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Follicular hyperkeratosis and inammation is usually not seen and patients are usually without symptoms buy terramycin 250mg line virus in children. The clinical presentation is frequently similar to alope- cia areata (thus the term pseudo pelade terramycin 250 mg for sale antibiotics for uti sulfa, the French word for alopecia areata) however on close inspection the characteristic loss of follicular markings distinguishes the two types of hair loss cheap terramycin 250 mg with amex antimicrobial insulation. The literature on hot-comb alopecia describes hair loss primarily in middle-aged black women 250 mg terramycin otc antibiotics for acne permanent, and suggests that specic haircare practices are associated with this disorder (37,39). As the name suggests, this disorder typically starts at the crown and advances to the parietal scalp; the reason for the hair loss in this typical pattern remains unexplained (1). Patients may complain of itching or discomfort, or have no symptoms at all, but notice an enlarging area of alopecia over time (Fig. Some classify this disorder along with a heterogeneous group of related disorders (keratosis pilaris atrophicans faciei/ulerythema opryogenes, atrophoderma vermiculata, and folliculitis spinulosa decalvans) under the umbrella of keratosis pilaris atrophicans (43). Tufted folliculits is sometimes considered a localized vari- ant of follicultitis. Dissecting cellulitis may present as part of the so-called follicular occlusion triad that includes acne conglobata and hidradenitis suppurativa and is seen primarily in black men. The lesions typically start as small papules or pustules on the back of the neck but can progress to larger hypertrophic scars or keloid-like plaques; occasionally there are coexisting sinus tracks and pus. It has been postulated that mechan- ical irritation, injury during short haircuts, and inammation from impaction of short curved hair may trigger the problem. However it has recently been suggested that folliculitis keloidalis is a primary scarring alopecia based on the histopathologic appearance of early lesions (45). Erosive pustular dermatosis is a rare disorder in which patients are described as having a large, asymptomatic, boggy plaque on the scalp with supercial crusts and pustules. The lesions are seen most commonly in the elderly with extensive actinic or traumatic skin damage (46). Acne nectrotica is another rare, relapsing disorder seen in adults that is characterized by papulopustules in the frontal hair line and seborrheic areas that heal with hemorrhagic crusts and eventual punched-out varioliform scars (47). The biopsy should be taken from the active border of hair loss where some hairs still remain. A 4-mm punch biopsy is adequate and must include subcutane- ous fat to ensure sampling of the entire follicular unit and any anagen follicles. Routine staining with hematoxylin and eosin is recommended as a standard evaluation. Direct immunouorescence is of value in histopathologically inconclusive cases, with a high specicity and sensitivity for chronic cutaneous lupus erythematosus and a high specicity but low sensi- tivity for lichen planus (51). The North American Hair Research Society characteristic categorization is advocated as a provisional classication method. Typical histopathologic features seen in biopsy specimens of patients with lymphocytic and neutrophilic are listed in Table 2. With these common goals, patient and clinician can work together to determine the best treatment regimen and to evalu- ate its efcacy over time. The therapeutic strategy is generally based on (i) the degree of inam- matory inltrate on biopsy (sparse, moderate, dense), and (ii) clinical assessment of disease. The treatment guidelines listed below are not meant to be exhaustive, but instead reect the practices of the author. Lymphocytic Topical/intralesional therapy Topical anti-inammatory agents are considered the mainstay of treatment for lymphocytic scarring alopecia and can be used exclusively for limited disease, or for maintenance/remission. The vehicle chosen for the scalp varies, depending on the needs and hairstyles of the patients with topi- cal solution or foam preferred by many white patients and ointment or oil preferred by many blacks. Nonsteroid topical anti-inammatory cream or ointment (tacrolimus, pimecrolimus) can