [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/23\">",
    " 23",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H7\">",
    " <span class=\"h2\">",
    " Autoimmune variant",
    " </span>",
    " &nbsp;&mdash;&nbsp;The autoimmune variant group includes patients with anti-
    GAD, anti-islet-cell, and other organ-specific autoantibodies [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/24\">",
    " 24",
    " </a>",
    " ]. These patients frequently develop another autoimmune disease.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H8\">",
    " <span class=\"h2\">",
    " Paraneoplastic variant",
    " </span>",
    " &nbsp;&mdash;&nbsp;The paraneoplastic variant of SPS consists of patients with
    associated neoplasms and circulating non-organ-specific autoantibodies but without
    anti-GAD and anti-islet cell antibodies. In some patients with SPS and solid
    tumors, the presence of an antibody to a 128-kd protein has been detected [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/24,25\">",
    " 24,25",
    " </a>",
    " ]. The protein was subsequently identified as amphiphysin, a non-intrinsic
    membrane protein concentrated in nerve terminals; within these terminals, a pool of
    both GAD and amphiphysin is associated with the cytoplasmic surface of synaptic
    vesicles [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/26\">",
    " 26",
    " </a>",
    " ]. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?6/27/6583?
    source=see_link&amp;anchor=H6#H6\">",
    " \"Paraneoplastic syndromes affecting the spinal cord and dorsal root
    ganglia\", section on 'Stiff-person syndrome'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " The combination of SPS and paraneoplastic encephalopathy has also been seen in
    association with anti-amphiphysin antibodies [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/27,28\">",
    " 27,28",
    " </a>",
    " ]. Passive transfer of IgG from an affected patient reproduced clinical
    features in rats, further supporting a role for autoantibodies in the pathogenesis
    of this disorder [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/29\">",
    " 29",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Remission of neurologic symptoms has been noted following tumor excision and
    treatment with glucocorticoids [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/26,28,30\">",
    " 26,28,30",
    " </a>",
    " ]. This observation suggests that neurologic symptoms are due to functional
    rather than structural changes in the central nervous system.",
    " </p>",
    " <p>",
    " The role of anti-GAD",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " anti-amphiphysin autoantibodies in the pathogenesis of SPS in this setting is
    unclear. Superficially, the expression of GAD and amphiphysin on the cytoplasmic
    surface of plasma membranes would appear to preclude their interaction with
    autoantibodies. However, such autoantibodies may potentiate a functional impairment
    of GABA-ergic transmission by blocking membrane-associated GAD during the
    exocytosis of GABA [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/25,31\">",
    " 25,31",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H9\">",
    " <span class=\"h2\">",
    " Idiopathic variant",
    " </span>",
    " &nbsp;&mdash;&nbsp;The idiopathic variant is comprised of patients with SPS
    who do not have evidence of either autoantibody production or association with
    other clinically evident disease. This group constitutes approximately 35 percent
    of patients with SPS.",
    " </p>",
    " <p>",
    " The lack of autoantibody production in such a high percentage of patients
    suggests that humoral immunity does not play a role in the pathogenesis of SPS.
    However, this does not preclude a possible cellular mechanism of autoimmune disease
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/31\">",
    " 31",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H10\">",
    " <span class=\"h1\">",
    " CLINICAL CHARACTERISTICS",
    " </span>",
    " &nbsp;&mdash;&nbsp;Since SPS is rare and is not readily recognized, the true
    prevalence cannot be established. Over the past 25 years, approximately 150 cases
    have been reported in the medical literature [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/1\">",
    " 1",
    " </a>",
    " ]. Women appear to be affected more often than men; symptoms usually begin
    between the third and seventh decades of life. The onset of the disease in
    childhood is rare [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/32\">",
    " 32",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H11\">",
    " <span class=\"h2\">",
    " Symptoms and signs",
    " </span>",
    " &nbsp;&mdash;&nbsp;The clinical hallmark of SPS is an extreme degree of muscle
    stiffness and rigidity. The persistent nature of these symptoms may lead to fixed
    spinal deformities, such as a pronounced lumbar or cervical lordosis; this is
    thought to be due to the simultaneous contraction of opposing paraspinal muscle
    groups.",
    " </p>",
    " <p>",
    " The onset of stiffness and rigidity in the axial muscles, either lumbar or
    cervical, is insidious and generally progresses slowly over time to involve
    proximal limb muscles. There may be considerable pain in a symmetric fashion, and
    volitional movements become difficult. The characteristic stiff gait has been
    likened to that of &ldquo;Frankenstein's monster&rdquo; [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/7\">",
    " 7",
    " </a>",
    " ]. As truncal flexibility is lost, ambulation slows considerably; the patient
    may eventually require assistive devices to walk.",
    " </p>",
    " <p>",
    " Postural reflexes are overridden by stiffness so the patient may fall
    &ldquo;like a tin soldier,&rdquo; resulting in a high risk of fracture [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/33\">",
    " 33",
    " </a>",
    " ]. The prolonged lack of mobility and stiffness may also lead to ankylosis of
    lower extremity joints including the knees, ankles, and hips [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/34\">",
    " 34",
    " </a>",
    " ]. Activities of daily living, such as getting into or out of bed, arising
    from a chair, or dressing, are severely limited; some patients become bedridden.",
    " </p>",
    " <p>",
    " Superimposed, episodic muscle spasm precipitated by sudden movement, noise, or
    emotional upset is a sensitive and specific feature of SPS [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/35\">",
    " 35",
    " </a>",
    " ]. Spasms usually begin in the axial muscles and may spread to the
    extremities. They are painful and can generate sufficient force to fracture bone.
    The muscle spasm is generally easily visualized; the affected area has a tight,
    rock-hard appearance and a unique, board-like feel [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/36\">",
    " 36",
    " </a>",
    " ]. Palpation may provoke even more intense spasm.",
    " </p>",
    " <p>",
    " The head retraction reflex (HRR) is a vestigial withdrawal reflex of the face
    and is suppressed in healthy subjects. In one study, 17 of 28 SPS patients
    demonstrated a positive HRR, suggesting that the presence of this finding in the
    setting of a patient with unexplained stiffness and spasms might help to avoid the
    otherwise frequent misdiagnosis of a psychogenic motor disturbance [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/37\">",
    " 37",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Some patients have an associated seizure disorder; both focal and grand mal
    seizures have been described. In addition, the delay in establishing a diagnosis
    and the progressive clinical deterioration contribute to the development of
    depression in many patients [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/38-40\">",
    " 38-40",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " A patient with some features of SPS who was highly seropositive for glutamic
    acid decarboxylase (GAD65) autoantibody has been described who exhibited a
    supranuclear gaze palsy and parkinsonism-mimicking progressive supranuclear palsy
    (PSP) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/40\">",
    " 40",
    " </a>",
    " ]. Videonystagmography findings, a fatiguing pattern of saccade initiation
    with repetitive saccades, helped exclude a diagnosis of PSP, as did startle-induced
    spasms typical of SPS and prominent early upgaze palsy.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H12\">",
    " <span class=\"h3\">",
    " Neurologic dysfunction",
    " </span>",
    " &nbsp;&mdash;&nbsp;Paroxysmal autonomic dysfunction, characterized by
    transient hyperpyrexia, diaphoresis, tachypnea, tachycardia, pupillary dilatation,
    and arterial hypertension, has been described and may result in sudden death [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/41\">",
    " 41",
    " </a>",
    " ]. Some of these deaths have been attributed to respiratory problems,
    including sudden apnea with cyanosis, tachypnea, and respiratory arrest; these
    difficulties may result from diaphragmatic spasm, impaired respiratory function,
    and severe respiratory muscle rigidity [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/42,43\">",
    " 42,43",
    " </a>",
    " ]. Esophageal dysmotility and swallowing difficulties may lead to aspiration
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/44\">",
    " 44",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Other than the abnormal gait described earlier and hyperreflexia, the motor
    and sensory nerve examinations are usually normal.",
    " </p>",
    " <p>",
    " Specific phobia is a frequent non-motor symptom of SPS. In one study, 19 of 44
    patients (44.2 percent) developed task-specific phobia, that is, fear and avoidance
    of situations difficult to master owing to the motor symptoms of SPS (such as
    crossing streets) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/45\">",
    " 45",
    " </a>",
    " ]. Anxiousness may further exacerbate muscle stiffness or may trigger spasms.
    Anxiety and avoidance behavior may lead to a misdiagnosis of a phobic disorder [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/46\">",
    " 46",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H13\">",
    " <span class=\"h2\">",
    " Electromyographic studies",
    " </span>",
    " &nbsp;&mdash;&nbsp;Electromyographic (EMG) studies reveal continuous motor-
    unit activity which is typically decreased or abolished by intravenous",
    " <a class=\"drug drug_general\" href=\"UTD.htm?15/46/16105?source=see_link\">",
    " diazepam",
    " </a>",
    " , sleep, and local or general anesthesia [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/5\">",
    " 5",
    " </a>",
    " ]. There are no distinguishing electrophysiologic features between GAD
    antibody positive and negative patients [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/23\">",
    " 23",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " In one study that used simultaneous video electroencephalographic and a
    surface EMG recorder, the following features were described [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/47\">",
    " 47",
    " </a>",
    " ]:",
    " </p>",
    " <p>",
    " <ul class=\"bulletCompact-block\">",
    " <li>",
    " Continuous muscle activity that varied with waking and sleep states, passive
    and active movements, and medications",
    " </li>",
    " <li>",
    " Superimposed intermittent, generalized contractions while awake, which
    continued into drowsiness and interfered with the onset of sleep",
    " </li>",
    " <li>",
    " Abnormal co-contractions of antagonistic muscles",
    " </li>",
    " <li>",
    " A unique motor response, termed spasmodic reflex myoclonus, which was
    observed in all patients",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " The last response, spasmodic reflex myoclonus, was not observed in normal
    subjects or in patients with other disorders causing increased muscle tone. It
    consisted of a sequence of one to three synchronous myoclonic bursts, lasting 60 to
    70 milliseconds after median nerve stimulation, which was followed by a tonic
    decrescendo activity. The recruitment order of muscles along the neuroaxis in
    spasmodic reflex myoclonus suggested that it was generated in the spinal cord and
    was conveyed peripherally via propriospinal tracts. Spasmodic reflex myoclonus may
    serve not only as a diagnostic tool but also as a key to understanding some aspects
    of the pathophysiology of both spasms and stiffness in SPS.",
    " </p>",
    " <p>",
    " In patients with SPS, unexpected noises often trigger violent muscle jerks
    resulting in falls. The pattern of EMG-onset latency in these patients suggests
    that the audiogenic muscle jerks in SPS originate in the acoustic startle response
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/48\">",
    " 48",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H14\">",
    " <span class=\"h2\">",
    " Neuroradiology",
    " </span>",
    " &nbsp;&mdash;&nbsp;No specific neuroradiologic findings have been noted in SPS
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/23\">",
    " 23",
    " </a>",
    " ]. In one case, spinal T2-weighted magnetic resonance imaging revealed a
    hyperintense lesion in the cervical spine that corresponded with the clinical
    symptoms and signs [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/49\">",
    " 49",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H15\">",
    " <span class=\"h2\">",
    " Neuropathology",
    " </span>",
    " &nbsp;&mdash;&nbsp;Few detailed neuropathologic studies of patients with SPS
    have been reported [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/41\">",
    " 41",
    " </a>",
    " ]. Although no characteristic changes have been noted, brainstem and spinal
    cord perivascular lymphocytic inflammation has been described in cases of SPS with
    encephalomyelitis and rigidity. One such patient who died suddenly was found to
    have a lymphocytic perivascular infiltration in the brainstem, basal ganglia, and
    spinal cord.",
    " </p>",
    " <p>",
    " Necropsy in patients with cancer-associated SPS of brief duration has revealed
    only perivascular lymphocyte cuffs in the brain and spinal cord; by comparison, the
    loss of anterior horn neurons was observed only in long-standing cases [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/50\">",
    " 50",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H16\">",
    " <span class=\"h1\">",
    " CLINICAL ASSOCIATIONS",
    " </span>",
    " &nbsp;&mdash;&nbsp;A number of well-defined disorders appear to occur with
    increased frequency among those diagnosed with SPS.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H17\">",
    " <span class=\"h2\">",
    " Type 1 diabetes mellitus",
    " </span>",
    " &nbsp;&mdash;&nbsp;As previously mentioned, an association with type I
    diabetes is observed in approximately 25 percent of patients [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/6\">",
    " 6",
    " </a>",
    " ]. Type 1 diabetes may precede, coincide with, or follow the onset of SMS.
