;
Buy Viagra Jelly - Discount online Viagra Jelly

Loading

Viagra Jelly

2019, Mississippi State University, Thorald's review: "Buy Viagra Jelly - Discount online Viagra Jelly".

Is amlodipine the best initial monotherapy for Continence Nursing 2003 buy viagra jelly 100mg with amex erectile dysfunction quiz test;30(1):44-51 buy viagra jelly 100mg free shipping erectile dysfunction effexor xr. Pelvic floor exercises for treating post-micturition dribble in men Dogra P N cheap viagra jelly 100 mg mastercard erectile dysfunction pumpkin seeds, Rajeev T P, Aron M. Medicolegal aspects in the with erectile dysfunction: a randomized controlled management of erectile dysfunction. Direct effects controlled trial of pelvic floor muscle exercises and of selective type 5 phosphodiesterase inhibitors alone or with manometric biofeedback for erectile dysfunction. Recovery of sexual function prostatectomy compared with incision of the prostate after prostate cancer treatment. Curr Opin in the treatment of prostatism caused by small benign Urol 2006;16(6):444-448. Role of transrectal ultrasound guided salvage cryosurgery for recurrent prostate Dorrance A M, Lewis R W, Mills T M. Prostate Cancer & Prostatic treatment reverses erectile dysfunction in male stroke Diseases 2005;8(3):235-242. Is it an effective and safe treatment for localised of ginkgo (ginkgo biloba) during pregnancy and prostate cancer?. Value of noninvasive tests compared with penile versus photon radiotherapy in locally advanced duplex ultrasonography. Evaluation of 1972-1987 single institutional experience: Comparison of side effects of sildenafil in group of young healthy standard radical prostatectomy and nerve-sparing technique. Assessment of the physical problems in men and women: a cross functional role of accessory pudendal arteries in erection by sectional population survey. How, why and when should study of the prevalence and need for health care in the urologists evaluate male sexual function?. Sexual Function raloxifene on gonadotrophins, sex hormones, bone Before and After Radical Retropubic Prostatectomy: A turnover and lipids in healthy elderly men. Eur J Systematic Review of Prognostic Indicators for a Successful Endocrinol 2004;150(4):539-546. Sexual dysfunction in male patients with Dubocq F, Tefilli M V, Gheiler E L et al. Diabetic neuropathy: men with benign prostatic hyperplasia: 10-year An intensive review. Can an erectogenic pharmacotherapy regimen after radical prostatectomy improve postoperative erectile function?. Lower urinary tract symptoms in patients with erectile dysfunction: is there a vascular Eden C G, Cahill D, Vass J A et al. Screening for ischemic heart disease in patients with erectile dysfunction: role Eglau Uwe. A risk-benefit assessment of treatment with finasteride in benign prostatic hyperplasia. Apomorphine versus mating behavior in testing El-Bahrawy M, El-Baz M A, Emam A et al. Urology vacuum constriction device in the management of erectile 1995;45(4):715-719. Erectile dysfunction in smokers: a penile dynamic and vascular El-Gabry E A, Strup S E, Gomella L G. Importance of thermal dose and antenna location in transurethral microwave Eri L M, Tveter K J. Effects of pollen extract preparation Prostat/Poltit on lower urinary tract symptoms in patients with chronic Erkan E, Muslumanoglu A Y, Oktar T et al. Dual radioisotopic study: a technique for the evaluation of vasculogenic Emberton M, Neal D E, Black N et al. Mediterranean diet improves erectile function in Englert H, Schaefer G, Roll S et al. Int J Impot Res dysfunction among middle-aged men in a metropolitan area in 2006;18(4):405-410. Sexual functioning in a lifestyle changes on erectile dysfunction in obese men: population-based study of men aged 40-69 years: the good news. Modulation of angiogenesis in patients intracavernous papaverine test always indicate a normal penile with myelodysplastic syndrome. Evaluation of penile hemodynamic status and adjustment of treatment alternatives in Ethans K D, Casey A R, Schryvers O I et al. Invest Med behalf of Gruppo Italiano Studio Deficit Erettile nei Int 1992;18(4):163-168. Experience with tranylcypromine in early cavernosography in standardized cavernosometry. Pituitary clinical experience with water-jet dissection (hydro 2004;7(3):145-148. Cadaveric dura mater graft for correction of penile Technologies: Mitat 2002;11(5-6):257-264. Neurobehavioral and psychological Ferraz Marcos, Rochedo Ferraz, Marcia Martins et al. Expert Review of Neurotherapeutics behavior with