be compounded in a lotion to provide an alternative treatment. Tier 3 treatments are typically reserved for patients that have active disease and have failed Tiers 1 and 2. Injections are directed at the active border, where signs of inammation or a posi- tive anagen hair pull is present. Hydroxychloroquine has been used worldwide as an anti-malarial, but is also an established steroid-sparing antilymphocytic medication. Given its safety and low side-effect prole, hydroxychloroquine is considered to be the rst line systemic treatment for lymphocytic mediated alopecia. The usual starting dose is 200 mg twice daily, with the expecta- tion that the medication will start to take effect after 8 10 weeks, and will be continued for 6 12 months (48). As an al- ternative for patients who do not tolerate hydroxychloroquine, doxycycline or minocycline at doses of 50 100 mg daily can be used. Acitretin: Acitretin is considered a rst-line treatment for cutaneous lichen planus based on a blinded placebo-controlled study (54,55). Mycophenolate mofetil is an immunomodulating medication known to inhibit activated T cells. Given its effectiveness, tolerability, and safety prole, it has been advocated as the preferred second-line treatment for patients with persistent symptoms and hair loss after a 3 6 month trial of hydroxychloroquine (48). Supplemental topical antibiotics: mupirocin, clindamycin, isotretinion 146 Mirmirani as interferon-gamma responsible for macrophage activation (56). CsA is also known to cause hypertrichosis, which is likely mediated by hair keratinocyte differentiation as well as retarda- tion of catagen. Oral prednisone can be used to rapidly diminish the inammatory signs and symptoms, however given the side-effect prole, it is not considered for long-term use and is used only as a temporary or bridge treatment. Neutrophilic Recognizing the central role of Staphylococcus aureus, treatment regimens aimed at eradication of bacterial carriage have provided a signicant improvement of outcome. It must be noted how- ever, that repeat cultures may be needed to determine the offending bacteria, since the predomi- nant bacteria may change over time. Culture material is obtained from intact pustules, or from extracted hair bulbs or biopsy specimens. A regimen of clindamycin 300 mg twice daily and rifampin 300 mg twice daily for 10 weeks has been shown to be effective in inducing a sustained remission, although further courses may be needed (17,57). The addition of topical mupirocin to the nares for staphylococcal eradication or for longer duration of remission may be advisable. Topical clindamycin solution can be prescribed for ongoing treatment/prevention of recurrence. Other antistaphylococcal antibiotics such as erythromycin, cepahlosporins, trim- ethoprim sulfamethoxozole, or a uoroquinolone with or without concomitant rifampin are variably effective. Dramatic improvements in dissecting cellulitis have been reported with use of isotretinoin, especially if the disease is found in tandem with other features of the so-called follicular occlusion triad. Small starting doses with slow escalation to avoid ares are recom- mended, but with a goal of treatment dose of 1 mg/kg/day for at least 5 months although a longer treatment course may be required (48). If dissecting cellulitis is seen unaccompanied, or if there is a strong suppurative component with growth of S. If the predominant morphology is that of pustules crusting and sinus tracts then topical and/or oral antibiotics should be emphasized in the treatment regimen. Antibiotics are often combined with intralesional corticosteroids for treatment of concomitant inammatory papules or hypertrophic scars. Current surgical treatments consist of scalp aps, reduc- tion procedures with or without prior tissue expansion, and autologous hair transplantation; these procedures are often combined or done serially (58). Patients with traumatic types of alopecia are generally seen to be the most appropriate candidates for surgery since there is little likelihood for progression of hair loss. There are no studies to determine the optimal period of quiescence before undertak- ing surgery; some have advocated 6 9 months, while others have waited 3 years (58,59). Other limitations to surgical hair restoration include the lack of appropriate donor sites and atrophy of the recipient area.