    Although some patients with type 1 diabetes develop periarticular stiffness, this
    symptom is easily distinguished from the more intense stiffness and board-like
    muscle hardening noted in SPS. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?12/15/12534?
    source=see_link\">",
    " \"Limited joint mobility in diabetes mellitus\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H18\">",
    " <span class=\"h2\">",
    " Myasthenia gravis and thymoma",
    " </span>",
    " &nbsp;&mdash;&nbsp;An association between thymoma, myasthenia gravis, and SPS
    has been noted [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/51,52\">",
    " 51,52",
    " </a>",
    " ]. Following thymectomy and three courses of intravenous immune globulin,
    symptoms of SPS resolved in one patient [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/52\">",
    " 52",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H19\">",
    " <span class=\"h2\">",
    " Other",
    " </span>",
    " &nbsp;&mdash;&nbsp;Thyroiditis, adrenal insufficiency, vitiligo, and
    pernicious anemia have been associated with SPS [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/3-5,10\">",
    " 3-5,10",
    " </a>",
    " ]. Two cases of Borrelia burgdorferi myelitis (Lyme disease) presenting with
    features of SPS have also been described [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/53,54\">",
    " 53,54",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20\">",
    " <span class=\"h1\">",
    " DIAGNOSIS",
    " </span>",
    " &nbsp;&mdash;&nbsp;Establishing the diagnosis of SPS requires a high index of
    suspicion. The following clinical features should be sought [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/5\">",
    " 5",
    " </a>",
    " ]:",
    " </p>",
    " <p>",
    " <ul class=\"bulletCompact-block\">",
    " <li>",
    " Prodrome of stiffness and rigidity in axial muscles",
    " </li>",
    " <li>",
    " Slow progression of stiffness resulting in impairment of ambulation",
    " </li>",
    " <li>",
    " Fixed deformity of the spine and pronounced lordosis",
    " </li>",
    " <li>",
    " Presence of superimposed episodic spasms that are precipitated by sudden
    movement, noise, or emotional upset",
    " </li>",
    " <li>",
    " Normal findings on motor and sensory nerve examinations",
    " </li>",
    " <li>",
    " Continuous motor-unit activity on EMG that is abolished by intravenous",
    " <a class=\"drug drug_general\" href=\"UTD.htm?15/46/16105?
    source=see_link\">",
    " diazepam",
    " </a>",
    " or a positive therapeutic response to oral diazepam",
    " </li>",
    " <li>",
    " Normal intellect",
    " </li>",
    " <li>",
    " Presence of either anti-glutamic acid decarboxylase antibodies (60 percent
    of patients) or anti-amphiphysin antibodies (&lt;5 percent of patients)",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " Muscle hardening to a board-like sensation is probably the most specific
    clinical observation that establishes the diagnosis. The absence of these spasms in
    an untreated patient should raise doubts about the diagnosis.",
    " </p>",
    " <p>",
    " The spinal deformity is another helpful clinical clue. Since most patients
    have a history of progressive functional decline, an early diagnosis (such as
    within the first year of symptoms) is unusual.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H21\">",
    " <span class=\"h1\">",
    " DIFFERENTIAL DIAGNOSIS",
    " </span>",
    " &nbsp;&mdash;&nbsp;Stiff-person syndrome must be distinguished from neurologic
    disorders characterized by motor overactivity, including neuromyotonia (Isaacs'
    syndrome), chronic tetany, tetanus, and startle disease [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/55,56\">",
    " 55,56",
    " </a>",
    " ]. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?36/27/37304?
    source=see_link&amp;anchor=H16#H16\">",
    " \"Paraneoplastic syndromes affecting peripheral nerve and muscle\", section
    on 'Paraneoplastic neuromyotonia'",
    " </a>",
    " .) EMG studies show continuous motor activity in the paraspinal muscles",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " lower limbs in patients with SPS but not in those with the other disorders.",
    " </p>",
    " <p>",
    " The spasms of the trunk and limbs seen in SPS can simulate the clinical
    findings in tetanus. The absence of trismus or facial spasms and the rapid response
    to",
    " <a class=\"drug drug_general\" href=\"UTD.htm?15/46/16105?source=see_link\">",
    " diazepam",
    " </a>",
    " described below distinguish SPS from true tetanospasms [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/55\">",
    " 55",
    " </a>",
    " ]. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?7/11/7353?
    source=see_link\">",
    " \"Tetanus\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Progressive encephalomyelitis with rigidity and myoclonus (PERM) may also
    resemble SPS; transient oculomotor disturbances are noted in these patients [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/57\">",
    " 57",
    " </a>",
    " ]. Continuous EMG activity at rest is a feature of PERM [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/58\">",
    " 58",
    " </a>",
    " ]. Some authors postulate that PERM and SPS may be part of a spectrum of
    encephalomyelopathies displaying autoimmunity against GABA-ergic neurons, since
    some patients with PERM are anti-GAD antibody positive. Overlapping features of
    PERM and stiff-person syndrome have also been noted in anti-GAD-negative patients
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/59,60\">",
    " 59,60",
    " </a>",
    " ]. One such patient had anti-Ri (antineuronal nuclear autoantibody type 2, or
    ANNA-2) antibodies present in her serum [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/59\">",
    " 59",
    " </a>",
    " ] and the other anti-glycine receptor antibodies [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/60\">",
    " 60",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H22\">",
    " <span class=\"h1\">",
    " TREATMENT",
    " </span>",
    " &nbsp;&mdash;&nbsp;The observation that",
    " <a class=\"drug drug_general\" href=\"UTD.htm?15/46/16105?source=see_link\">",
    " diazepam",
    " </a>",
    " was effective for SPS provided a major breakthrough in the management of this
    previously untreatable disorder [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/5,61,62\">",
    " 5,61,62",
    " </a>",
    " ]. Benzodiazepines are thought to modulate the levels and activity of GABA.",
    " </p>",
    " <p>",
    " Benzodiazepines are generally considered the optimal initial therapy for
    patients with SPS. There are no studies to guide the choice of initial drug. We
    generally begin with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?15/46/16105?source=see_link\">",
    " diazepam",
    " </a>",
    " at a dose of 20 to 60",
    " <span class=\"nowrap\">",
    " mg/day",
    " </span>",
    " (given in divided doses). Daily doses needed to control the disease can be as
    high as 200 to 300",
    " <span class=\"nowrap\">",
    " mg/day",
    " </span>",
    " in some patients.",
    " </p>",
    " <p>",
    " If there is an unsatisfactory response or toxicity to escalating doses of
    benzodiazepines, we either switch to",
    " <a class=\"drug drug_general\" href=\"UTD.htm?35/31/36342?source=see_link\">",
    " baclofen",
    " </a>",
    " , a GABA-modulating drug, as monotherapy or add baclofen to the
    benzodiazepine. Baclofen can be administered orally (20 mg two or three times
    daily) or via an intrathecal route. Complications of the procedure included spasm-
    induced rupture and dislocation of the intrathecal catheter [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/34,63\">",
    " 34,63",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " A number of other potential therapies have been tried anecdotally in SPS.
    These include the muscle relaxant",
    " <a class=\"drug drug_general\" href=\"UTD.htm?24/6/24677?source=see_link\">",
    " methocarbamol",
    " </a>",
    " given intravenously [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/64\">",
    " 64",
    " </a>",
    " ], botulinum toxin A (injected into the paraspinal muscles) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/65\">",
    " 65",
    " </a>",
    " ], sodium valproate [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/66\">",
    " 66",
    " </a>",
    " ], vigabatrin [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/67\">",
    " 67",
    " </a>",
    " ], and propofol [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/68\">",
    " 68",
    " </a>",
    " ]. The role of these agents is unclear.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H23\">",
    " <span class=\"h2\">",
    " Immunosuppressive therapy",
    " </span>",
    " &nbsp;&mdash;&nbsp;Immunosuppressive therapy should be considered in patients
    with severe disease unresponsive to benzodiazepines",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " <a class=\"drug drug_general\" href=\"UTD.htm?35/31/36342?source=see_link\">",
    " baclofen",
    " </a>",
    " or in those with life-threatening complications. Glucocorticoids, given orally
    or intravenously, have been effective in many cases [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/30,69\">",
    " 30,69",
    " </a>",
    " ]. We begin with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?37/43/38585?source=see_link\">",
    " prednisone",
    " </a>",
    " at 60",
    " <span class=\"nowrap\">",
    " mg/day,",
    " </span>",
    " which is subsequently tapered based upon patient response. However,
    significant toxicity, particularly hyperglycemia, may occur, given the association
    of type 1 diabetes with SPS [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/1\">",
    " 1",
    " </a>",
    " ].",
    " <a class=\"drug drug_general\" href=\"UTD.htm?38/3/38967?source=see_link\">",
    " Azathioprine",
    " </a>",
    " has been used as a steroid-sparing agent in some cases [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/33\">",
    " 33",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Patients not responsive to or unable to tolerate glucocorticoids may be
    treated with intravenous immune globulin (IVIG); this is administered at a dose of
    2",
    " <span class=\"nowrap\">",
    " g/kg",
    " </span>",
    " given over three to five days [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/70-72\">",
    " 70-72",
    " </a>",
    " ]. In one study, functional status improved markedly in three bedridden
    patients with previously refractory disease [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/70\">",
    " 70",
    " </a>",
    " ]. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?28/11/28857?
    source=see_link\">",
    " \"General principles in the use of immune globulin\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " The efficacy of IVIG has been confirmed in a crossover study comparing placebo
    with IVIG therapy [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/73\">",
    " 73",
    " </a>",
    " ]. Eleven of 16 patients who received immune globulin were able to walk more
    easily or without assistance, their frequency of falls decreased, and they were
    able to perform work-related or household tasks. The duration of the beneficial
    effects of IVIG varied from six weeks to one year. Anti-GAD65 antibody titers
    declined after therapy with IVIG but not after placebo administration.",
    " </p>",
    " <p>",
    " Patients with life-threatening respiratory decline have also been treated with
    plasmapheresis with variable results [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/74\">",
    " 74",
    " </a>",
    " ]. The short-term benefit along with the high cost of the procedure preclude
    its widespread use.",
    " </p>",
    " <p>",
    " B lymphocyte depletion and associated diminution of autoantibody levels may be
    beneficial in SPS. Benefit has been found in some case reports [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/75,76\">",
    " 75,76",
    " </a>",
    " ] but not in others [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/77,78\">",
    " 77,78",
    " </a>",
    " ]. In one report, a patient with disease that was refractory to other
    treatments had dramatic clinical improvement following infusion of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?40/12/41161?source=see_link\">",
    " rituximab",
    " </a>",
    " , a chimeric B cell depleting anti-CD20 monoclonal antibody [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/75\">",
    " 75",
    " </a>",
    " ]. Further study of this approach is needed.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H24\">",
    " <span class=\"h1\">",
    " PROGNOSIS",
    " </span>",
    " &nbsp;&mdash;&nbsp;The prognosis for patients with SPS is variable. Patients
    with more limited disease may continue to function normally for extended periods of
    time [",
    " <a class=\"abstract\" href=\"UTD.htm?0/41/665/abstract/1\">",
    " 1",
    " </a>",
    " ]. However, a functional decline is generally noted over time. The association
    of SPS with type 1 diabetes",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " malignancy requires that the clinician be vigilant for these diagnoses.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H22724262\">",
    " <span class=\"h1\">",
    " SUMMARY AND RECOMMENDATIONS",
    " </span>",
    " &nbsp;&mdash;&nbsp;Stiff-person syndrome (SPS) is an uncommon disorder
    characterized by progressive muscle stiffness, rigidity, and spasm involving the
    axial muscles, resulting in severely impaired ambulation. SPS is often associated
    with type 1 diabetes mellitus and, less often, with thyroiditis, vitiligo, and
    pernicious anemia. The prognosis for patients with SPS is variable. Patients with
    more limited disease may continue to function normally for extended periods, but a
    functional decline is generally noted over time. (See",
    " <a class=\"local\" href=\"#H1\">",
    " 'Introduction'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H2\">",
    " 'Pathogenesis'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H16\">",
    " 'Clinical associations'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H24\">",
    " 'Prognosis'",
    " </a>",
    " above.)",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Antibodies in the cerebrospinal fluid of the majority of patients with SPS
    target GABA-ergic (gamma amino butyric acid) neurons and their nerve terminals. The
    dominant antigen recognized by these antibodies is the GABA-synthesizing enzyme,
    glutamic acid decarboxylase (GAD). The antibodies may also recognize pancreatic
    beta cells, although the concentration of anti-GAD antibodies is increased in the
    cerebrospinal fluid compared with that in sera in patients with SPS. (See",
    " <a class=\"local\" href=\"#H2\">",
    " 'Pathogenesis'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H4\">",
    " 'Relationship between SPS and diabetes mellitus'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " SPS has been subdivided into three subsets based upon the presence or
    absence of autoantibodies and other medical disorders, although these subsets do
    not differ clinically. The autoimmune variant includes patients with anti-GAD,
    anti-islet-cell, and other organ-specific autoantibodies; these patients frequently
    develop another autoimmune disease. The paraneoplastic variant includes patients
    with associated neoplasms and circulating non-organ-specific autoantibodies, some
    of whom exhibit antibodies against amphiphysin, a membrane protein found in nerve
    terminals, but these patients lack anti-GAD and anti-islet cell antibodies. An
    idiopathic variant, including approximately 35 percent of patients with SPS, is
    comprised of patients without evidence of either autoantibodies or associated
    diseases. (See",
    " <a class=\"local\" href=\"#H6\">",
    " 'Subsets of SPS'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H7\">",
    " 'Autoimmune variant'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H8\">",
    " 'Paraneoplastic variant'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H9\">",
    " 'Idiopathic variant'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Symptoms usually begin between the third and seventh decades of life. Women
    appear to be affected more often than men. Signs and symptoms which are
    characteristic include a prodrome of stiffness and rigidity in axial muscles, slow
    progression of stiffness resulting in impairment of ambulation, fixed deformity of
    the spine and pronounced lordosis, and the presence of superimposed episodic spasms
    that are precipitated by sudden movement, noise, or emotional upset. Patients
    exhibit normal findings on motor and sensory nerve examinations, other than the
    abnormal gait and hyperreflexia, and exhibit normal intellect. (See",
    " <a class=\"local\" href=\"#H10\">",
    " 'Clinical characteristics'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H11\">",
    " 'Symptoms and signs'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H20\">",
    " 'Diagnosis'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Paroxysmal autonomic dysfunction has been described and may result in sudden
    death, possibly related to sudden apnea and respiratory arrest from diaphragmatic
    spasm, impaired respiratory function, and severe respiratory muscle rigidity.