hydralazine, isradipine or captopril co 2002;2(5):709-716. The role of statins in Vasculogenic Impotence is Partially Resistant to Adenosine erectile dysfunction. Color cryoglobulinemic vasculitis: An update on its etiopathogenesis Doppler sonography in the evaluation of erectile and therapeutic strategies. Aging-related expression of inducible nitric oxide synthase and markers of tissue damage Fitzpatrick J M, Artibani W. Geriatric prostate cancer with the combination of finasteride Nephrology & Urology 1998;8(1):15-19. Clinical & Experimental Hypertension (New York) 1999;21(5 Firoozi F, Longhurst P A, White M D. The value of testing pudendal nerve conduction in evaluating erectile dysfunction in diabetics. Cutaneous temperature measurements in men with penile prostheses: a comparison study. Experimental approaches for the development of pharmacological Fitch William, Tecumseh Sherman. Sexual moderate dose of postoperative radiation on urinary continence dysfunction in men with lower urinary tract and potency in patients with prostate cancer treated with nerve symptoms. Combination treatment with sustained-release verapamil and indapamide in the treatment of mild-to Forssmann W-G, Meyer M, Forssmann K. Australian Journal of Clinical Hypnotherapy and Hypnosis 1991;12(1):61 Fowler F J, Collins M M, Corkery E W et al. Endothelin-1 in required, in the treatment of mild to moderate diabetic and nondiabetic men with erectile dysfunction. Phosphodiesterase-5 inhibition: The evaluation after endoscopic third ventriculostomy molecular biology of erectile function and dysfunction. Enhanced function following high energy microwave thermotherapy: external counterpulsation as a new treatment modality results of a randomized controlled study comparing transurethral for patients with erectile dysfunction.

order viagra jelly pills in toronto

Improved ejaculation control was reported by 51% and 58% of patients in the 30 mg and 60 mg groups trusted 100 mg viagra jelly erectile dysfunction treatment in unani, respectively order viagra jelly 100mg online erectile dysfunction pills at gas stations. Common adverse events for 30 mg and 60 mg doses of dapoxetine buy 100mg viagra jelly fast delivery erectile dysfunction pump infomercial, respectively, were nausea (8. In a subanalysis of these two studies (33), 32% of men reported a two-category (from a 5-point scale, very poor to very good) or greater increase in control and satisfaction with sexual intercourse after treatment. The proportions of men with a two-category or greater increase in control with dapoxetine 30 and 60 mg were 36. They may reduce performance anxiety due to better erections and may down-regulate the erectile threshold to a lower level of arousal so that greater arousal is required to achieve the ejaculation threshold. There is only one well-designed, randomised, double-blind, placebo-controlled study comparing sildenafil to placebo (39). Tramadol is a centrally acting analgesic agent that combines opioid receptor activation and re-uptake inhibition of serotonin and noradrenaline. However, they are time 3 C intensive, require the support of a partner and can be difficult to do. Anesthetic block of the dorsal penile nerve inhibits vibratory- induced ejaculation in men with spinal cord injuries. Topical anaesthetic use for treating premature ejaculation: a double-blind, randomized, placebo-controlled study. Topical lidocaine-prilocaine spray for the treatment of premature ejaculation: a proof of concept study. Paroxetine treatment of premature ejaculation: a double-blind, randomized, placebo-controlled study. Relevance of methodological design for the interpretation of efficacy of drug treatment of premature ejaculation: a systematic review and meta- analysis. Efficacy and tolerability of dapoxetine in treatment of premature ejaculation: an integrated analysis of two double-blind, randomised controlled trials. Dapoxetine for the treatment of premature ejaculation: results from a randomized, double-blind, placebo-controlled phase 3 trial in 22 countries. The role of phosphodiesterase type 5 inhibitors in the management of premature ejaculation: a critical analysis of basic science and clinical data. In vivo evaluation of serotonergic agents and alpha-adrenergic blockers on premature ejaculation by inhibiting the seminal vesicle pressure response to electrical nerve stimulation. Alpha-1 blockade pharmacotherapy in primitive psychogenic premature ejaculation resistant to psychotherapy. Safety and efficacy of tramadol in the treatment of