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It is not possible to differentiate differ Focal lesions within the parenchyma of the trans ent types of collection with ultrasound alone. It is important to determine if a collection is Other causes of focal lesions in the early postoper infected in a clinically ill patient. Recent recipients of liver transplants will often have some free intraperitoneal fluid and a right pleural effusion, which resolve spontaneously. Rejection Rejection episodes are common in the first 2 weeks after transplantation. Graft rejection may be acute, in which case the immunosuppression is increased, or chronic following several acute episodes. Rejection does not have any specific ultrasound features on either conventional imaging or Doppler, and the diagnosis is made from a liver biopsy following clinical suspicion. Because of the immunosuppression, patients are at greater risk than normal for developing malig nancy. Most of these manifest as post-transplant done on the ultrasound appearances alone and lymphoproliferative disorder (similar in appearance guided aspiration is usually required. A monly found ultrasound appearances include focal, leaking bile duct anastomosis is potentially a seri hypoechoic liver lesions and lymphadenopathy. Pancreatic metastases 133 the operator must make the best use of available Benign focal pancreatic lesions 133 acoustic windows and different patient positions Focal fatty sparing of the pancreas 133 and techniques to investigate the pancreas fully. Focal pancreatitis 133 the most useful technique is to start by scan Cysts 134 ning the epigastrium in transverse plane, using the Trauma of the pancreas 134 left lobe of the liver as an acoustic window. Using Pancreatic transplant 135 the splenic vein as an anatomical marker, the body of the pancreas can be identified anterior to this. The tail of pancreas is slightly cephalic to the head, so the transducer should be obliqued accordingly to display the whole organ (Fig.

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Vitamin C improves the absortion of iron and can be used to assist in iron repletion. Copper Copper is important to the function of numerous Other Water-SolubleVitamins enzymes involved in connective tissue synthesis, iron transport, and energy production. It is available in Deficiency of ribofavin, a component of coenzyme organ meats, shellfish, and nuts. As stated previously, vitamin D Deficiency of the trace elements is due to either (800 U) in postmenopausal women and patients over inadequate dietary intake or increased loss in body age 65 appears efective in slowing osteoporosis. Vitamins are organic compounds that serve as diets high in antioxidants decrease coronary artery cofactors and are obtained primarily through diet. Minerals are inorganic compounds that are and studies are currently in progress to assess if this common components of enzymes and proteins. Therapeutic uses ofvitamins include vitamin 0 supplementation to prevent osteoporosis, folate supplementation to prevent neural tube defects, and niacin treatment to lower cholesterol. The role of antioxidants (vitamins A, C, and E) in decreasing coronary disease or cancer remains unproved. Hyperlipidemia consists of elevated cholesterol levels number of individuals with extreme elevations in or elevated triglyceride levels. Familial combined hyperlipidemia is weaker association with heart disease but at high a more common disorder that may present with levels leads to pancreatitis. Treatment may be divided into eyelids) nonpharmacologic measures (diet, exercise, smoking cessation) and pharmacologic measures. On average, cholesterol will decrease by 5% to 10% of total value this calculation is accurate only in the fasting state with dietary measures. Referral to a Bile acid sequestrants (cholestyramine, colestipol, dietitian is recommended. Side effe cts include bloating and constipation, effe cts, potency and lipid-lowering properties (Table binding of certain drugs. Given the risk of myopathy when niacin limited by its side effects, most notably flushing. To or fbric acid derivatives are added to statin therapy, avoid these side efects, begin with low-dose niacin the statins are best combined with bile acid resins (l 00 mg thrice daily), use prophylactic aspirin when combination therapy is required. Screening for hyperlipidemia consists of a fasting will discontinue the medication.