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For this reason buy 250 mg terramycin fast delivery antibiotics sinus infection yeast infection, their pro- longed use is liable to give rise to preservative reactions terramycin 250mg online antibiotics for acne probiotics. Some patients with a severe dry eye problem might need to instill the drops every hour or even more frequently order terramycin 250 mg without a prescription 775 bacteria that triple every hour. Local steroids are widely used in the treatment of eye disease; systemic steroids are not used unless the sight of the eye is threatened purchase terramycin 250 mg otc antibiotics for acne long term effects. It must Ophtha], ketorolac [Acular] and urbiprofen be remembered that systemic steroids give the [Ocufen]) to reduce our dependence on topical patient a sense of well-being, which might give steroids. They have been shown to be of use in a false impression of the real benet obtained. Local steroids should also be applied with Anti-angiogenic Drugs caution, and it is a good rule always to have a specic reason for giving them. That is to say,they and the Eye should not be prescribed just to make red eyes turn white without a clear diagnosis. Inhibiting their growth offers us the hope of The most potent steroid in this respect is dexam- dramatically reducing the number of patients ethasone, followed by betamethasone, pred- going blind each year. It has been claimed angiogenic response is caused by elevated levels that rimexolone, clobetasone and uorometho- of a cytokine called vascular endothelial growth lone are relatively safe in this respect. Recently, a treatments are showing great promise in clini- number of cases of uveitis have been reported cal trials. An alternative mechanism of treat- in patients using bisphosphonates for the treat- ment is the destruction of preformed new ment and prevention of osteoporosis. Methyl alcohol is toxic to Damage to the Eyes by Drugs the ganglion cells of the retina and blindness is a hazard of meths drinkers. It sometimes con- Administered Systemically taminates crudely prepared alcoholic beverages leading to unexpected loss of vision. The list of There are a number of drugs, which if given drugs with ocular side effects is large and the in excessive doses, can lead to severe visual reader should consult a specialised textbook handicap and blindness. Chloroquine and indeed lawsuits should be avoidable if the drug hydroxychloroquine in excessive doses can lead literature is checked before prescribing an to pigmentary degeneration of the retina and unfamiliar drug. Some patients are referred becomes permanently blind, he or she might be by their general practitioners or social workers lost from the care of the ophthalmologist. A means that the ophthalmologist might not have special form is completed and copies go to the personal experience of the size of the problem patient, the general practitioner, the social serv- and might not be in a position to experience the ices department and the Ofce of Population relative incidences of different causes of blind- and Censuses. The keeping of accurate statistics is of Certain guidelines are laid down when con- great importance, and in order to keep statis- sidering blind registration; the visual acuity tical records it is necessary to have a clear should be less than 3/60 in the worse eye but if denition of blindness. Many people who dread the eld of vision is constricted, the visual blindness imagine having no perception of light acuity might be better than this. Fortunately,this situation is uncom- vision is not bad enough for blind registration mon, but many people are severely debilitated but none the less have signicant visual handi- by visual loss. In these patients the binocular elderly where visual loss is often combined with vision should normally be worse than 6/18. Sensory deprivation is thus a Patients sometimes erroneously claim the major scourge at the present time; the problem benets of the partially sighted because they is undoubtedly going to be much worse as the have only one eye, even though the remaining proportion of elderly people increases. When the vision with one or both eyes is 6/18 or better, the patient is not usually considered to be partially sighted. In actual fact, the amount of refers to persons who are so blind as to be incapacity depends a great deal on the age of the unable to perform any work for which eyesight patient. When a patient s vision falls below to being one-eyed, even to the extent of being this level, registration as a blind person can be able to perform with skill at ball games. This is a voluntary process, which who become one-eyed nd difculty in judging allows the patient access to the social services distances or performing ne manual tasks. Double vision is a bar to driving, if it cannot be corrected by prisms in the glasses or the wearing of an eye patch. Of the male population,8% suffers from have parking concessions and a free National some form of congenital colour blindness. Disability living allowance Inheritance of this type of defect is sex-linked so can be available for blind people under the age of that unaffected female carriers pass the gene 65 years but for the over-65s, only those who are to 50% of their sons. Those seeking children for colour blindness is now widely these concessions should consult an expert in the practiced because of the occupational implica- eld. The Ishihara test is the simplest and the tions that run clubs, social centres and supply best test for congenital colour blindness. It It is an advantage to the child to be aware of any also supplies regular funds for research into the defect during the early years of schooling. In this instance, registration calls Incidence and Causes attention to the need for special educational of Blindness requirements. These can include a specialist resource teacher, low visual aids, and other In England and Wales, the prevalence of blind- special supplies and equipment. If necessary, ness in 1980 for children under ve years was special schooling might need to be considered. In the western world, blindness in children is largely because of inher- Standards of Vision for ited genetic disease and birth trauma. In adults Various Occupations aged 20 60 years, the major causes are diseases of the retina, including diabetic