    Esophageal dysmotility and swallowing difficulties may lead to aspiration. Specific
    phobias may occur, and anxiety may further exacerbate muscle stiffness or may
    trigger spasms. Anxiety and avoidance behavior may lead to a misdiagnosis of a
    phobic disorder. (See",
    " <a class=\"local\" href=\"#H11\">",
    " 'Symptoms and signs'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H12\">",
    " 'Neurologic dysfunction'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Electromyographic (EMG) studies reveal continuous motor-unit activity which
    is typically decreased or abolished by intravenous",
    " <a class=\"drug drug_general\" href=\"UTD.htm?15/46/16105?
    source=see_link\">",
    " diazepam",
    " </a>",
    " , sleep, and local or general anesthesia. There are no distinguishing
    electrophysiologic features between GAD antibody positive and negative patients. No
    specific neuroradiologic findings have been noted in SPS. No characteristic
    neuropathologic changes have been noted. (See",
    " <a class=\"local\" href=\"#H13\">",
    " 'Electromyographic studies'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H14\">",
    " 'Neuroradiology'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H15\">",
    " 'Neuropathology'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " The diagnosis of SPS is based upon the presence of characteristic clinical
    features. Muscle hardening to a board-like sensation is probably the most specific
    clinical observation that establishes the diagnosis. The absence of these spasms in
    an untreated patient should raise doubts about the diagnosis. The spinal deformity
    is another helpful clinical clue. Since most patients have a history of progressive
    functional decline, an early diagnosis (such as within the first year of symptoms)
    is unusual. (See",
    " <a class=\"local\" href=\"#H20\">",
    " 'Diagnosis'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Stiff-person syndrome must be distinguished from neurologic disorders
    characterized by motor overactivity, including neuromyotonia (Isaacs' syndrome),
    chronic tetany, tetanus, and startle disease. EMG studies show continuous motor
    activity in the paraspinal muscles",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " the lower limbs in patients with SPS but not in those with the other
    disorders. Other considerations in the differential diagnosis include tetanus and
    progressive encephalomyelitis with rigidity and myoclonus. (See",
    " <a class=\"local\" href=\"#H21\">",
    " 'Differential diagnosis'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Benzodiazepines are generally considered the optimal initial therapy for
    patients with SPS. If there is an unsatisfactory response or toxicity to escalating
    doses of benzodiazepines, we either switch to",
    " <a class=\"drug drug_general\" href=\"UTD.htm?35/31/36342?
    source=see_link\">",
    " baclofen",
    " </a>",
    " , a GABA-modulating drug, as monotherapy or add baclofen to the
    benzodiazepine. Immunosuppressive therapy (eg, glucocorticoids or intravenous
    immune globulin) may be of benefit in patients with severe disease unresponsive to
    benzodiazepines",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " baclofen or in those with life-threatening complications. Results of B cell
    depletion have been mixed. (See",
    " <a class=\"local\" href=\"#H22\">",
    " 'Treatment'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H23\">",
    " 'Immunosuppressive therapy'",
    " </a>",
    " above.)",
    " </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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    " Roobol TH, Kazzaz BA, Vecht CJ. Segmental rigidity and spinal myoclonus as a
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    " Nicholas AP, Chatterjee A, Arnold MM, et al. Stiff-persons' syndrome
    associated with thymoma and subsequent myasthenia gravis. Muscle Nerve 1997;
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    " Piccolo G, Martino G, Moglia A, et al. Autoimmune myastenia gravis with
    thymoma following the spontaneous remission of stiff-man syndrome. Ital J Neurol
    Sci 1990; 11:177.",
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    " Martin R, Meinck HM, Schulte-Mattler W, et al. Borrelia burgdorferi myelitis
    presenting as a partial stiff man syndrome. J Neurol 1990; 237:51.",
    " </a>",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/41/665/abstract/54\">",
    " Requena I, Arias M, Pardo J, et al. [Syndromes of continuous muscular
    activity: report of a central case (stiff-man) and a peripheral case
    (neuromyotonia) associated with neuroborreliosis]. Rev Neurol 1995; 23:129.",
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    " Andreadou E, Kattoulas E, Sfagos C, Vassilopoulos D. Stiff person syndrome:
    avoiding misdiagnosis. Neurol Sci 2007; 28:35.",
    " </a>",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/41/665/abstract/56\">",
    " Ryan SG, Sherman SL, Terry JC, et al. Startle disease, or hyperekplexia:
    response to clonazepam and assignment of the gene (STHE) to chromosome 5q by
    linkage analysis. Ann Neurol 1992; 31:663.",
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    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/41/665/abstract/57\">",
    " Meinck HM, Ricker K, H&uuml;lser PJ, et al. Stiff man syndrome: clinical and
    laboratory findings in eight patients. J Neurol 1994; 241:157.",
    " </a>",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/41/665/abstract/58\">",
    " Barker RA, Revesz T, Thom M, et al. Review of 23 patients affected by the
    stiff man syndrome: clinical subdivision into stiff trunk (man) syndrome, stiff
    limb syndrome, and progressive encephalomyelitis with rigidity. J Neurol Neurosurg
    Psychiatry 1998; 65:633.",
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    " McCabe DJ, Turner NC, Chao D, et al. Paraneoplastic \"stiff person
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    " Hutchinson M, Waters P, McHugh J, et al. Progressive encephalomyelitis,
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    " HOWARD FM Jr. A new and effective drug in the treatment of the stiff-man
    syndrome: preliminary report. Proc Staff Meet Mayo Clin 1963; 38:203.",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/41/665/abstract/62\">",
    " Cohen L. Stiff-man syndrome. Two patients treated with diazepam. JAMA 1966;
    195:222.",
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    " Silbert PL, Matsumoto JY, McManis PG, et al. Intrathecal baclofen therapy in
    stiff-man syndrome: a double-blind, placebo-controlled trial. Neurology 1995;
    45:1893.",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/41/665/abstract/64\">",
    " Voci JM, al-Hakim M, Dokko Y, Katirji MB. Intravenous methocarbamol in the
    treatment of stiff-man syndrome. Muscle Nerve 1993; 16:434.",
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    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/41/665/abstract/65\">",
    " Liguori R, Cordivari C, Lugaresi E, Montagna P. Botulinum toxin A improves
    muscle spasms and rigidity in stiff-person syndrome. Mov Disord 1997; 12:1060.",
    " </a>",
    " </li>",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/41/665/abstract/66\">",
    " Spehlmann R, Norcross K, Rasmus SC, Schlageter NL. Improvement of stiff-man
    syndrome with sodium valproate. Neurology 1981; 31:1162.",
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    " Prevett MC, Brown P, Duncan JS. Improvement of stiff-man syndrome with
    vigabatrin. Neurology 1997; 48:1133.",
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    " Hattan E, Angle MR, Chalk C. Unexpected benefit of propofol in stiff-person
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    " Piccolo G, Cosi V, Zandrini C, Moglia A. Steroid-responsive and dependent
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    " Karlson EW, Sudarsky L, Ruderman E, et al. Treatment of stiff-man syndrome
    with intravenous immune globulin. Arthritis Rheum 1994; 37:915.",
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    " Barker RA, Marsden CD. Successful treatment of stiff man syndrome with
    intravenous immunoglobulin. J Neurol Neurosurg Psychiatry 1997; 62:426.",
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    " Khanlou H, Eiger G. Long-term remission of refractory stiff-man syndrome
    after treatment with intravenous immunoglobulin. Mayo Clin Proc 1999; 74:1231.",
    " </a>",
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    " Dalakas MC, Fujii M, Li M, et al. High-dose intravenous immune globulin for
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    " Brashear HR, Phillips LH 2nd. Autoantibodies to GABAergic neurons and
    response to plasmapheresis in stiff-man syndrome. Neurology 1991; 41:1588.",
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    " Baker MR, Das M, Isaacs J, et al. Treatment of stiff person syndrome with
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    " Dupond JL, Essalmi L, Gil H, et al. Rituximab treatment of stiff-person
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/41/665/abstract/78\">",
    " Rizzi M, Knoth R, Hampe CS, et al. Long-lived plasma cells and memory B
    cells produce pathogenic anti-GAD65 autoantibodies in Stiff Person Syndrome. PLoS
    One 2010; 5:e10838.",
    " </a>",
    " </li>",
    " </ol>",
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    " <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=\"#H22724262\" 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\">",
    " PATHOGENESIS",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H3\">",
    " Anti-GAD antibodies",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H4\">",
    " - Relationship between SPS and diabetes mellitus",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H5\">",
    " Genetics",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H6\">",
    " SUBSETS OF SPS",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H7\">",
    " Autoimmune variant",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H8\">",
    " Paraneoplastic variant",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H9\">",
    " Idiopathic variant",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H10\">",
    " CLINICAL CHARACTERISTICS",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H11\">",
    " Symptoms and signs",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H12\">",
    " - Neurologic dysfunction",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H13\">",
    " Electromyographic studies",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H14\">",
    " Neuroradiology",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H15\">",
    " Neuropathology",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H16\">",
    " CLINICAL ASSOCIATIONS",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H17\">",
    " Type 1 diabetes mellitus",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H18\">",
    " Myasthenia gravis and thymoma",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H19\">",
    " Other",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H20\">",
    " DIAGNOSIS",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H21\">",
    " DIFFERENTIAL DIAGNOSIS",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H22\">",
    " TREATMENT",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H23\">",
    " Immunosuppressive therapy",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H24\">",
    " PROGNOSIS",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H22724262\">",
    " SUMMARY AND RECOMMENDATIONS",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a href=\"#references\">",
    " REFERENCES",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " <h1>",
    " RELATED TOPICS",
    " </h1>",
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    " <div id=\"topicContent\">",
    " <div id=\"topicTitle\">",
    " Imaging studies after bariatric surgery",
    " </div>",
    " <div id=\"topicContributors\">",
    " <div>",
    " <a id=\"authors\">",
    " </a>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"./imaging-studies-after-bariatric-surgery/contributors\">",
    " Author",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"./imaging-studies-
    after-bariatric-surgery/contributors\">",
    " Marina Kurian, MD",
    " </a>",
    " <br/>",
    " </div>",
    " <div>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"./imaging-studies-after-bariatric-surgery/contributors\">",
    " Section Editor",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"./imaging-studies-
    after-bariatric-surgery/contributors\">",
    " Daniel Jones, MD",
    " </a>",
    " <br/>",
    " </div>",
    " <div>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"./imaging-studies-after-bariatric-surgery/contributors\">",
    " Deputy Editor",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"./imaging-studies-
    after-bariatric-surgery/contributors\">",
    " Rosemary B Duda, MD, MPH, FACS",
    " </a>",
    " <br/>",
    " </div>",
    " </div>",
    " <div id=\"disclosures\">",
    " <a href=\"./imaging-studies-after-bariatric-surgery/contributor-disclosure\"
    target=\"_blank\">",
    " Disclosures",
    " </a>",
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    " <div id=\"reviewProcess\">",
    " <span>",
    " All topics are updated as new evidence becomes available and our",
    " </span>",
    " <a href=\"/home/editorial-policy\" target=\"_blank\">",
    " peer review process",
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    " is complete.",
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    " <span class=\"emphasis\">",
    " Literature review current through:",
    " </span>",
    " Oct 2013.",
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    " This topic last updated:",
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    " Apr 10, 2013.",
    " </div>",
    " <div id=\"topicText\">",
    " <p class=\"headingAnchor\" id=\"H703842067\">",
    " <span class=\"h1\">",
    " INTRODUCTION",
    " </span>",
    " &nbsp;&mdash;&nbsp;Postoperative radiographic imaging studies following
    bariatric surgical procedures are typically obtained to identify the integrity and
    patency of anastomoses and to identify postoperative complications (eg, anastomotic
    leaks) precisely and early [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/1\">",
    " 1",
    " </a>",
    " ]. In addition, for patients who have had a gastric banding procedure,
    radiographic images allow for evaluation of band position and the size of the
    gastric pouch.",
    " </p>",
    " <p>",
    " This topic review will present the normal and abnormal findings seen on
    radiologic evaluation after gastric banding, gastric bypass, sleeve gastrectomy,
    and biliopancreatic diversion. An overview of the various bariatric procedures and
    their complications and the role of endoscopic management of gastrointestinal
    complications of the most common bariatric surgical procedures are presented
    separately. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?32/31/33274?
    source=see_link\">",
    " \"Surgical management of severe obesity\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link\">",
    " \"Complications of bariatric surgery\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/52/28489?
    source=see_link\">",
    " \"Endoscopy in patients who have undergone bariatric surgery\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H703842074\">",
    " <span class=\"h1\">",
    " THE ROLE OF IMAGING AFTER BARIATRIC SURGERY",
    " </span>",
    " &nbsp;&mdash;&nbsp;The role of routine postoperative upper gastrointestinal
    (UGI) series after bariatric surgical procedures remains somewhat controversial [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/2-4\">",
    " 2-4",
    " </a>",
    " ]. Most bariatric surgeons obtain films on postoperative day one for patients
    who have had an operation that includes an anastomosis or stapling procedure, prior
    to starting patients on a diet. The advantage of performing a routine UGI series on
    all patients at this time is that if a leak is present, it can be addressed
    quickly. However, some surgeons prefer to perform postoperative imaging
    selectively, based upon the patient's clinical progress [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/4-6\">",
    " 4-6",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " When bariatric surgery patients present with complaints of heartburn, nausea
    or vomiting, abdominal pain, or weight loss failure, imaging studies should be
    obtained to ensure prompt diagnosis of infection, obstruction, ischemia, or
    mechanical or technical failures of an operation [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/7,8\">",
    " 7,8",
    " </a>",
    " ]. Radiologic examination of severely obese patients can be technically
    difficult because of patient size, resulting in suboptimal imaging [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/9\">",
    " 9",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Radiologic evaluation and endoscopy are complementary studies, and endoscopy
    is often necessary for diagnostic certainty in bariatric patients with
    postoperative complications [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/10\">",
    " 10",
    " </a>",
    " ]. Usually, imaging is performed first and then a decision about proceeding to
    endoscopy is made based upon the imaging findings and the patient&rsquo;s symptoms.