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Already practiced in the technique of endoscopically examining Located at the tip of the endoscope are the lens and video the upper digestive tract, the beginner will learn about similari chip, which produces the image (Fig. Compared with Instrument Features the colonoscope, the gastroscope can be moved to a greater degree upward, but to a lesser degree in all other directions All endoscopes can be divided into three sections: the insertion (Figs. The functions necessary for maneu Standard video endoscopes Colonoscope Gastroscope vering the tip the endoscope, for suction, cleansing, and air in sufflation are all located on the control head. These buttons can generally be used for freeze frames, video recording, print ing, and adjusting illumination intensity (peak and average). Newer generations are equipped with so-called big chips that allow the projection of a high-resolution screen-size image onto a video monitor. The universal cord connects the endoscope to the light source, air supply, water supply, suction pump, and video processor. The video processor transmits the image to the monitor screen on the video tower (Figs. The index finger of the left hand can be used to depress the suction button while the middle finger can the sigmoidoscope measures only 60 cm in total length. Be either press the air/water button lightly for insufflation or more cause of its high degree of maneuverability, it is sometimes used firmly to activate the washing system (Fig. Different colonoscope models can vary in length, outer diameter, and width of the instrument channel. Using the thumb of the left hand, the large nated team, the assistant can advance the insertion tube in the wheel can be turned to move the tip of the endoscope up or colon while the physician uses both hands on the control head down while the smaller wheel directs the tip of the endoscope to steer the tip of the endoscope (Fig. Each wheel has a locking aminers prefer to advance the shaft themselves in order to bet device so that it can be fixed in one position, allowing, for ex ter feel the position of the instrument. In this case, the right ample, the right hand to remain free to use the instrument chan hand is used only for fine adjustments using the angling wheels nel (Fig. Depending on the Large wheel: toward examiner Raises the tip computer program, the virtual endoscopy simulator can simu Large wheel: away from examiner Lowers the tip late normal and pathological findings in the colon, helping to improve later detection of pathologies on actual patients.

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Advantages to using the duodenoscope are the ability to puncture at a perpendicular angle to the collection, the use of an elevator, and the ability to enter collections in the cardia or fundus in a retroflexed position. The disadvantages are a lack of dedicated large-caliber needles that allow passage of 0. The needle, however, is short and not designed for guidewire passage; the wire often does not pass through the sheath after it is angled. Exchanges are difficult, and the small diameter wire is not sufficiently robust to allow accessories to pass through the thicker gastric wall. In these cases, a triple-lumen needle knife or other cautery device is passed over the wire and into the cavity to allow entry and subsequent upsizing to a 0. Standard upper endoscopes can also be used to create the puncture but a perpendicular approach to the posterior gastric wall may not be possible unless the collection is massively bulging into the gastric lumen so that an end-on view of the collection is feasible. The disadvantages are the relative inflexibility, the need to have a straight access due to stiffness of the needle, the tangential nature of the puncture, and the tendency of the punctures to be more proximal both because of the access angle and due to the proximal location of the exit site relative to the transducer. In some cases, 20 mm dilation is performed at the time of initial puncture, though this may be associated with higher risks of bleeding and perforation due to tearing of vessels and separation of the wall of the collection. This is still relatively long compared to the distance between the luminal site and the inside of the cavity and results in an excessive stent length inside the lumen or the cavity. Diagnostic channel scopes have the advantage of flexibility but the small working channel makes suctioning thick secretions difficult and also fills up with debris, making it difficult to pass acces sories for debridement. A therapeutic channel endoscope also has water jet capabilities to aid in loosening adherent necrosis. A jumbo channel endoscope with a 6 mm channel and dual suction designed for removal of clots during gastrointestinal bleeding can be used. This endoscope is rather inflexible but large fragments of necrotic debris can be suction once loosened into smaller fragments. The endoscope is passed into the cavity and necrotic material is removed using mechanical measures. Accessories used include standard polypectomy snares, polyp retrieval nets, and grasping forceps. Unfortunately, these snares deform after many uses and it is not uncommon to use several during the course of one procedure. Once the tissue is grasped, it is withdrawn from the cavity and deposited in the lumen. Complete necrosectomy in one session is usually not possible, particularly when there is a large necrotic burden. A nasocystic irrigation tube is sometimes placed between necrosectomy sessions, though its use is not clear [11]. The duration between procedures can be as short as 24 h or as long as several weeks.

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