retinopathy and The standards for various occupations can vary optic atrophy. Over the age of 60 years, macular from year to year and are more or less exacting, degeneration, glaucoma and cataract are the depending on the occupation. This must extend at least 120 horizon- important cause in adults but in certain areas, tally and 20 above and below. The eld is for example southern Sudan, onchocerciasis measured by perimetry using a standard target. It is assumed that any healthy person applying It is apparent that the problems of blindness to drive has a normal eld of vision but if the in Europe and North America are different from driver has any eye condition that might lead to those in poorer parts of the world where much visual handicap, he or she must declare it. The could still be done by improving standards of driver and vehicle licensing centre might then nutrition and living conditions. Blindness 205 skin and even by means of implanted electrodes Aids for the Blind in the visual cortex. The most widely recognised aid and symbol of One important advance has been voice blindness is the white stick. Many current models most useful aids because it identies the patient have this facility, so that the user can hear as blind and encourages others to give assis- emails, and programmes are available to allow tance. In spite of these advances,the they appear ill-mannered when failing to recog- elderly visually handicapped patient can benet nise someone and are grateful for some indica- most from someone who is prepared to give the tion of their handicap. Some volun- Many different electronic devices have been tary local societies can provide this service. An ordinary hand mag- when moved across the page, can read out the nifying glass is the simplest and can often be the page. Many of these devices rely on adequate and the patient has been a keen reader, the patient s hearing to identify an audible a telescopic lens can be tted to a spectacle warning signal, but most blind people prefer to frame with advantage. These multi-lens systems use their undistracted sense of hearing as an are known as low visual aids and hence the important clue to their whereabouts. Apart from Dogs for the Blind Society and the patient must special telescopic lenses, closed-circuit televi- also take part in the training. Some young sion aids are now available: a small television people nd that a guide dog can expand their camera is held over the page and a magnied mobility to a great degree. This system of The well-being of a blind or partially sighted reading for the blind was introduced from person can be greatly enhanced by relatively France more than 100 years ago. Advice in the home the alphabet are represented by numbers of about the use of gas or electricity can be impor- raised dots on stiff paper. Blind children can tant and the patient can be made aware of the learn Braille rapidly and develop a high reading availability of local social clubs for the blind or speed. An elderly sufciently sensitive and this applies especially patient who plays the piano can be helped to diabetics.

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Some myopic patients are sus- result cheap terramycin 250 mg without a prescription infection 8 weeks after giving birth, and the rare but dreaded complication ceptible to degeneration of the retina in later of ocular perforating injuries sympathetic years; known as myopic chorioretinal degener- ophthalmia can now be treated effectively ation 250mg terramycin visa lafee virus, it can account for visual deterioration in with systemic steroids buy 250mg terramycin amex antibiotic cefuroxime. Amblyopia of disuse has myopes who have otherwise undergone suc- already been mentioned; the treatment is cessful cataract or retinal surgery generic terramycin 250mg without a prescription antibiotics for sinus infection safe for pregnancy. One must be careful here before dismissing the patient as untreat- Untreatable Causes of able because on rare occasions a contusion injury to the eye or orbit can result in a haem- Failing Vision orrhage into the sheath of the optic nerve. Some degree of visual recovery can sometimes occur Ophthalmologists are sometimes asked if the in these patients and it has been claimed that sight can be restored to a blind eye and, as a recovery might be helped by surgically opening general rule, one can say that if there is no per- the nerve sheath. There is one odd exception ception of light in the eye, it is unlikely that the to this dramatic form of blindness that can sight can be improved, irrespective of the cause. Patients with retrobulbar neuritis for which there is no known effective treatment (optic neuritis) nearly always recover their and it is sometimes important that the patient vision again, whether or not they receive treat- is made aware of this at an early stage in order ment. The explanation is that the visual loss is to avoid unnecessary anxiety, and perhaps caused by pressure from oedema rather than to unnecessary visits to the doctor. It is ative diseases of the retina fail to respond to hardly necessary to say that any neurological treatment. If the retina is out of place, it can be damage proximal to the optic nerve tends to replaced, but old retinae cannot be replaced produce permanent and untreatable visual with new. So far,there has been no rm evidence loss, as exemplied by the homonymous that any drug can alter the course of inherited haemianopic eld defect that can follow a retinal degenerations, such as retinitis pigmen- cerebrovascular accident. Age-related macular degen- but in fact serious attempts are now being made eration tends to run a progressive course in to treat them with radiotherapy in specialised spite of any attempts at treatment, and although units and the prognosis appears to be improv- most patients do not become completely blind, ing in some cases. The time of day could be important: raised begin with the realisation that more or less intracranial pressure has the reputation of everyone suffers from headache at some time or causing an early morning headache, which is other. In fact, the majority of headaches that described as bursting or throbbing and can be present have no detectable cause and are often made worse by straining or coughing. We must labelled psychogenic if there seems to be a back- always remember the triad