    (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/52/28489?
    source=see_link\">",
    " \"Endoscopy in patients who have undergone bariatric surgery\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H703842081\">",
    " <span class=\"h1\">",
    " GASTRIC BANDING",
    " </span>",
    " &nbsp;&mdash;&nbsp;Laparoscopic adjustable gastric banding (LAGB) is a purely
    restrictive procedure that compartmentalizes the upper stomach by placing a soft,
    adjustable silicone ring around the entrance to the stomach (",
    " <a class=\"graphic graphic_figure graphicRef60081 \" href=\"UTD.htm?
    21/54/22368\">",
    " figure 1",
    " </a>",
    " ). The gastric band is connected to an infusion port placed in the
    subcutaneous tissue. The band diameter and degree of gastric restriction can be
    adjusted via the port by withdrawing or injecting saline from the port. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?32/31/33274?
    source=see_link&amp;anchor=H22#H22\">",
    " \"Surgical management of severe obesity\", section on 'Laparoscopic
    adjustable gastric banding'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H796902923\">",
    " <span class=\"h2\">",
    " Normal postoperative findings after LAGB",
    " </span>",
    " &nbsp;&mdash;&nbsp;The band should be visible just below the gastroesophageal
    junction at a 45-degree angle toward the left shoulder with the medial aspect of
    the band juxtaposed to the left pedicle of the vertebra [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/11\">",
    " 11",
    " </a>",
    " ]. Normally, the band points to the 2 o&rsquo;clock and 8 o&rsquo;clock
    position on x-ray (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef75937 \" href=\"UTD.htm?
    25/19/25919\">",
    " image 1",
    " </a>",
    " ).",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H796902994\">",
    " <span class=\"h2\">",
    " Abnormalities on imaging after LAGB",
    " </span>",
    " &nbsp;&mdash;&nbsp;Most of the complications of LAGB are due to a band that is
    too tight, slips into the wrong position, or erodes through the stomach wall. A
    tight band can lead to symptoms of heartburn, nausea, vomiting, or abdominal pain.
    Another cause of abdominal pain and complications after LAGB is disconnected port
    tubing, which can migrate and lead to obstruction or compression of other organs.
    Rarely, acute abdominal pain is caused by erosion and perforation following
    placement of a gastric band. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H40#H40\">",
    " \"Complications of bariatric surgery\", section on 'Gastric banding'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " For patients who have complications after gastric banding, an abdominal x-ray
    with posteroanterior and oblique views and an esophagram with Gastrografin will
    provide the most useful diagnostic information [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/7\">",
    " 7",
    " </a>",
    " ]. These tests can detect band slippage, gastric prolapse, pouch dilation,
    esophageal dilation or spasm, or a hiatal hernia. A computed tomography (CT) scan
    may also be needed if the patient&rsquo;s symptoms do not seem to be related to the
    gastric band, or if a diagnosis is not made with plain films or esophagram.",
    " </p>",
    " <p>",
    " Endoscopy is also useful for detection of band erosion. Endoscopic findings
    after bariatric surgery are discussed elsewhere. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/52/28489?
    source=see_link&amp;anchor=H8#H8\">",
    " \"Endoscopy in patients who have undergone bariatric surgery\", section on
    'Laparoscopic adjustable gastric banding'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " The imaging findings for complications after LAGB are discussed below.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H168815156\">",
    " <span class=\"h3\">",
    " Band slippage and gastric prolapse",
    " </span>",
    " &nbsp;&mdash;&nbsp;Gastric prolapse is caused by band slippage and migration
    of the stomach above the band, which causes varying degrees of gastric obstruction
    associated with pain in the left upper quadrant, left chest, or back. Gastric
    prolapse can be identified on an abdominal x-ray by the axis of the band if it has
    shifted from the usual &ldquo;2 to 8 o'clock&rdquo; to a more horizontal &ldquo;10
    to 4 o'clock&rdquo; position (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef56993 \" href=\"UTD.htm?
    7/59/8127\">",
    " image 2",
    " </a>",
    " ). An esophagram will demonstrate the outline of the pouch with rugal folds
    above the band (",
    " <a class=\"graphic graphic_figure graphicRef81074 \" href=\"UTD.htm?
    12/24/12673\">",
    " figure 2",
    " </a>",
    " and",
    " <a class=\"graphic graphic_diagnosticimage graphicRef59420 \" href=\"UTD.htm?
    25/51/26420\">",
    " image 3",
    " </a>",
    " ).",
    " </p>",
    " <p>",
    " If a prolapse is identified and pain persists after the band is loosened,
    urgent surgical exploration to reposition, replace, or remove the band is
    indicated. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H44#H44\">",
    " \"Complications of bariatric surgery\", section on 'Band slippage and gastric
    prolapse'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20337807\">",
    " <span class=\"h3\">",
    " Pouch dilation",
    " </span>",
    " &nbsp;&mdash;&nbsp;In contrast to gastric prolapse, which is associated with
    gastric obstruction, pouch dilation is enlargement of the gastric pouch without
    obstruction and without any change in the angle of the band [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/11,12\">",
    " 11,12",
    " </a>",
    " ]. Pouch enlargement is caused by overinflation of the band or overeating. The
    diagnosis is made on UGI series (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef73273 \" href=\"UTD.htm?
    35/52/36687\">",
    " image 4",
    " </a>",
    " ).",
    " </p>",
    " <p>",
    " Pouch dilation will usually respond to nonoperative treatment with band
    deflation, a low calorie diet, and small portion sizes for four to six weeks. The
    band can then be reinflated incrementally. If this is unsuccessful and the pouch
    does not return to its original size, surgical removal or replacement is indicated
    [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/11\">",
    " 11",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20337824\">",
    " <span class=\"h3\">",
    " Esophageal dilation",
    " </span>",
    " &nbsp;&mdash;&nbsp;Esophageal dilation proximal to the band device
    or \"pseudoachalasia syndrome\" may develop when the band is too tight or with
    excessive amounts of food intake (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef52070 \" href=\"UTD.htm?
    19/31/19953\">",
    " image 5",
    " </a>",
    " ). Typically, patients with esophageal dilation present with food and saliva
    intolerance, reflux, and epigastric discomfort. Patients can also experience
    substernal chest pain. An esophagram usually identifies both esophageal and pouch
    dilation (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef73273 \" href=\"UTD.htm?
    35/52/36687\">",
    " image 4",
    " </a>",
    " ).",
    " </p>",
    " <p>",
    " The treatment for a tight band is to deflate the band and allow the esophagus
    or stomach to regain its tone. If loosening the band does not resolve the symptoms,
    band removal is required. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H47#H47\">",
    " \"Complications of bariatric surgery\", section on 'Esophageal dilatation'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/52/28489?
    source=see_link&amp;anchor=H24#H24\">",
    " \"Endoscopy in patients who have undergone bariatric surgery\", section on
    'Esophageal dilation'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20337841\">",
    " <span class=\"h3\">",
    " Esophageal spasm",
    " </span>",
    " &nbsp;&mdash;&nbsp;Esophageal spasm typically presents as severe or squeezing
    chest pain. Esophageal spasm can accompany esophagitis from reflux, when the band
    is too loose, or can reflect an underlying esophageal motility disorder [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/13\">",
    " 13",
    " </a>",
    " ]. Radiographic findings are variable in patients suspected of having
    esophageal spasms and may demonstrate severe nonperistaltic contractions, which may
    produce striking abnormalities in the",
    " <a class=\"drug drug_general\" href=\"UTD.htm?12/17/12564?source=see_link\">",
    " barium",
    " </a>",
    " column, termed \"rosary bead\" or \"corkscrew\" esophagus (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef69821 \" href=\"UTD.htm?
    26/30/27118\">",
    " image 6",
    " </a>",
    " and",
    " <a class=\"graphic graphic_diagnosticimage graphicRef81244 \" href=\"UTD.htm?
    13/46/14062\">",
    " image 7",
    " </a>",
    " ). However, esophageal spasm is difficult to capture on imaging and the
    diagnosis should be based upon associated clinical and manometric findings. The
    treatment of esophageal spasm is discussed elsewhere. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?12/50/13096?
    source=see_link&amp;anchor=H4#H4\">",
    " \"Diffuse esophageal spasm, nutcracker esophagus, and hypertensive lower
    esophageal sphincter\", section on 'Diffuse (or distal) esophageal spasm'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20337858\">",
    " <span class=\"h3\">",
    " Hiatus hernia",
    " </span>",
    " &nbsp;&mdash;&nbsp;Hiatus hernia refers to herniation of elements of the
    abdominal cavity through the",
    " <strong>",
    " </strong>",
    " esophageal hiatus of the diaphragm. This is often a pre-existing but
    unrecognized condition in patients undergoing bariatric surgery",
    " <strong>",
    " </strong>",
    " and can lead to ongoing intractable reflux necessitating reoperation or band
    removal",
    " <strong>",
    " </strong>",
    " (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef82446 \" href=\"UTD.htm?
    43/24/44431\">",
    " image 8",
    " </a>",
    " )",
    " <strong>",
    " </strong>",
    " [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/14\">",
    " 14",
    " </a>",
    " ]. The diagnosis of hiatus hernia is made with a combination of radiography,
    endoscopy, and esophageal manometry. This is discussed elsewhere.",
    " <strong>",
    " </strong>",
    " (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?7/22/7527?
    source=see_link&amp;anchor=H3#H3\">",
    " \"Hiatus hernia\", section on 'Types of hiatal hernia'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H40#H40\">",
    " \"Complications of bariatric surgery\", section on 'Gastric banding'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20337881\">",
    " <span class=\"h3\">",
    " Band erosion",
    " </span>",
    " &nbsp;&mdash;&nbsp;Band erosion through the wall of the stomach can be caused
    by an excessively tight band or injury to the gastric wall during placement (",
    " <a class=\"graphic graphic_figure graphicRef76700 \" href=\"UTD.htm?
    11/13/11472\">",
    " figure 3",
    " </a>",
    " and",
    " <a class=\"graphic graphic_picture graphicRef73420 \" href=\"UTD.htm?
    14/44/15047\">",
    " picture 1",
    " </a>",
    " and",
    " <a class=\"graphic graphic_diagnosticimage graphicRef82717 \" href=\"UTD.htm?
    36/48/37633\">",
    " image 9",
    " </a>",
    " ). Erosions typically present months after the initial surgery; however,
    erosions in the immediate postoperative period have been described [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/15,16\">",
    " 15,16",
    " </a>",
    " ]. Band erosion can cause epigastric pain, gastrointestinal bleeding, intra-
    abdominal abscesses,",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " port site infection [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/11\">",
    " 11",
    " </a>",
    " ]. An esophagram",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " an endoscopy will show evidence of gastric band erosion, which is not always
    visible on CT scan.",
    " </p>",
    " <p>",
    " Band erosion is managed with removal of the band and closure of the
    gastrotomy. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H43#H43\">",
    " \"Complications of bariatric surgery\", section on 'Band erosion'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/52/28489?
    source=see_link&amp;anchor=H20#H20\">",
    " \"Endoscopy in patients who have undergone bariatric surgery\", section on
    'Band erosion'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20337901\">",
    " <span class=\"h3\">",
    " Tubing migration or disconnection",
    " </span>",
    " &nbsp;&mdash;&nbsp;The tubing can disconnect from the port and cause abdominal
    pain by migrating and causing pressure. In such cases, a radiograph will show the
    tubing separated from the port. The abdominal quadrant where the end of the tubing
    lies often corresponds with the patient&rsquo;s pain. The tubing can also migrate
    and cause obstructive symptoms by wrapping around intra-abdominal organs, or around
    the base of the mesentery (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef77520 \" href=\"UTD.htm?
    24/37/25171\">",
    " image 10",
    " </a>",
    " and",
    " <a class=\"graphic graphic_diagnosticimage graphicRef56114 \" href=\"UTD.htm?
    25/52/26439\">",
    " image 11",
    " </a>",
    " and",
    " <a class=\"graphic graphic_diagnosticimage graphicRef57587 \" href=\"UTD.htm?
    14/52/15168\">",
    " image 12",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/17\">",
    " 17",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Disconnected or migrated tubing requires surgical repair. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H45#H45\">",
    " \"Complications of bariatric surgery\", section on 'Port malfunction'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20337911\">",
    " <span class=\"h3\">",
    " Perforation",
    " </span>",
    " &nbsp;&mdash;&nbsp;After gastric banding or a revision of gastric banding,
    severe abdominal pain should raise concern for a possible perforation, although
    this is extremely rare [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/18\">",
    " 18",
    " </a>",
    " ]. In such cases, an acute abdominal series shows leakage of contrast or free
    air (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef70228 \" href=\"UTD.htm?
    7/9/7313\">",
    " image 13",
    " </a>",
    " ). A CT should be obtained if the plain films do not confirm the clinically
    suspected diagnosis.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20337921\">",
    " <span class=\"h3\">",
    " Esophageal reflux",
    " </span>",
    " &nbsp;&mdash;&nbsp;Esophageal reflux can lead to esophagitis, esophageal
    erosions, and strictures, which, in turn, cause maladaptive eating patterns and
    failure of weight loss. In such cases, patients tend to eat softer foods that are
    easier to swallow but are more calorically dense. A limited UGI, which visualizes
    the esophagus and stomach but does not follow contrast into the small bowel, will
    show reflux of the contrast material into the esophagus and may show thickening of
    the esophageal folds, ulcerations, or strictures. However, radiography is not
    diagnostic because reflux can be provoked in normal patients as well. If esophageal
    reflux is suspected, endoscopy is generally indicated to confirm the diagnosis.