premature ejaculation: a double-blind, placebo-controlled, fixed-dose, randomized study. It is very important that the physician warns the patient that sexual intercourse is a vigorous physical activity, which increases heart rate as well as cardiac work. Any successful pharmacological treatment for erectile failure demands a degree of integrity of the penile mechanisms of erection. Further studies of individual agents and synergistic activity of available substances are underway. The search for the ideal pharmacological therapy for erectile failure aims to fulfil the following characteristics: good efficacy, easy administration, freedom from toxicity and side-effects, with a rapid onset and a possible long-acting effect. Premature ejaculation is another very common male sexual dysfunction, with prevalence rates of 20% to 30%. Physical examination and laboratory testing may be needed in selected patients only. Behavioural techniques may be efficacious as a monotherapy or in combination with pharmacotherapy, but they can be difficult to perform. This information is publically accessible through the European Association of Urology website. This guidelines document was developed with the financial support of the European Association of Urology. E1, which affect penile blood flow, can result in Impotency remains largely unrecognized simply prolonged erections necessitating other drug therapy because most men do not discuss sexual problems to counter act its efects. In addition, many physicians do can cause burning and eventual fbrosis of the penis. Primary causes are rare and may be belief, ageing is not an inevitable cause of impotency. Sex disorders of the male are classifed into disorders of A man may have a sexual problem if he: sexual function, sexual orientation and sexual behaviour. Such factors include Is unable to have an erection sufcient for pleasurable neural activity, vascular events, intracavernosal nitric oxide intercourse system and androgens. Sexual dysfunction in men refers to repeated inability to achieve normal sexual intercourse. While sexual dysfunction rarely threatens physical health, it can take a heavy psychological Disorders of Desire toll, bringing on depression, anxiety and debilitating Disorders of desire can involve either a deficient or feelings of inadequacy. Dysfunctions that can neglected by the healthcare team who strive more with the occur during the desire phase include: technical and more medically manageable aspects of the i. It results in a complete or females and thus, it is conventional to focus more on male almost complete lack of desire to have any type of sexual sexual difculties. Generally, wide range of complex sexual behaviours that have a prevalence of about 10% occurs across all ages. These have contributed in no small measure to everything else) and sexual impulsivity (failure to resist prevalence of sexual dysfunction in the aged. These changes Disorders of Ejaculation were highly correlated with both weight loss and activity There exists a spectrum of disorders of ejaculation ranging levels. However, it should be emphasized that controlled from mild premature to severely retard or absent ejaculation. This procedure may lead to treatmentspecifc sequelae afecting healthrelated QoL. Cavernosal impact on the quality of life (QoL) of suferers and their nerve injury induces pro-apoptotic (loss of smooth muscle) partners and families. These changes may also be caused by Epidemiology poor oxygenation due to changes in the blood supply to Recent epidemiological data have shown a high prevalence the cavernosa. Although further studies are hyperprolactinaemia), which can be potentially cured with needed to make clear the role of lifestyle changes in the specifc treatment. Testosterone is associated with the preservation of smooth muscle within replacement is contraindicated in men with a history the human corpora cavernosa. Daily sildenafl also resulted of prostate carcinoma or with symptoms of prostatism. Adverse events are generally mild in nature, surgery for veno-occlusive dysfunction is no longer selflimited by continuous use. The recommended starting dose is 10 mg and should be adapted according to the patients Firstline Therapy response and sideefects. Afer 12 weeks in a doseresponse arterial blood fow leading to smooth muscle relaxation, study, improved erections were reported by 66%, 76% and vasodilatation and penile erection. Efcacy initiators of erection and require sexual stimulation to was confirmed in post-marketing studies.