of headache, vomit- ground of stress. The implication is that the suf- ing and papilloedema in this respect, especially ferer is perhaps exaggerating mild symptoms in as the vomiting might not be accompanied order to gain sympathy from his or her spouse, by nausea, and is not necessarily mentioned or even perhaps the doctor. The family history should also be extremely cautious about not accepting be noted, especially where there is a history symptoms at their face value, and certainly of migraine. If the psychogenic headache is the com- monest, then the headache caused by raised Classication intracranial pressure and a space-occupying lesion must be the most important. Between When considering the different common causes these two,the whole spectrum of causes must be of headache, an anatomical classication is a considered. The rise a permanent checklist in order that obvious following should be considered by the causes are not omitted. Cerebrospinal Fluid History A rise or fall from normal of the cerebrospinal Often the history is the total disease in the uid pressure is associated with headache. When the acutely raised, a severe headache may ensue, rise of intracranial pressure is caused by a accompanied by blurring of vision. Any adults space-occupying lesion, signs of focal brain with headaches should have their blood pres- damage can also be present. Another form of headache associated with abnormality of the blood Blood Vessels vessels is that caused by an intracranial aneurysm of the internal carotid artery or one A variety of diseases involving the blood vessels of its branches. The commonest is prob- throbbing in nature and there might be other ably migraine. Classical migraine is thought to signs of a space-occupying lesion at the apex of be caused by an initial spasm followed by dilata- the orbit, for example a cranial nerve palsy or a tion of the meningeal arteries. In the case of a family history of the same problem showing elderly patients, the possibility of giant cell dominant inheritance, and attacks can some- arteritis must always be kept in mind. This is an times be precipitated by stress or taking certain inammation of the walls of many of the foods, such as cheese. Before the headache medium-sized arteries in the body, but it tends begins, there is usually a visual aura charac- to affect the temporal arteries preferentially. The that is centred above the eye and is described headache is made particularly bad by brushing as a boring pain. The headache lasts for any time the hair and other systemic symptoms include between 1 h and 24 h and then disperses. Migraine can begin quite early in childhood and continue at regular inter- vals for many years. Migraines are more common in women and tend to improve at the time of the menopause. The visual aura might appear by itself or the migraine attack might be accompanied by gastrointestinal symptoms or by ophthalmople- gia. The attack might be preceded by oliguria and uid retention and be followed by a diuresis. Cross-section of the temporal artery from patient the original diagnosis must be reviewed care- with temporal arteritis. Of some importance is the fact that a the large number of giant cells (with acknowledgement to history of migraine increases the risk of devel- Dr J. Headache 73 importance of this type of headache rests on the merges with cluster headache, being described fact that the eye is involved in about 60% of as severe ocular pain associated with meiosis cases and the patient can suddenly go blind in and ptosis. Trigeminal neuralgia can be easily one eye and then a short time later go blind in distinguished from these other forms of the other. A touching a part of the cheek or by chewing and temporal artery biopsy is helpful in specic sit- swallowing. The pain is so severe that the patient uations to assist with the diagnosis, particularly can become suicidal,and surgical division of the in those with indeterminate clinical ndings. Steroid people after an attack of trigeminal herpes treatment is effective in preventing blindness zoster. The pain seems to be more severe in the and is required usually for a 12 18-month elderly and it can persist for many years. Once instituted, the response to treat- cause of the headache is usually evident when ment and the side effects should be very care- one inspects the skin of the forehead, which is fully monitored, preferably in co-operation with slightly whitened and scarred from the previous a general physician with regular measurement attack of herpes zoster. It is easy to forget that Bones anaemic patients often have headaches, which can be cured by treating the anaemia. Likewise, In Paget s disease of bone, the bones of the head patients with polycythaemia might also com- enlarge and grow abnormally, the abnormal plain of headache. Hypoglycaemia is another growth being associated with headache and, recognised cause; here, the symptoms occur incidentally, an increase in hat size. The eyes after strenuous exercise or insulin excess in a themselves might show optic atrophy, and close diabetic patient. Oxycephaly is a congenital defect of the skull caused by premature closure of the In many respects, cluster headache resembles sutures; patients sometimes complain of migraine,although it is more common in men in headache, as well as visual loss because of optic the third or fourth decade. Multiple myeloma is the refers to the timing of the attacks, which can be name given to a malignant proliferation of repeated several times over a few weeks, fol- plasma cells within the bone marrow. There is lowed by a period of remission for several also an excessive production of immunoglobu- months. There is conjunctival congestion the skull, and headache can be an accompani- and constriction of the pupil on the affected ment. Tenderness over the affected side of nosis is made by examining the urine for the face and nasal discharge are also features. Bence Jones proteins and the serum for abnor- Raeder s paratrigeminal neuralgia probably mal immunoglobulins. Disease of the cervical 74 Common Eye Diseases and their Management vertebrae is another cause of headache, because commonly in adults aged 30 40 years who are of the effect of spasm of the neck muscles. Relief beginning to have difculty in accommodating of the pain by neck manipulation has been through their long-sightedness.