    (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?21/41/22168?
    source=see_link&amp;anchor=H13576252#H13576252\">",
    " \"Clinical manifestations and diagnosis of gastroesophageal reflux in
    adults\", section on 'Radiographic findings'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H6651457\">",
    " <span class=\"h1\">",
    " ROUX-EN-Y GASTRIC BYPASS",
    " </span>",
    " &nbsp;&mdash;&nbsp;The Roux-en-Y gastric bypass (RYGB) is characterized by a
    small (less than 30 mL) proximal gastric pouch divided and separated from the
    stomach remnant, with drainage of food to the rest of the gastrointestinal tract
    via a gastrojejunal anastomosis and a Roux-en-Y small bowel arrangement (",
    " <a class=\"graphic graphic_figure graphicRef70745 \" href=\"UTD.htm?
    5/15/5364\">",
    " figure 4",
    " </a>",
    " ). A RYGB procedure results in three &ldquo;limbs&rdquo;: the Roux limb, which
    is anastomosed to the stomach; the biliopancreatic (BP) limb, which is anastomosed
    to the Roux limb; and the common channel (CC), which continues to the terminal
    ileum and cecum [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/7\">",
    " 7",
    " </a>",
    " ]. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?32/31/33274?
    source=see_link&amp;anchor=H17#H17\">",
    " \"Surgical management of severe obesity\", section on 'Roux-en-Y gastric
    bypass'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H796903104\">",
    " <span class=\"h2\">",
    " Normal postoperative findings after RYGB",
    " </span>",
    " &nbsp;&mdash;&nbsp;A limited UGI series will demonstrate the pouch size, the
    gastrojejunal anastomosis, and the Roux limb diameter (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef57009 \" href=\"UTD.htm?
    41/3/42047\">",
    " image 14",
    " </a>",
    " ). The gastric pouch volume should be approximately 30 mL, which is similar to
    the size of a lower thoracic or lumbar vertebral body [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/8,9\">",
    " 8,9",
    " </a>",
    " ]. This comparison allows fast and reliable identification of a pouch that is
    too large or too small. The gastric pouch can extend towards the spleen on an UGI
    series and may be misdiagnosed as a leak. It is important to ensure that this
    region of the pouch empties on subsequent views to make this determination.",
    " </p>",
    " <p>",
    " Contrast medium in the jejunal limb should demonstrate normal mucosal folds
    and motility. The duodenum, the excluded stomach, and the distal anastomosis are
    difficult to visualize on the UGI series. It is not unusual for the Roux limb to be
    slightly dilated up to 3 cm post gastric bypass, presumably due to the division of
    the small bowel to create the Roux-en-Y. Narrowing of the gastrojejunostomy with
    delayed pouch emptying is usually a sign of normal postoperative edema [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/8\">",
    " 8",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " CT scan imaging after gastric bypass will identify the gastric pouch, the
    position of the Roux limb (antecolic antegastric, retrocolic antegastric, or
    retrocolic retrogastric), the size of the remnant stomach, and the position and
    size of the three limbs (Roux, BP, and CC) (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef68770 \" href=\"UTD.htm?
    41/31/42484\">",
    " image 15",
    " </a>",
    " ). The excluded stomach may contain a small amount of air, but should not be
    distended. The limbs, the native duodenum, and proximal jejunum should not be
    greater than 2.5 cm in diameter [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/9\">",
    " 9",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Most bariatric surgeons place the Roux limb medial to the BP limb. However,
    the position of the Roux limb and BP limb can be reversed depending upon the
    approach used by the surgeon to perform the gastric bypass. The operative note
    should be reviewed, if possible, to help interpret the imaging findings.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H851418758\">",
    " <span class=\"h2\">",
    " Abnormalities on imaging after RYGB",
    " </span>",
    " &nbsp;&mdash;&nbsp;Complications after RYGB include stenosis, marginal ulcer,
    gastrogastric fistula, obstruction, internal hernia, hiatal hernia, leak, Roux
    stasis syndrome, and pouch enlargement. For patients who present with problems
    after Roux-en-Y gastric bypass, the evaluation is guided by the patient&rsquo;s
    symptoms and timing of symptom presentation (eg, early postoperative period [within
    30 days after surgery] or later) [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/7\">",
    " 7",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Early complications, such as leaks, are usually identified on an UGI series.
    If a leak is suspected and the UGI is negative, a CT scan can be obtained. However,
    re-exploration may be necessary without definitive imaging if a leak is suspected
    clinically and the patient is too obese for the CT scanner or for adequate
    radiologic penetration on UGI. If an abscess or fluid collection is suspected, CT
    of the abdomen and pelvis will provide the most useful information.",
    " </li>",
    " <li>",
    " For later complications, such as obstruction, an abdominal x-ray and a CT of
    the abdomen and pelvis provide the most useful information. Upper endoscopy may
    also be necessary if indicated by imaging findings or if the imaging studies fail
    to provide a diagnosis. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H27#H27\">",
    " \"Complications of bariatric surgery\", section on 'Roux-en-Y gastric
    bypass'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/52/28489?
    source=see_link&amp;anchor=H6#H6\">",
    " \"Endoscopy in patients who have undergone bariatric surgery\", section on
    'Roux-en-Y gastric bypass'",
    " </a>",
    " .)",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " The imaging findings for complications after RYGB are discussed below.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20337937\">",
    " <span class=\"h3\">",
    " Gastrojejunal stenosis",
    " </span>",
    " &nbsp;&mdash;&nbsp;Gastrojejunal stenosis after RYGB will lead to postprandial
    epigastric pain and vomiting and can be diagnosed on a limited UGI series [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/9\">",
    " 9",
    " </a>",
    " ]. The stoma should be approximately 12 mm in diameter. Stenosis can also be
    identified by upper endoscopy (",
    " <a class=\"graphic graphic_picture graphicRef74282 \" href=\"UTD.htm?
    16/39/17008\">",
    " picture 2",
    " </a>",
    " ).",
    " </p>",
    " <p>",
    " The treatment of stenosis with balloon dilation is discussed elsewhere. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/52/28489?
    source=see_link&amp;anchor=H14#H14\">",
    " \"Endoscopy in patients who have undergone bariatric surgery\", section on
    'Stomal stenosis'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20337951\">",
    " <span class=\"h3\">",
    " Marginal ulcer",
    " </span>",
    " &nbsp;&mdash;&nbsp;A marginal ulcer can form on the jejunal side of the
    gastrojejunostomy after gastric bypass, causing pain, nausea, bleeding,",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " perforation. Marginal ulcers are difficult to detect on UGI or CT scans and
    the diagnosis is usually made on endoscopy (",
    " <a class=\"graphic graphic_picture graphicRef66371 \" href=\"UTD.htm?
    19/0/19458\">",
    " picture 3",
    " </a>",
    " ). Medical management is usually successful. Surgical revision is rarely
    needed, but may be necessary for persistent pain or recurrent bleeding, despite
    maximal medical management.",
    " </p>",
    " <p>",
    " If a marginal ulcer does not heal with medical management, a limited UGI
    should be obtained to detect a gastrogastric fistula, which can cause reflux and
    increased acid exposure for the gastrojejunostomy (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef73814 \" href=\"UTD.htm?
    24/50/25382\">",
    " image 16",
    " </a>",
    " ). (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H30#H30\">",
    " \"Complications of bariatric surgery\", section on 'Marginal ulcers'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?36/59/37817?
    source=see_link\">",
    " \"Indications and diagnostic tests for Helicobacter pylori infection\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20339057\">",
    " <span class=\"h3\">",
    " Gastrogastric fistula",
    " </span>",
    " &nbsp;&mdash;&nbsp;A gastrogastric fistula is a communication between the
    gastric pouch and the gastric remnant. This can lead to reflux, abdominal pain, and
    weight regain. A gastrogastric fistula can be identified on limited UGI series or
    CT scan. If suspected and not seen on UGI, an upper endoscopy can be performed to
    evaluate the gastric pouch and anastomosis (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef73814 \" href=\"UTD.htm?
    24/50/25382\">",
    " image 16",
    " </a>",
    " ).",
    " </p>",
    " <p>",
    " If gastrogastric fistula is present in a patient with poor weight loss or
    gradual weight regain, repair or closure by surgery or endoscopy is indicated.
    (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?25/47/26362?
    source=see_link&amp;anchor=H38#H38\">",
    " \"Medical management of patients after bariatric surgery\", section on
    'Weight loss'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20337966\">",
    " <span class=\"h3\">",
    " Obstruction",
    " </span>",
    " &nbsp;&mdash;&nbsp;Obstruction will cause nausea, vomiting, and pain.
    Occasionally, an obstruction of the biliopancreatic limb alone will result in
    bloating and hiccups rather than nausea and vomiting [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/9\">",
    " 9",
    " </a>",
    " ]. An obstruction can be due to adhesions, an intraluminal cause, such as a
    blood clot, or an internal hernia (discussed below) (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef50431 \" href=\"UTD.htm?
    7/43/7859\">",
    " image 17",
    " </a>",
    " and",
    " <a class=\"graphic graphic_diagnosticimage graphicRef75430 \" href=\"UTD.htm?
    0/24/390\">",
    " image 18",
    " </a>",
    " and",
    " <a class=\"graphic graphic_diagnosticimage graphicRef54902 \" href=\"UTD.htm?
    3/50/3877\">",
    " image 19",
    " </a>",
    " ). The level of the obstruction can be determined by whether the emesis is
    bilious or nonbilious. Bilious emesis implies an obstruction at the
    enteroenterostomy or in the common channel, while nonbilious emesis implies an
    obstruction in the Roux limb or at the enteroenterostomy.",
    " </p>",
    " <p>",
    " A CT of the abdomen is the most useful imaging study in patients with
    obstruction of the common channel and will show dilation proximal to the
    obstruction and dilation of the BP limb, gastric remnant, and the Roux limb.
    Obstruction of the Roux limb will show collapse of the CC and BP limbs with
    dilation of the Roux limb (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef52088 \" href=\"UTD.htm?
    37/10/38053\">",
    " image 20",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/7\">",
    " 7",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20337974\">",
    " <span class=\"h3\">",
    " Internal hernia",
    " </span>",
    " &nbsp;&mdash;&nbsp;An internal hernia is caused by a mesenteric defect
    (Petersen's defect), which is created when performing the Roux-en-Y procedure (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef75430 \" href=\"UTD.htm?
    0/24/390\">",
    " image 18",
    " </a>",
    " ). Closure of the mesenteric and Petersen's defects at the time of bypass
    reduces the incidence of bowel obstruction in the postoperative period [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/19,20\">",
    " 19,20",
    " </a>",
    " ]. However, the defects can recur with significant weight loss [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/19,21,22\">",
    " 19,21,22",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " An UGI series with small bowel follow-through or a CT scan can show clustering
    of the small bowel in the left upper quadrant, which is a sign of an internal
    hernia [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/23\">",
    " 23",
    " </a>",
    " ]. A CT scan of the abdomen will show evidence of an internal hernia, with a
    swirled appearance of the mesenteric vessels in the superior mesenteric artery
    region (&ldquo;mesenteric swirl sign&rdquo;) (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef69765 \" href=\"UTD.htm?
    43/32/44548\">",
    " image 21",
    " </a>",
    " and",
    " <a class=\"graphic graphic_diagnosticimage graphicRef76574 \" href=\"UTD.htm?
    40/30/41441\">",
    " image 22",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/24,25\">",
    " 24,25",
    " </a>",
    " ]. For pregnant patients who need to avoid radiation, an MRI can be obtained
    if an internal hernia is suspected (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef78706 \" href=\"UTD.htm?
    33/52/34625\">",
    " image 23",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/26\">",
    " 26",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " If a patient is suspected to have an internal hernia as the etiology of
    abdominal pain, urgent surgical exploration is indicated. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H33#H33\">",
    " \"Complications of bariatric surgery\", section on 'Internal hernias'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H772596999\">",
    " <span class=\"h3\">",
    " Hiatal hernia after RYGB",
    " </span>",
    " &nbsp;&mdash;&nbsp;Hiatus hernia is often a pre-existing but unrecognized
    condition in patients undergoing bariatric surgery and can cause intractable
    reflux, nausea, and abdominal pain (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef61777 \" href=\"UTD.htm?
    1/34/1569\">",
    " image 24",
    " </a>",
    " ). (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?7/22/7527?
    source=see_link&amp;anchor=H10#H10\">",
    " \"Hiatus hernia\", section on 'Treatment'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20337989\">",
    " <span class=\"h3\">",
    " Leak",
    " </span>",
    " &nbsp;&mdash;&nbsp;Abdominal pain and fever after a gastric bypass is a
    concern for a leak at either the gastrojejunostomy or the enteroenterostomy. An
    esophagram or UGI series will show extravasation of the contrast material (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef57699 \" href=\"UTD.htm?
    19/11/19635\">",
    " image 25",
    " </a>",
    " and",
    " <a class=\"graphic graphic_diagnosticimage graphicRef74948 \" href=\"UTD.htm?
    43/18/44334\">",
    " image 26",
    " </a>",
    " ). The clinical assessment of the patient is critical if there is any question
    about the radiographic image. If a leak is suspected clinically, emergent surgical
    exploration should be performed even if the imaging is negative, given the rapid
    progression to sepsis in the severely obese patient with comorbidities. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H21#H21\">",
    " \"Complications of bariatric surgery\", section on 'Leaks'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H1199440297\">",
    " <span class=\"h3\">",
    " Abscess",
    " </span>",
    " &nbsp;&mdash;&nbsp;CT scan plays a critical role in the evaluation of patients
    suspected of having an abscess or abdominal fluid collection [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/9\">",
    " 9",
    " </a>",
    " ]. It is prudent to obtain the CT scan on the interventional scanner so that
    percutaneously CT-guided aspiration or drainage of an abscess or fluid collection
    can be performed immediately if detected.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20338053\">",
    " <span class=\"h3\">",
    " Roux stasis syndrome",
    " </span>",
    " &nbsp;&mdash;&nbsp;The Roux stasis syndrome is due to a motility disorder of
    the Roux limb as a consequence of surgical separation from the natural small
    intestinal pacemaker in the duodenum. Roux stasis syndrome causes abdominal pain,
    vomiting, and early satiety. In most cases, this syndrome can be diagnosed by
    limited UGI series (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef82563 \" href=\"UTD.htm?