100mg viagra jelly overnight delivery

Recurrence 20% Secondary: in any lung disease Treatment: Insert 14g iv cannula into midaxillary line at level of nipple (any lower and may get diaphragm) Hissing of air is diagnostic th th 490 4 and 5 Year Notes Remove needle and leave cannula in place purchase discount viagra jelly line impotence unani treatment in india. Open Pneumothorax Sucking wound cant create ive intrathoracic pressure Occlusive dressing and positive pressure Massive Haemothorax 1500 ml in thorax or > 200 ml per hour Mainly penetrating wounds of pulmonary vessels (e viagra jelly 100 mg with amex erectile dysfunction humor. If great vessels affected usually dont survive Significant amount of blood needs surgical removal thoracotomy Flail Chest Needs lots of force so suspect pulmonary contusion as well Independent segment of chest wall paradoxical movement order 100 mg viagra jelly with visa erectile dysfunction pills south africa. So do random cultures in the hope of getting a hit Definitions: Bacteraemia: no host response. Happens all the time (eg after cleaning teeth) Septicaemia: sustained bacteria in the blood stream on going delivery of bugs into the blood stream from a replicating focus (dont multiply in blood). Coli, -haemolytic streptococci Group B (eg streptococcus agalactiae normal vaginal flora), rarely listeria Children < 14 years: H. Reduces fever and gives misleading impression of clinical improvement Antibiotic regimes: Empiric antibiotic treatment: Neonate 3 mths: Amoxycillin 50 mg/kg (for listeria) + Ceftriaxone 50 mg/kg (E coli and Strep). All cases should have audiologist check within 6 8 weeks of discharge Death in 5%, 10 15% pneumococcal meningitis, 20% in fulminant meningococcaemia Meningococcal Disease Cause: Neisseria Meningitidia Epidemiology: 10-year epidemic started in 1990 with about 50 reported cases. Current case fatality rate is 3 5 % Leading infectious cause of death in children 500 reported cases in 2000. Nasal carriage higher in adults than children Rifampicin: 4 doses, 600 mg bd for adults, 10 mg/kg bd for kids (very high dose). Broad spectrum antibiotic Offer to index case (if only treated with penicillin), all intimate, household and day-care contacts during last 10 days Contraindications: pregnancy (use single dose ceftriaxone), liver disease. May get purpura in flexures Tongue affected white then strawberry red Streptococcus Toxic Shock Syndrome: First described in children. Spreads along facial planes Infection of subcutaneous tissue progressive destruction of fascia and fat but may spare the skin itself. Normally first 3, except if from Pacific Islands where use all 4 due to isoniazid resistance. Recurrences usually less severe and become less frequent Diagnosis: clinical suspicion. There are two antigenic types of Herpes Simplex Virus: Type 1 is associated with lesions on the face and fingers, and sometimes genital lesions. Prevalence: 70% of population Type 2 is associated almost entirely with genital infections, and affects the genitalia, vagina, and cervix and may predispose to cervical dysplasia. Acyclovir Infectious Diseases 503 Genital Herpes (type 2) Description: Painful, recurrent condition. Neonatal transmission is rare (1 in 10,000 live births), but carries risk of ophthalmic infection caesarean section indicated if active blisters at delivery Prevention of genital herpes: Condoms with new partner (although doesnt eliminate risk). Avoid sex during an outbreak Can have extra genital lesions on thighs and buttocks. Can radiculoneuropathy urinary retention/constipation Treatment of Genital Herpes (type 1 or 2): Acute: Acyclovir 200 mg 5 times daily for 5 days. Symptomatic treatment: salt bathing, local anaesthetic creams, oral analgesia, oral fluids. Counselling and follow-up important written information for patients and partners, Herpes Helpline (0508 11 12 13) Suppressive Therapy: Where frequent outbreaks or psychological morbidity. Elderly and immunocompromised are high risk th th 504 4 and 5 Year Notes Symptoms: Dermatomal pain, then fever malaise for several days, then macule-papules + vesicles, especially in thoracic or ophthalmic division of trigeminal dermatomes. Thoracic (50%), cervical (20%), trigeminal (15%) Complications: If shingles around eye (especially end of nose), then are likely to have a dendritic ulcer on cornea. Stain with Fluorescein and shine on blue light, corneal abrasions will shine green. Also kitten faeces (eg cyst in garden pregnant gardeners should wear gloves) Presentation: Immunocompetent: Lymphadenopathy (eg unilateral) Maybe: fever, myalgia, acute pharyngitis, hepatosplenomegaly, atypical mononucleosis Usually self-limiting may take months to settle If persistent/recurrent lymphadenopathy ? If you dont, they will relapse Relapse common (20%) maybe several months later. Serum antibody test Treatment: Intestinal amoebiasis: metronidazole then diloxanide furoate Extra-intestinal: metronidazole (surgical drainage may be necessary) Asymptomatic: Diloxanide furoate Giardiasis Diagnosis: Stool examination for Giardia Lamblia cysts, 3 samples 48 hours apart Duodenal aspirate and direct examination for trophozoites Treatment: Tinidazole 2g stat or Metronidazole 400 mg 8 hourly for 7 days Test for cure with repeat stool sample. Dogs infected from eating raw sheep offal (ie liver) containing hydatid cysts Clinical: Often acquired in childhood, present in older age with solitary cysts (liver, lung, brain) Treatment: surgical drainage + aldendazole as adjunct Diagnosis: Serology: haemaglutination test + complement fixation test Cryptosporidium Common protozoan parasite Profuse watery diarrhoea for 48 hours. Relapse in 25% See also Other pneumonias, page 70 Travel Medicine Travel History: Where are you going How are you getting there How long there What will you be doing Where are you staying Have you been there before Examples: 3 week package to Hong Kong, Singapore, Bangkok: Hep A and Tetanus up to date. Risk in main resort areas of Asia is low Typhoid: Injectable: salmonella typhi antigen, 70% protection for 3 years Oral vaccine: attenuated live strain, doses at 0, 3 and 5 days gives protection for one year. Resistant (eg kids): Ceftriaxone Resistant and Meningitis: Cefotaxime + Vancomycin (act synergistically) Resistant and Endocarditis: Vancomycin Strep faecalis Trimethoprim Strep agalactiae Penicillin. Also sensitive to flucloxacillin Strep sanguis Penicillin [ haemolytic] Staph aureus Flucloxacillin. Elderly/immunocompromised: ciprofloxacin (quinolone not in kids) Clostridium difficile Metronidazole Enterococcus faecalis Amoxycillin G ive Bacilli E Coli Trimethoprim. Consider gentamycin or cotrimoxazole Campylobacter Jejuni Erythromycin Infectious Diseases 511 H Influenzae Cefaclor, Augmentin, Tetracycline 5% resistant to penicillin, not sensitive to erythromycin Legionella Erythromycin. Maybe Tobramycin or piperacillin Meningitis: Ceftazidine Gardnerella Vaginalis Metronidazole. Metronidazole is otherwise inactive against aerobes Bordetella Pertussis Erythromycin Branhamella Catarrhalis Augmentin, cefaclor, tetracycline, cefuroxime 70% penicillinase Anaerobes Bacteroides Fragilis Metronidazole. Not penicillin or cephalosporins Helicobacter Pylori Clarithromycin + metronidazole + omeprazole (7 days) Cocci Neisseria Meningitidis Penicillin. Prophylaxis: Rifampicin, ceftriaxone if pregnant Neisseria Gonorrhoea Stat: Amoxycillin + Probenecid Ciprofloxacin or tetracycline if penicillin allergy or resistant. Cellular wall similar to G-ive but not actually a G-ive bacteria Others nd Mycoplasma Erythromycin. Maybe Paromomycin (oral, non-absorbed aminoglycoside) Giardiasis Tinidazole stat or metronidazole 7 days Trichomonas Doxycycline, Metronidazole Pneumocystis Carinii Cotrimoxazole Pneumonia Malaria Prophylaxis Mefloquine weekly: good for chloroquine resistant falciparum. Not epilepsy, pregnant, babies Doxycycline daily: Esp Mefloquine resistant falciparum. Principle use is infectious exacerbations of chronic bronchitis Haemophilus influenzae Increasing E coli resistance Branhamella Catarrhalis Flucloxacillin Staph Aureus Penicillinase producers. If true anaphylaxis seek specialist advice Immune suppression: dont give live vaccine. If Heart failure vasoconstriction to maintain blood flow liver flow elimination (eg lignocaine, propranolol). Total body clearance cant exceed cardiac output (5 l/min) Clearance and Volume of Distribution are independent of each other, but