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Advantages and disad- ited accessibility of the abomasum in the left ank in vantages of each procedure will be discussed cheap terramycin 250mg without a prescription bacteria estomacal. This approach omasum is not tightly opposed to the parietal perito- allows the best access to the abomasum and allows it to neum or if the sutures break cheap terramycin 250 mg fast delivery infection nail bed. Nonabsorbable sutures are Blind Tack Abomasopexy and Toggle-Pin recommended for the abomasopexy procedure to en- Abomasopexy generic terramycin 250 mg bacteria size. The cow is cast and rolled dorsal recumbency purchase terramycin 250 mg free shipping antibiotic resistance mutation, the risk of incisional hernia or stula into dorsal recumbency and the gas-distended aboma- formation, incisional infection resulting from contami- sum located by simultaneous auscultation and percus- nation of the incision site, regurgitation during recum- sion in the right paramedian area. In the blind tack pro- bency, and concern about ventral parturient edema and cedure, following minimal preparation of the surgical supercial abdominal vessels associated with the mam- site, a large half circle upholstery needle attached to non- mary circulation in cattle with large udders. The proce- absorbable suture is driven through the abdominal wall dure also would be contraindicated in cattle concurrently into the abomasal lumen and back out the abdominal affected with acute or chronic bronchopneumonia, cer- wall. Despite the list of disadvantages, this procedure has been The toggle-pin procedure is similar in that two sepa- used successfully in thousands of cattle and is the proce- rate toggle pins attached to sutures are placed through a dure of choice for valuable cattle because it minimizes the sharp cannula driven into the abomasal lumen. Attention to surgical detail minimizes the this technique cite the advantage of being able to obtain chance of incisional problems following abomasopexy. It can be performed with minimal characteristic odor of abomasal gas through the cannula. Cattle that require an exploratory for toggle complica- tions generally have a guarded to poor outcome. We con- around the lesser curvature that involves the aboma- tinue to see cattle referred because of complications such sum, omasum, and reticulum. The resultant malposi- as toggle pins placed in the cecum, proximal colon, and tion places the omasum medial to the abomasum and rumen. Many of these complications have fatal outcomes the reticulum caudal to the omasum and medial to the even following referral and exploratory laparotomy in an abomasum. Therefore these procedures cannot be recommended for valuable Clinical Signs dairy cows. Appetite and milk production decrease acutely and and labor-saving option in grade cattle. Simultaneous Tympanic area resulting from abomasal volvulus in a auscultation and percussion will produce a large area of Holstein cow. The greater omentum is palpable covering the organ in most instances and seems to help differentiate it from a distended cecum or proxi- mal colon. Only by rectal examination could the more cecal distention, the examiner can usually palpate caudal-dorsal ping be determined to be cecal dilation both the medial and lateral surface of the distended instead of pneumorectum, pneumoperitoneum, or gas viscus. Early suspicion by the owner with tion and moderate to severe hypochloremic, hypokale- subsequent early diagnosis and surgical correction ( 12 mic, metabolic alkalosis. Serum chloride concentrations hours duration) by the veterinarian offers a good prog- range from 80 to 90 in early cases to 65 to 80 in ne- nosis in most instances. Plasma chloride values and base for longer than 24 hours probably have a less than 50% excess show a roughly direct correlation with the clini- prognosis following surgical correction, and cattle af- cal prognosis in most cases. Marked elevation in consists of either right ank omentopexy or right para- plasma L-lactate could indicate poor systemic and/or median abomasopexy, depending on the preference and abomasal perfusion. Other surgical approaches are but hypochloremia and hypokalemia also are present, contraindicated because they offer no direct means of the possibility of severe ketoacidosis should be investi- access to the affected abomasum, omasum, and reticu- gated and the prognosis adjusted accordingly. The surgeon will encounter the omasum lying tory acidosis is often present due to respiratory compen- medial to the abomasum and the reticulum caudal to its sation for metabolic alkalosis or severe abdominal normal location because of volvulus involving the lesser distention, which may compromise depth of respira- curvature of the abomasum, omasum, and reticulum. Examples of anticipated or approximate acid-base The right ank