    3/22/3425\">",
    " image 27",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/27\">",
    " 27",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Most patients with Roux stasis syndrome can be managed in the same manner as
    those with chronic intestinal pseudo-obstruction. Some patients who have retained
    food predominantly in the gastric remnant require subtotal gastrectomy. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?32/50/33576?
    source=see_link&amp;anchor=H16#H16\">",
    " \"Treatment of delayed gastric emptying\", section on 'Roux-en-Y stasis
    syndrome'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?2/26/2474?
    source=see_link\">",
    " \"Chronic intestinal pseudo-obstruction\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20338062\">",
    " <span class=\"h3\">",
    " Pouch enlargement",
    " </span>",
    " &nbsp;&mdash;&nbsp;Technical failure of a gastric bypass is characterized by
    either gastric pouch enlargement or dilation of the gastrojejunostomy. Patients
    with pouch enlargement are able to eat \"normal\" portions and experience weight
    regain from their lack of restriction [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/28\">",
    " 28",
    " </a>",
    " ]. A limited UGI series will usually demonstrate the size of the gastric pouch
    and possibly the stomal diameter of the gastrojejunostomy. Endoscopy will also show
    a dilated gastrojejunostomy and can measure pouch size (",
    " <a class=\"graphic graphic_picture graphicRef81895 \" href=\"UTD.htm?
    5/49/5907\">",
    " picture 4",
    " </a>",
    " ). (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/52/28489?
    source=see_link&amp;anchor=H16#H16\">",
    " \"Endoscopy in patients who have undergone bariatric surgery\", section on
    'Stomal and/or pouch dilation'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H703842095\">",
    " <span class=\"h1\">",
    " SLEEVE GASTRECTOMY",
    " </span>",
    " &nbsp;&mdash;&nbsp;Sleeve gastrectomy (SG) is a partial gastrectomy in which
    the majority of the greater curvature of the stomach is removed and a tubular
    stomach is created (",
    " <a class=\"graphic graphic_figure graphicRef54612 \" href=\"UTD.htm?
    35/40/36480\">",
    " figure 5",
    " </a>",
    " ). (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?32/31/33274?
    source=see_link&amp;anchor=H23#H23\">",
    " \"Surgical management of severe obesity\", section on 'Sleeve gastrectomy'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H796903645\">",
    " <span class=\"h2\">",
    " Normal postoperative findings after SG",
    " </span>",
    " &nbsp;&mdash;&nbsp;The normal postoperative appearance of a SG is an upside
    down seven (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef82047 \" href=\"UTD.htm?
    43/40/44672\">",
    " image 28",
    " </a>",
    " ). Occasionally, spasm at the angularis will give the appearance of a
    stricture or of a dilated proximal sleeve.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H796903601\">",
    " <span class=\"h2\">",
    " Abnormalities on imaging after SG",
    " </span>",
    " &nbsp;&mdash;&nbsp;Complications after SG include hiatal hernia, angulation or
    stricture of the sleeve, dilated sleeve, dumbbell sleeve, leak, and mesenteric
    venous thrombosis. For patients who have complications following SG, a limited UGI
    series and endoscopy will usually identify the common underlying problems, such as
    dilation or stricture of the sleeve. A limited UGI series will demonstrate the
    reduction in gastric volume, the rate of emptying of the sleeve, evidence of spasm,
    or the presence of a leak. The imaging findings for these diagnoses are discussed
    below. Endoscopy findings are discussed elsewhere. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H48#H48\">",
    " \"Complications of bariatric surgery\", section on 'Sleeve gastrectomy'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/52/28489?
    source=see_link&amp;anchor=H9#H9\">",
    " \"Endoscopy in patients who have undergone bariatric surgery\", section on
    'Sleeve gastrectomy'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20339355\">",
    " <span class=\"h3\">",
    " Hiatal hernia after SG",
    " </span>",
    " &nbsp;&mdash;&nbsp;Hiatus hernia refers to herniation of elements of the
    abdominal cavity through the",
    " <strong>",
    " </strong>",
    " esophageal hiatus of the diaphragm. Hiatal hernias are significantly increased
    in morbidly obese patients and can cause intractable reflux, nausea, and abdominal
    pain (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef64853 \" href=\"UTD.htm?
    18/4/18496\">",
    " image 29",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/29,30\">",
    " 29,30",
    " </a>",
    " ]. The diagnosis of hiatus hernia is made with a combination of radiographic
    imaging, endoscopy, and esophageal manometry. An UGI will show the GE junction
    above the diaphragm. The diagnosis and treatment of hiatus hernia is discussed
    elsewhere. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?7/22/7527?
    source=see_link&amp;anchor=H10#H10\">",
    " \"Hiatus hernia\", section on 'Treatment'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20339394\">",
    " <span class=\"h3\">",
    " Stricture or stenosis of the SG",
    " </span>",
    " &nbsp;&mdash;&nbsp;A stricture, angulation, or corkscrew configuration of the
    sleeve can result in nausea, heartburn, vomiting, and chest pain or abdominal pain
    due to changes in the lower esophageal sphincter pressure (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef81485 \" href=\"UTD.htm?
    6/32/6658\">",
    " image 30",
    " </a>",
    " and",
    " <a class=\"graphic graphic_picture graphicRef50496 \" href=\"UTD.htm?
    7/19/7473\">",
    " picture 5",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/31-34\">",
    " 31-34",
    " </a>",
    " ]. This may occur soon after surgery or can appear weeks to months after the
    operation.",
    " </p>",
    " <p>",
    " The most common reasons for the development of narrowing or stenosis are over-
    sewing the staple line and using a bougie that is too small. A stricture may also
    occur adjacent to a leak. The gastroesophageal junction and the incisura angularis
    are the two most common areas where stenosis occurs, and this can be diagnosed by
    an UGI series, which will show kinking, tortuosity, or a long thinning or lack of
    progression of contrast.",
    " </p>",
    " <p>",
    " Management of stenosis primarily consists of endoscopic dilation. If the area
    of stenosis is too long, surgical intervention may be necessary with conversion to
    a gastric bypass, gastric stricturoplasty, or resection with gastrogastrostomy.
    (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H48#H48\">",
    " \"Complications of bariatric surgery\", section on 'Sleeve gastrectomy'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H318295461\">",
    " <span class=\"h3\">",
    " Dilated SG",
    " </span>",
    " &nbsp;&mdash;&nbsp;A dilated sleeve may lead to",
    " <strong>",
    " </strong>",
    " failure of weight loss or weight regain. This can best be assessed on limited
    UGI series (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef62104 \" href=\"UTD.htm?
    22/34/23073\">",
    " image 31",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/35\">",
    " 35",
    " </a>",
    " ]. A dilated sleeve can be corrected with a repeat gastric sleeve to reduce
    the gastric sleeve volume [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/36\">",
    " 36",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20339683\">",
    " <span class=\"h3\">",
    " Dumbbell SG",
    " </span>",
    " &nbsp;&mdash;&nbsp;A \"dumbbell sleeve&rdquo; is a wide, dilated fundus with a
    relatively narrow midstomach but without complete obstruction. This can cause
    nausea and vomiting after sleeve gastrectomy and can be identified on limited UGI
    series (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef77655 \" href=\"UTD.htm?
    15/50/16161\">",
    " image 32",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/37\">",
    " 37",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " This may require conversion to a gastric bypass or the fundus may need to be
    &ldquo;re-sleeved&rdquo;. It is crucial to ensure that the there is not a stricture
    at the angularis prior to proceeding with a &ldquo;re-sleeve&rdquo; of the
    fundus.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20339698\">",
    " <span class=\"h3\">",
    " Leak after SG",
    " </span>",
    " &nbsp;&mdash;&nbsp;Abdominal pain after SG may represent a leak (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef60609 \" href=\"UTD.htm?
    21/36/22081\">",
    " image 33",
    " </a>",
    " ). Most leaks are due to local factors at the site of the staple line, such as
    inadequate blood supply and oxygenation, which impede the healing process. Leaks
    can also be due to gastric-wall ischemia, a consequence of the heat generated by
    the electrocautery used during dissection of the greater curve. Although the blood
    supply to the stomach is robust, the gastroesophageal junction tends to be an area
    of decreased vascularity, and thus more prone to perforation and leaks. SG produces
    high intragastric pressure, which can also be a causative factor in a leak. High
    gastric pressures can affect the healing process and lengthen the amount of time
    for a leak to close.",
    " </p>",
    " <p>",
    " The best modality to identify a leak is an",
    " <span class=\"nowrap\">",
    " esophagram/limited",
    " </span>",
    " UGI series, although a CT scan of the upper abdomen with contrast may also
    demonstrate the leak. Abscess formation in the postoperative period is best
    diagnosed by a CT scan of the abdomen (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef70429 \" href=\"UTD.htm?
    0/53/853\">",
    " image 34",
    " </a>",
    " ).",
    " </p>",
    " <p>",
    " If a leak is diagnosed within a week after SG, reoperation with primary repair
    is the best option. If the leak is diagnosed later, drainage and stenting of the
    leak are options. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H48#H48\">",
    " \"Complications of bariatric surgery\", section on 'Sleeve gastrectomy'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20339428\">",
    " <span class=\"h3\">",
    " Mesenteric venous thrombosis",
    " </span>",
    " &nbsp;&mdash;&nbsp;Mesenteric venous thrombosis has been identified with
    increasing frequency in the sleeve gastrectomy patient, although it can also occur
    following other bariatric surgical procedures such as the gastric bypass procedure
    [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/38\">",
    " 38",
    " </a>",
    " ]. Mesenteric venous thrombosis is likely due to dehydration, which is more
    common after sleeve gastrectomy than with other bariatric procedures. Patients who
    have sleeve gastrectomies often have difficulty with nausea and have delayed
    gastric emptying, all of which contribute to less fluid intake and dehydration. The
    diagnosis of mesenteric venous thrombosis is made by a CT scan of the abdomen (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef70633 \" href=\"UTD.htm?
    21/5/21585\">",
    " image 35",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/38\">",
    " 38",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Standard initial treatment for acute mesenteric venous thrombosis includes",
    " <a class=\"drug drug_general\" href=\"UTD.htm?39/34/40489?source=see_link\">",
    " heparin",
    " </a>",
    " anticoagulation and resection of infarcted bowel. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?43/21/44377?
    source=see_link&amp;anchor=H25#H25\">",
    " \"Acute mesenteric ischemia\", section on 'Mesenteric venous thrombosis'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H703842102\">",
    " <span class=\"h1\">",
    " BILIOPANCREATIC DIVERSION (BPD) WITH OR WITHOUT DUODENAL SWITCH (DS)",
    " </span>",
    " &nbsp;&mdash;&nbsp;A",
    " <span class=\"nowrap\">",
    " BPD/DS",
    " </span>",
    " consists of a partial gastrectomy, which is essentially a sleeve gastrectomy
    (SG), along with a bypass procedure (gastroileostomy or duodenoileostomy) (",
    " <a class=\"graphic graphic_figure graphicRef67432 \" href=\"UTD.htm?
    18/53/19284\">",
    " figure 6",
    " </a>",
    " ). (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?32/31/33274?
    source=see_link&amp;anchor=H24#H24\">",
    " \"Surgical management of severe obesity\", section on 'Biliopancreatic
    diversion'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20339801\">",
    " <span class=\"h2\">",
    " Normal postoperative findings after BPD/DS",
    " </span>",
    " &nbsp;&mdash;&nbsp;A CT scan or UGI series in a",
    " <span class=\"nowrap\">",
    " BPD/DS",
    " </span>",
    " patient will demonstrate the SG, the gastroileostomy or duodenoileostomy, and
    the relationship of the alimentary limb to the biliopancreatic limb (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef50406 \" href=\"UTD.htm?
    8/12/8390\">",
    " image 36",
    " </a>",
    " ). The alimentary limb will contain the contrast, and the BP limb will be non-
    opacified until the distal anastomosis and the common channel.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20339816\">",
    " <span class=\"h2\">",
    " Abnormalities on imaging after BPD/DS",
    " </span>",
    " &nbsp;&mdash;&nbsp;Complications after",
    " <span class=\"nowrap\">",
    " BPD/DS",
    " </span>",
    " are due to either the SG or the gastroileostomy or duodenoileostomy portion of
    the procedure. For patients with complications following BPD, the evaluation is
    guided by the patient&rsquo;s symptoms and whether these arise in the early
    postoperative period (within 30 days after surgery) or later. Early complications
    such as leaks can generally be identified on an UGI series and CT of the abdomen
    and pelvis. For later complications, a CT of the abdomen and pelvis and an upper
    endoscopy are more likely to demonstrate the abnormality.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20339831\">",
    " <span class=\"h3\">",
    " Sleeve related complications",
    " </span>",
    " &nbsp;&mdash;&nbsp;The complications of the SG portion of the BPD are similar
    to those described following a SG alone, and the radiographic imaging findings are
    also similar (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef62104 \" href=\"UTD.htm?