T is dependent on both Maintenance Dose = clearance * desired concentration Compartments: One or multi compartment models Ka = absorption into compartment Ke = elimination from compartment th th 522 4 and 5 Year Notes Linear kinetics First order kinetics: rate of transport or elimination proportional to drug concentration in the compartment Zero order kinetics: elimination has maximum value rate is non-linear and its a capacity limited process. So if dose rate is greater than clearance rate, then a small increase in dose rate leads to a dramatic increase in plasma concentration (ie accumulation) Michaelis-Menten kinetics For a drug that undergoes zero-order elimination, when the concentration is low enough, elimination no longer occurs at its maximum rate (V max) but at a rate dependent on but not proportional to the plasma concentration. As the concentration reaches the maximum rate (km), first order elimination occurs So, elimination will increase with increasing dose, but not proportional to the dose Zero-order kinetics will be approached risk of accumulation Issue for any drug having zero-order kinetics within its therapeutic range E. In one compartment model: Ke = Cl/Vd = Measure of how the whole body handles the drug how quickly it gets out But it doesnt work in practice For slowly excreted drugs, 5 * T and it will be eliminated for practical purposes But for anaesthetic drugs that you want to switch on and off quickly the therapeutic window is often in the redistribution phase not the elimination phase. Need a more complex model where the drug redistributes to (then from) slow and fast compartments, as well as being excreted from blood context sensitive half-life. If drug is over infused, it builds up in other compartments and then takes a long time to wash out.

cheap viagra jelly 100mg visa

Alagilles syndrome is a marked reduction in intrahepatic (actually interlobular) bile ducts buy viagra jelly in india erectile dysfunction doctor patient uk. Although it is believed to be congenital purchase 100mg viagra jelly with visa impotence 24, being inherited in an autosomal dominant pattern cheap 100mg viagra jelly amex erectile dysfunction by age, presentation may be as a neonatal jaundice or as cholestasis in older children. Outcome is variable, depending upon the attendant anomalies and the severity of the liver disease. Complete absence of the extrahepatic bile ducts reflects either an arrest in remodeling of the ductal plate in utero or, more probably, an inflammatory destruction of the formed bile ducts during the postpartum period. An initial viral injury may initiate the epithelial injury that then progresses by an immune-mediated sclerosing process, abetted by bile salt leakage that adds detergent damage. The resultant sclerosing inflammation obliterates both the intra- and extrahepatic bile ducts, resulting in profound cholestasis and then secondary biliary cirrhosis. Chronic cholestasis then leads to steatorrhea, skin xanthomas, bone disease and failure to thrive. Surgery is usually necessary to confirm the diagnosis and attempt some form of biliary drainage. In some, existence of a patent hepatic duct or dilated hilar ducts allows correction of the obstruction by anastomosis to the small intestine (e. More common is an absence of patent ducts; dense fibrous tissue encases the perihilar area and precludes conventional surgery. Such obliteration of the proximal extrahepatic biliary system requires the Kasai procedure. A conduit for biliary drainage is fashioned by resecting the fibrous remnant of the biliary tree and anastomosing the porta hepatis to a roux-en-Y loop of jejunum. With either surgery, most children eventually develop chronic cholangitis, hepatic fibrosis/cirrhosis and portal hypertension. When the child is larger, hepatic transplantation dramatically improves the prognosis. Liver transplantation becomes necessary in 50% by 2 years of age, 80% by 20 years. Other causes of neonatal cholestasis can be attributed to hepatocellular transport defects, best exemplified by familial intrahepatic cholestatic syndromes. These small, multiple cysts are usually asymptomatic though potentially complicated by cholangiocarcinoma. Cholangitis Cholangitis is any