approach is less stressful, less likely to and electrolyte values are provided in Table 5-2. The major advantage of right clinicians must not fail to look at the patient when of- paramedian abomasopexy is exact relocation of the ab- fering a prognosis. A cow should never be denied surgi- omasum once correction of the volvulus is completed. Abomaso- cow is acidotic and recumbent, the prognosis is ex- pexy is arguably more difcult for the inexperienced tremely grave. In either ap- overshadowed by acid-base and electrolyte abnormali- proach, manipulation of the omasum can be helpful ties. Rehydration and correction of acid-base/ electrolyte decits may be performed postoperatively in A early cases, but it may be necessary to address some of these needs preoperatively in severe cases, lest hypoka- lemia progress to diffuse muscular weakness. Oral uids probably are contraindi- cated preoperatively because they may worsen abdomi- B nal distention before surgery. Associated hypocalcemia or ketosis and any concurrent diseases should be treated as indicated. Clinical experi- may survive for weeks before death occurs (see the sec- ence, however, indicates that a good prognosis cannot tion on Vagus Indigestion). Because the clinical syndrome can vary tremendously depending on the size and number of perforations, this discussion will be di- vided into a section on perforations that cause localized peritonitis and another on those that cause diffuse peri- tonitis. Perforating ulcers that cause localized peritonitis in cattle produce a syndrome similar to traumatic retic- uloperitonitis. The septic reaction from the perforation may also be trapped and localized between the abomasum and diaphragm. The cow will be reluctant to move, and deep palpation of the ventral abdomen usually will localize a painful area of the mid- Abomasal Ulcers ventral abdomen to the right of the midline. In calves, Etiology the same signs are present, but ruminal tympany is Abomasal ulcers in dairy cattle and calves are common more common secondary to ileus because of the local- clinical problems. Intensive management and highly ized peritonitis; calves with perforating abomasal ulcers acidic diets consisting of concentrates and silage probably seem to be more likely to develop diffuse peritonitis contribute to the pathogenesis of abomasal ulcers. Occasionally some affected cattle will omasal ulcers occur frequently in herds that feed high- grind their teeth. Anatomic localization of pain is done moisture corn and corn silage as a major portion of the more easily in acute cases. Additionally, higher pro- making the differentiation of this syndrome from trau- ducing cattle seem predisposed to abomasal ulcers, and it matic reticulitis difcult. Ultrasound examination may is possible that the greater increase in cardiac output go- be helpful in determining the extent of the peritonitis. Most clinically detectable abomasal ulcers abomasal ulceration is much more likely than hard- in dairy cattle occur within the rst 4 to 6 weeks of lacta- ware; conversely, if the cow is in the mid or late lactation tion. The second most common time in adult dairy cattle stage, abomasal ulceration is less likely than hardware. Young, rapidly growing calves also frequently are affected with abomasal ulceration and per- foration. In many cases, predisposing factors may be dif- cult to determine, although feeding of large volumes of milk in only two daily feedings may be involved in the pathogenesis. Cattle and calves affected with ulcers that cause diffuse peritonitis are much different on initial presentation than those with localized peritoni- tis. Signs include acute complete anorexia, complete stasis of the forestomach and distal gastrointestinal tract, fever (typ- ically 104. The entire course of the disease can be peracute, with death occurring within 6 hours, or can be extended to 36 to 72 hours or longer if medical support is provided. The prognosis is grave, and if the body temperature begins to decrease or is subnormal when the animal is rst attended, the ani- mal usually dies within 12 to 36 hours. In adult cows, they can be seen at any stage of lactation but are most com- mon during the rst 6 weeks of lactation. Bleeding abomasal ulcers can be categorized by the extent of ab- omasal hemorrhage. Large perforating abomasal ulcer that caused diffuse Asymptomatic cattle that have mild bleeding may pass peritonitis and death in a cow. Abomasal mucosa pro- small, tarry, partially digested blood clots intermittently trudes through the full-thickness ulcer. Black tarry feces (melena) caused by a bleeding abomasal Positive diagnosis is difcult and is made by elimina- ulcer. A fecal occult blood test should be performed on a sample ob- tained before an extensive rectal examination to avoid false-positive results.

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