    22/34/23073\">",
    " image 31",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/39\">",
    " 39",
    " </a>",
    " ]. However, because the SG in a DS is performed over a larger bougie, more
    contrast may be necessary to adequately distend the \"sleeved\" stomach for imaging
    (see",
    " <a class=\"local\" href=\"#H703842095\">",
    " 'Sleeve gastrectomy'",
    " </a>",
    " above).",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H318296174\">",
    " <span class=\"h3\">",
    " Bypass related complications",
    " </span>",
    " &nbsp;&mdash;&nbsp;The complications of the bypass portion of the BPD are
    similar to those described following gastric bypass, with similar radiographic
    imaging findings. Common complications of the BPD include strictures of the
    duodenoileostomy or the gastroileostomy, leaks, marginal ulcers, hiatal hernia,
    internal hernias, and obstruction (see",
    " <a class=\"local\" href=\"#H6651457\">",
    " 'Roux-en-Y gastric bypass'",
    " </a>",
    " above) [",
    " <a class=\"abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/40,41\">",
    " 40,41",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H703842109\">",
    " <span class=\"h1\">",
    " GASTRIC PLICATION",
    " </span>",
    " &nbsp;&mdash;&nbsp;Gastric plication involves folding or imbricating the
    stomach along the greater curvature after the greater curve vessels have been
    divided. The normal postprocedure appearance on UGI is similar to that of a SG,
    while the endoscopic appearance shows gastric folds created by the plication,
    similar to the endoscopic findings after gastric plication for reflux (",
    " <a class=\"graphic graphic_diagnosticimage graphicRef58843 \" href=\"UTD.htm?
    12/58/13231\">",
    " image 37",
    " </a>",
    " and",
    " <a class=\"graphic graphic_picture graphicRef66564 \" href=\"UTD.htm?
    25/50/26415\">",
    " picture 6",
    " </a>",
    " ). (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?25/5/25688?
    source=see_link\">",
    " \"Endoscopic therapy for gastroesophageal reflux disease: Sewing and full-
    thickness plication techniques\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H1455121249\">",
    " <span class=\"h1\">",
    " SUMMARY AND RECOMMENDATIONS",
    " </span>",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " For bariatric surgery patients who present with complaints of heartburn,
    nausea or vomiting, abdominal pain, or weight loss failure, radiographic imaging
    studies should be obtained to ensure prompt diagnosis of infection, obstruction,
    ischemia, or mechanical or technical failures of an operation. (See",
    " <a class=\"local\" href=\"#H703842067\">",
    " 'Introduction'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Radiologic evaluation and endoscopy are complementary studies and endoscopy
    is often necessary for diagnostic certainty in bariatric patients with
    postoperative complications. Usually, imaging is performed first and then a
    decision about proceeding to endoscopy is made based on the imaging findings and
    the patient&rsquo;s symptoms. (See",
    " <a class=\"local\" href=\"#H703842074\">",
    " 'The role of imaging after bariatric surgery'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " For patients who have complications after gastric banding, a plain abdominal
    radiograph with posteroanterior and oblique views and an esophagram with
    Gastrografin will provide the most useful diagnostic information. Most
    complications of gastric banding are due to a band that is too tight or gastric
    prolapse. (See",
    " <a class=\"local\" href=\"#H703842081\">",
    " 'Gastric banding'",
    " </a>",
    " above and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H40#H40\">",
    " \"Complications of bariatric surgery\", section on 'Gastric banding'",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " For patients who have complications after Roux-en-Y gastric bypass, the
    evaluation is guided by the patient&rsquo;s symptoms and whether these arise in the
    early postoperative period (within 30 days after surgery) or later. Early
    complications, such as leaks, can generally be identified on an upper
    gastrointestinal (UGI) series",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " computed tomography (CT) of the abdomen and pelvis. However, reexploration
    may be necessary without definitive imaging if a leak is suspected clinically and
    the patient is too large for the CT scanner or for adequate radiologic penetration
    on UGI. For later complications, such as obstruction, an abdominal x-ray and a CT
    of the abdomen and pelvis will provide the most useful information. Upper endoscopy
    may also be necessary if indicated by imaging findings or based on the
    patient&rsquo;s symptoms. (See",
    " <a class=\"local\" href=\"#H6651457\">",
    " 'Roux-en-Y gastric bypass'",
    " </a>",
    " above and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H27#H27\">",
    " \"Complications of bariatric surgery\", section on 'Roux-en-Y gastric
    bypass'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/52/28489?
    source=see_link&amp;anchor=H6#H6\">",
    " \"Endoscopy in patients who have undergone bariatric surgery\", section on
    'Roux-en-Y gastric bypass'",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " For patients who have complications following sleeve gastrectomy, a limited
    upper GI series and an endoscopy will usually identify the common underlying
    problems, such as dilation or stricture of the sleeve. (See",
    " <a class=\"local\" href=\"#H703842095\">",
    " 'Sleeve gastrectomy'",
    " </a>",
    " above and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H48#H48\">",
    " \"Complications of bariatric surgery\", section on 'Sleeve gastrectomy'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/52/28489?
    source=see_link&amp;anchor=H9#H9\">",
    " \"Endoscopy in patients who have undergone bariatric surgery\", section on
    'Sleeve gastrectomy'",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " A biliopancreatic diversion (BPD) with or without duodenal switch (DS)
    consists of a partial gastrectomy, which is essentially a sleeve gastrectomy (SG),
    along with a bypass procedure. Thus, the complications and diagnostic strategies
    are similar to those after SG and gastric bypass. (See",
    " <a class=\"local\" href=\"#H703842102\">",
    " 'Biliopancreatic diversion (BPD) with or without duodenal switch (DS)'",
    " </a>",
    " above and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=see_link&amp;anchor=H55#H55\">",
    " \"Complications of bariatric surgery\", section on 'Biliopancreatic
    diversion and duodenal switch'",
    " </a>",
    " .)",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H19083649\">",
    " <span class=\"h1\">",
    " ACKNOWLEDGMENT",
    " </span>",
    " &nbsp;&mdash;&nbsp;The editorial staff at UpToDate, Inc. would like to
    acknowledge Dr. Michael Macari, who contributed to an earlier version of this topic
    review",
    " </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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    " Hope WW, Sing RF, Chen AY, et al. Failure of mesenteric defect closure after
    Roux-en-Y gastric bypass. JSLS 2010; 14:213.",
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    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/22\">",
    " Schneider C, Cobb W, Scott J, et al. Rapid excess weight loss following
    laparoscopic gastric bypass leads to increased risk of internal hernia. Surg Endosc
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    " </a>",
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    surgery/abstract/23\">",
    " Carucci LR, Turner MA, Shaylor SD. Internal hernia following Roux-en-Y
    gastric bypass surgery for morbid obesity: evaluation of radiographic findings at
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    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/24\">",
    " Iannuccilli JD, Grand D, Murphy BL, et al. Sensitivity and specificity of
    eight CT signs in the preoperative diagnosis of internal mesenteric hernia
    following Roux-en-Y gastric bypass surgery. Clin Radiol 2009; 64:373.",
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    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/25\">",
    " Ahmed AR, Rickards G, Johnson J, et al. Radiological findings in symptomatic
    internal hernias after laparoscopic gastric bypass. Obes Surg 2009; 19:1530.",
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    " </li>",
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    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/26\">",
    " Rosenkrantz AB, Kurian M, Kim D. MRI appearance of internal hernia following
    Roux-en-Y gastric bypass surgery in the pregnant patient. Clin Radiol 2010;
    65:246.",
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    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/27\">",
    " Decker GA, DiBaise JK, Leighton JA, et al. Nausea, bloating and abdominal
    pain in the Roux-en-Y gastric bypass patient: more questions than answers. Obes
    Surg 2007; 17:1529.",
    " </a>",
    " </li>",
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    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/28\">",
    " Abu Dayyeh BK, Lautz DB, Thompson CC. Gastrojejunal stoma diameter predicts
    weight regain after Roux-en-Y gastric bypass. Clin Gastroenterol Hepatol 2011;
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    " </a>",
    " </li>",
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    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/29\">",
    " Soricelli E, Casella G, Rizzello M, et al. Initial experience with
    laparoscopic crural closure in the management of hiatal hernia in obese patients
    undergoing sleeve gastrectomy. Obes Surg 2010; 20:1149.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/30\">",
    " Gagner M, Deitel M, Kalberer TL, et al. The Second International Consensus
    Summit for Sleeve Gastrectomy, March 19-21, 2009. Surg Obes Relat Dis 2009;
    5:476.",
    " </a>",
    " </li>",
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    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/31\">",
    " Bellanger DE, Greenway FL. Laparoscopic sleeve gastrectomy, 529 cases
    without a leak: short-term results and technical considerations. Obes Surg 2011;
    21:146.",
    " </a>",
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    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/32\">",
    " Carter PR, LeBlanc KA, Hausmann MG, et al. Association between
    gastroesophageal reflux disease and laparoscopic sleeve gastrectomy. Surg Obes
    Relat Dis 2011; 7:569.",
    " </a>",
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    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/33\">",
    " Braghetto I, Lanzarini E, Korn O, et al. Manometric changes of the lower
    esophageal sphincter after sleeve gastrectomy in obese patients. Obes Surg 2010;
    20:357.",
    " </a>",
    " </li>",
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    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/34\">",
    " Zundel N, Hernandez JD, Galvao Neto M, Campos J. Strictures after
    laparoscopic sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech 2010; 20:154.",
    " </a>",
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    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/35\">",
    " Iannelli A, Schneck AS, Noel P, et al. Re-sleeve gastrectomy for failed
    laparoscopic sleeve gastrectomy: a feasibility study. Obes Surg 2011; 21:832.",
    " </a>",
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    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/36\">",
    " Gagner M, Rogula T. Laparoscopic reoperative sleeve gastrectomy for poor
    weight loss after biliopancreatic diversion with duodenal switch. Obes Surg 2003;
    13:649.",
    " </a>",
    " </li>",
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    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/37\">",
    " Keidar A, Appelbaum L, Schweiger C, et al. Dilated upper sleeve can be
    associated with severe postoperative gastroesophageal dysmotility and reflux. Obes
    Surg 2010; 20:140.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/38\">",
    " Bellanger DE, Hargroder AG, Greenway FL. Mesenteric venous thrombosis after
    laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2010; 6:109.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/39\">",
    " Flanagin BA, Mitchell MT, Thistlethwaite WA, Alverdy JC. Diagnosis and
    treatment of atypical presentations of hiatal hernia following bariatric surgery.
    Obes Surg 2010; 20:386.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/40\">",
    " Mitchell MT, Carabetta JM, Shah RN, et al. Duodenal switch gastric bypass
    surgery for morbid obesity: imaging of postsurgical anatomy and postoperative
    gastrointestinal complications. AJR Am J Roentgenol 2009; 193:1576.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"./imaging-studies-after-bariatric-
    surgery/abstract/41\">",
    " Buchwald H, Kellogg TA, Leslie DB, Ikramuddin S. Duodenal switch operative
    mortality and morbidity are not impacted by body mass index. Ann Surg 2008;
    248:541.",
    " </a>",
    " </li>",
    " </ol>",
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    " <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>",
    " <a class=\"sr_button\" href=\"#H1455121249\" id=\"summRecButton\">",
    " <span>",
    " SUMMARY &amp; RECOMMENDATIONS",
    " </span>",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H703842067\">",
    " INTRODUCTION",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H703842074\">",
    " THE ROLE OF IMAGING AFTER BARIATRIC SURGERY",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H703842081\">",
    " GASTRIC BANDING",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H796902923\">",
    " Normal postoperative findings after LAGB",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H796902994\">",
    " Abnormalities on imaging after LAGB",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H168815156\">",
    " - Band slippage and gastric prolapse",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20337807\">",
    " - Pouch dilation",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20337824\">",
    " - Esophageal dilation",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20337841\">",
    " - Esophageal spasm",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20337858\">",
    " - Hiatus hernia",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20337881\">",
    " - Band erosion",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20337901\">",
    " - Tubing migration or disconnection",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20337911\">",
    " - Perforation",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20337921\">",
    " - Esophageal reflux",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H6651457\">",
    " ROUX-EN-Y GASTRIC BYPASS",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H796903104\">",
    " Normal postoperative findings after RYGB",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H851418758\">",
    " Abnormalities on imaging after RYGB",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20337937\">",
    " - Gastrojejunal stenosis",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20337951\">",
    " - Marginal ulcer",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20339057\">",
    " - Gastrogastric fistula",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20337966\">",
    " - Obstruction",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20337974\">",
    " - Internal hernia",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H772596999\">",
    " - Hiatal hernia after RYGB",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20337989\">",
    " - Leak",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H1199440297\">",
    " - Abscess",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20338053\">",
    " - Roux stasis syndrome",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20338062\">",
    " - Pouch enlargement",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H703842095\">",
    " SLEEVE GASTRECTOMY",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H796903645\">",
    " Normal postoperative findings after SG",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H796903601\">",
    " Abnormalities on imaging after SG",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20339355\">",
    " - Hiatal hernia after SG",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20339394\">",
    " - Stricture or stenosis of the SG",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H318295461\">",
    " - Dilated SG",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20339683\">",
    " - Dumbbell SG",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20339698\">",
    " - Leak after SG",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20339428\">",
    " - Mesenteric venous thrombosis",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H703842102\">",
    " BILIOPANCREATIC DIVERSION (BPD) WITH OR WITHOUT DUODENAL SWITCH (DS)",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H20339801\">",
    " Normal postoperative findings after BPD/DS",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H20339816\">",
    " Abnormalities on imaging after BPD/DS",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H20339831\">",
    " - Sleeve related complications",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H318296174\">",
    " - Bypass related complications",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H703842109\">",
    " GASTRIC PLICATION",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H1455121249\">",
    " SUMMARY AND RECOMMENDATIONS",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H19083649\">",
    " ACKNOWLEDGMENT",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a href=\"#references\">",
    " REFERENCES",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " <h1>",
    " <div class=\"openRelatedGraphics\" id=\"SURG/14953\" rel=\"outline_link\">",
    " GRAPHICS",
    " <a class=\"graphics_icon\" href=\"#\" title=\"View All Related Graphics\">",
    " View All",
    " </a>",
    " </div>",
    " </h1>",
    " <div id=\"relatedGraphics\">",
    " <ul>",
    " <li class=\"plainItem\">",
    " <div class=\"openRelatedGraphics\" id=\"SURG/14953|DiagnosticImage\">",
    " <a href=\"#\" title=\"DIAGNOSTIC IMAGES\">",
    " DIAGNOSTIC IMAGES",
    " </a>",
    " </div>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?25/19/25919\"
    title=\"diagnostic image 1\">",
    " Normal postoperative esophagram after gastric banding",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?7/59/8127\"
    title=\"diagnostic image 2\">",
    " Band slippage and gastric prolapse after gastric banding",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?25/51/26420\"
    title=\"diagnostic image 3\">",
    " Gastric prolapse after gastric banding",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?35/52/36687\"
    title=\"diagnostic image 4\">",
    " Pouch dilation after gastric banding",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?19/31/19953\"
    title=\"diagnostic image 5\">",
    " Esophageal dilation after gastric banding",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?26/30/27118\"
    title=\"diagnostic image 6\">",
    " Diffuse esophageal spasm barium swallow",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?13/46/14062\"
    title=\"diagnostic image 7\">",
    " Corkscrew esophagus barium swallow",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?43/24/44431\"
    title=\"diagnostic image 8\">",
    " Hiatal hernia after gastric banding",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?36/48/37633\"
    title=\"diagnostic image 9\">",
    " Gastric erosion after gastric banding - Case 2",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?24/37/25171\"
    title=\"diagnostic image 10\">",
    " The tubing from gastric banding causing abdominal pain",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?25/52/26439\"
    title=\"diagnostic image 11\">",
    " Tube related complications after gastric banding",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?14/52/15168\"
    title=\"diagnostic image 12\">",
    " Gastric banding tubing around mesentery",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?7/9/7313\"
    title=\"diagnostic image 13\">",
    " Perforation after gastric banding",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?41/3/42047\"
    title=\"diagnostic image 14\">",
    " Normal postoperative UGI series after gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?41/31/42484\"
    title=\"diagnostic image 15\">",
    " Normal postoperative CT scan after gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?24/50/25382\"
    title=\"diagnostic image 16\">",
    " Gastrogastric fistula after gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?7/43/7859\"
    title=\"diagnostic image 17\">",
    " Obstructed Roux limb after gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?0/24/390\"
    title=\"diagnostic image 18\">",
    " CT scan of Petersens hernia after gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?3/50/3877\"
    title=\"diagnostic image 19\">",
    " Intraluminal obstruction after gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?37/10/38053\"
    title=\"diagnostic image 20\">",
    " Obstructed biliopancreatic limb after gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?43/32/44548\"
    title=\"diagnostic image 21\">",
    " CT scan of internal hernia after gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?40/30/41441\"
    title=\"diagnostic image 22\">",
    " Mesenteric swirl",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?33/52/34625\"
    title=\"diagnostic image 23\">",
    " MRI of internal hernia",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?1/34/1569\"
    title=\"diagnostic image 24\">",
    " Hiatal hernia after gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?19/11/19635\"
    title=\"diagnostic image 25\">",
    " Leak after Roux-en-Y gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?43/18/44334\"
    title=\"diagnostic image 26\">",
    " Leak after gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?3/22/3425\"
    title=\"diagnostic image 27\">",
    " Roux stasis syndrome after gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?43/40/44672\"
    title=\"diagnostic image 28\">",
    " Normal postoperative UGI series after sleeve gastrectomy",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?18/4/18496\"
    title=\"diagnostic image 29\">",
    " Hiatal hernia after gastric sleeve",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?6/32/6658\"
    title=\"diagnostic image 30\">",
    " Stenosis after gastric sleeve",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?22/34/23073\"
    title=\"diagnostic image 31\">",
    " Dilated sleeve gastrectomy",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?15/50/16161\"
    title=\"diagnostic image 32\">",
    " Unresected fundus after gastric sleeve",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?21/36/22081\"
    title=\"diagnostic image 33\">",
    " Leak and stricture after sleeve gastrectomy",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?0/53/853\"
    title=\"diagnostic image 34\">",
    " Abscess after sleeve gastrectomy",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?21/5/21585\"
    title=\"diagnostic image 35\">",
    " Mesenteric venous thrombosis",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?8/12/8390\"
    title=\"diagnostic image 36\">",
    " Normal CT scan of biliopancreatic diversion with duodenal switch",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_diagnosticimage\" href=\"UTD.htm?12/58/13231\"
    title=\"diagnostic image 37\">",
    " Normal postoperative UGI series after gastric plication",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <div class=\"openRelatedGraphics\" id=\"SURG/14953|FIG\">",
    " <a href=\"#\" title=\"FIGURES\">",
    " FIGURES",
    " </a>",
    " </div>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_figure\" href=\"UTD.htm?21/54/22368\"
    title=\"figure 1\">",
    " Adjustable gastric band",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_figure\" href=\"UTD.htm?12/24/12673\"
    title=\"figure 2\">",
    " Gastric prolapse",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_figure\" href=\"UTD.htm?11/13/11472\"
    title=\"figure 3\">",
    " Gastric erosion",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_figure\" href=\"UTD.htm?5/15/5364\" title=\"figure
    4\">",
    " Retrocolic Roux-en-Y gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_figure\" href=\"UTD.htm?35/40/36480\"
    title=\"figure 5\">",
    " Sleeve gastrectomy",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_figure\" href=\"UTD.htm?18/53/19284\"
    title=\"figure 6\">",
    " Biliopancreatic diversion",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <div class=\"openRelatedGraphics\" id=\"SURG/14953|PIC\">",
    " <a href=\"#\" title=\"PICTURES\">",
    " PICTURES",
    " </a>",
    " </div>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_picture\" href=\"UTD.htm?14/44/15047\"
    title=\"picture 1\">",
    " Gastric erosion after gastric banding - Case 1",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_picture\" href=\"UTD.htm?16/39/17008\"
    title=\"picture 2\">",
    " Stenosis after bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_picture\" href=\"UTD.htm?19/0/19458\"
    title=\"picture 3\">",
    " Ulcer after gastric bypass",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_picture\" href=\"UTD.htm?5/49/5907\"
    title=\"picture 4\">",
    " Dilated gastrojejunostomy",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_picture\" href=\"UTD.htm?7/19/7473\"
    title=\"picture 5\">",
    " Angulated sleeve gastrectomy",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_picture\" href=\"UTD.htm?25/50/26415\"
    title=\"picture 6\">",
    " Endoscopic image after gastric plication",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " <h1>",
    " RELATED TOPICS",
    " </h1>",
    " <div id=\"relatedTopics\">",
    " <ul>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?43/21/44377?
    source=related_link\">",
    " Acute mesenteric ischemia",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?2/26/2474?
    source=related_link\">",
    " Chronic intestinal pseudo-obstruction",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?21/41/22168?
    source=related_link\">",
    " Clinical manifestations and diagnosis of gastroesophageal reflux in adults",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?40/58/41898?
    source=related_link\">",
    " Complications of bariatric surgery",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?12/50/13096?
    source=related_link\">",
    " Diffuse esophageal spasm, nutcracker esophagus, and hypertensive lower
    esophageal sphincter",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?25/5/25688?
    source=related_link\">",
    " Endoscopic therapy for gastroesophageal reflux disease: Sewing and full-
    thickness plication techniques",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/52/28489?
    source=related_link\">",
    " Endoscopy in patients who have undergone bariatric surgery",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?7/22/7527?
    source=related_link\">",
    " Hiatus hernia",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?36/59/37817?
    source=related_link\">",
    " Indications and diagnostic tests for Helicobacter pylori infection",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?25/47/26362?
    source=related_link\">",
    " Medical management of patients after bariatric surgery",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?32/31/33274?
    source=related_link\">",
    " Surgical management of severe obesity",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?32/50/33576?
    source=related_link\">",
    " Treatment of delayed gastric emptying",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " </div>"].join("\n");
    var title_f0_41_667="Clinical questions";
    var content_f0_41_667=[" <div id=\"graphicsToolbar\">",
    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
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    " <div class=\"graphic\">",
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    " <div class=\"ttl\">",
    " Clinical questions in daily practice",
    " </div>",
    " <div class=\"cntnt\">",
    " <table cellspacing=\"0\">",
    " <tbody>",
    " <tr>",
    " <td>",
    " Is the finding abnormal?",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " What is the diagnosis?",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " How often does it occur?",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " What are the risk factors for the disease?",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " What is the pathogenesis?",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " What is the natural history?",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " How effective (and harmful) is treatment?",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " How effective (and harmful) are preventive interventions?",
    " </td>",
    " </tr>",
    " </tbody>",
    " </table>",
    " </div>",
    " <div class=\"lgnd\">",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_41_667=[""].join("\n");
    var outline_f0_41_667=null;
    var title_f0_41_668="Tobacco associated cancers";
    var content_f0_41_668=[" <div id=\"graphicsToolbar\">",
    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
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    " &reg;",
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    " Email",
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    " <div class=\"graphic\">",
    " <div class=\"figure\">",
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    " Cancers associated with smoking tobacco",
    " </div>",
    " <div class=\"cntnt\">",
    " <table cellspacing=\"0\" class=\"container\">",
    " <tbody>",
    " <tr>",
    " <td class=\"container\">",
    " <table cellspacing=\"0\">",
    " <tbody>",
    " <tr>",
    " <td class=\"subtitle1_single\">",
    " Causation proven",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Colorectal",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Head and neck cancers, including esophagus",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Kidney",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Liver",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Lower urinary tract, including renal pelvis, ureter, and bladder",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Lung",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Mesothelioma",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Myeloid leukemia",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Nasal cavity and paranasal sinuses",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Pancreas",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Penis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Stomach",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Uterine cervix",
    " </td>",
    " </tr>",
    " </tbody>",
    " </table>",
    " </td>",
    " <td class=\"container\">",
    " <table cellspacing=\"0\">",
    " <tbody>",
    " <tr>",
    " <td class=\"subtitle1_single\">",
    " Evidence equivocal",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Breast",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Skin (including squamous cell carcinoma and basal cell carcinoma)",
    " </td>",
    " </tr>",
    " </tbody>",
    " </table>",
    " </td>",
    " </tr>",
    " </tbody>",
    " </table>",
    " </div>",
    " <div class=\"lgnd\">",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Adapted from: Vineis P, et al. Tobacco and cancer: recent epidemiological
    evidence. J Natl Cancer Inst 2004; 96:99.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_41_668=[""].join("\n");
    var outline_f0_41_668=null;
    var title_f0_41_669="Complications IV opioid use";
    var content_f0_41_669=[" <div id=\"graphicsToolbar\">",
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    " &copy;2013 UpToDate",
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    " &reg;",
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    title=\"Print this page\"/>",
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    " Email",
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    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\">",
    " <div class=\"ttl\">",
    " Complications of intravenous opioid use",
    " </div>",
    " <div class=\"cntnt\">",
    " <table cellspacing=\"0\" class=\"container\">",
    " <tbody>",
    " <tr>",
    " <td class=\"container\">",
    " <table cellspacing=\"0\">",
    " <tbody>",
    " <tr>",
    " <td class=\"subtitle1_single\">",
    " Infectious",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Bacterial endocarditis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Tetanus",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Hepatitis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Tuberculosis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " HIV infection",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Mycotic aneurysms",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Skin abscesses",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Wound botulism",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Cellulitis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Septic arthritis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Osteomyelitis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"subtitle1_single\">",
    " Renal",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Nephropathy (heroin, morphine, pentazocine)",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Myoglobinuric renal failure",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"subtitle1_single\">",
    " Gastrointestinal",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Intestinal pseudo-obstruction (due to fecal impaction)",
    " </td>",
    " </tr>",
    " </tbody>",
    " </table>",
    " </td>",
    " <td class=\"container\">",
    " <table cellspacing=\"0\">",
    " <tbody>",
    " <tr>",
    " <td class=\"subtitle1_single\">",
    " Cardiovascular",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Bacterial endocarditis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Venous thrombosis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Talc and cornstarch emboli (lungs, liver, kidney, retina)",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"subtitle1_single\">",
    " Respiratory",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Septic pulmonary emboli",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Aspiration pneumonia",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Tuberculosis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Pneumothorax",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"subtitle1_single\">",
    " Neurologic",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Pseudoaneurysm",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Parkinsonian effects (MPTP)",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Transverse myelitis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"subtitle1_single\">",
    " Musculoskeletal",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Septic arthritis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Polymyositis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Fibrous myopathy",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Osteomyelitis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Compartment syndrome",
    " </td>",
    " </tr>",
    " </tbody>",
    " </table>",
    " </td>",
    " </tr>",
    " </tbody>",
    " </table>",
    " </div>",
    " <div class=\"lgnd\">",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Adapted from Glick, CA, Evan, OB, Parks, BR. South Med J 1996; 889:1119.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
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    fTr2JjeMcPAynGxPUUUUUAf/9k=);\">",
    " </div>",
    " <div class=\"lgnd\">",
    " Approximately 30 percent of children have at least one episode of tympanostomy
    tube otorrhea, depicted above, while the tube remains in place. When otorrhea is
    refractory to thorough cleaning and suctioning of the tube and topical steroid-
    antibiotic drops, treatment is based on culture and sensitivity of organisms from
    the ear canal.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Reproduced with permission from: Isaacson G, Rosenfeld RM. Care of the child
    with tympanostomy tubes. A visual guide for the pediatrician. Pediatrics 1994;
    93:924. Copyright &copy; 1994 by the AAP.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_41_671=[""].join("\n");
    var outline_f0_41_671=null;

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