inflammatory process involving the bile ducts, but common usage implies a bacterial infection, usually above an obstructive site (usually a bile duct stone). The presence of bacteria in the biliary tree plus increased pressure within the system results in severe First Principles of Gastroenterology and Hepatology A. Any condition producing bile duct obstruction is likely to cause bacterial infection of bile. A less likely cause of infection is a stricture (such as a neoplasm) that has not been contaminated by a stent; only 10-15% of malignant biliary obstructions are associated with infection at presentation. The difference relates to the slowly progressive obstruction of non- contaminated strictures versus the intermittent blockage with a stone or acute blockage of as stent within a duct that has been colonized by bacteria via the stent. Such intermittent blockage allows retrograde ascent of bacteria: the stone or stent acting as a nidus for infection. The bacteria ascend the biliary tree (hence the term ascending cholangitis), but may also enter from above via the portal vein or from periductular lymphatics. In acute bacterial cholangitis, particularly if severe, the classical Charcots triad of intermittent fever and chills, jaundice and abdominal pain may be followed by septic shock. The duration of antibiotics needed after successful biliary drainage can be as short as three to five days, unless bacteremia coexists. The entity may appear either alone (20%) or in association with inflammatory bowel disease (80%), particularly ulcerative colitis and less commonly, Crohns colitis. The basis for the patchy scarring (sclerosis) that leads to fibrotic narrowing and eventually obliteration of the bile ducts is unknown. In a genetically predisposed individual, biliary epithelial damage likely begins with exposure to an infectious agent and/or enterohepatic toxin. In inflammatory bowel disease with defective intestinal permeability, this might originate from transmigration of bacteria and toxins. Complications include episodes of bacterial cholangitis with upper abdominal pain, fever and worsening cholestasis. Secondary biliary cirrhosis with portal hypertension supervenes and progressive liver failure. Those with ulcerative colitis have a heightened risk of colon and hepatobiliary cancers. Diagnosis requires high-resolution bile duct imaging to show diffuse strictures and First Principles of Gastroenterology and Hepatology A. Therapeutic trials of corticosteroids, immunosuppressive agents (for the presumed immunologically mediated inflammatory process), ursodeoxycholic acid (to theoretically displace any toxic bile acids and be anti-inflammatory) and proctocolectomy in patients with inflammatory bowel disease have all failed to change outcomes. As some patients may be asymptomatic for a decade, only careful observation is probably warranted early on. The development of jaundice, intractable pruritus and features of cirrhosis (ascites, portal hypertension with esophageal bleeding) are indications for liver transplantation (with a Roux-en- y choledochojejunostomy). Some 10-15% of patients develop cholangiocarcinoma, creating a diagnostic challenge. The development of cholangiocarcinoma prior to transplantation has a poor prognosis; the cancer progresses with immunosuppression, and is generally a contraindication to transplantation. Other Sclerosing Cholangitides Secondary sclerosing cholangitis causes diffuse stricturing. IgG4-associated cholangiopathy is an autoimmune, steroid-responsive, sclerotic process manifest by IgG-4-positive plasma cell infiltration producing segmental stricturing in the larger bile ducts. Half of the strictures are confined to the intrapancreatic portion of the bile duct. Shaffer 581 To aid the diagnosis, IgG4 immunostaining tissue can be obtained from the ducts, ampulla or pancreas (e. Associated autoimmune pancreatitis with inflammatory masses, and associated weight loss, can sometimes make this difficult to differentiate from malignancy. Neoplasia Benign tumors (adenomas, papillomas, cystadenomas) are rare causes of mechanical biliary obstruction. Ampullary adenocarcinomas should be considered for a Whipples pancreaticoduodenectomy. The most common malignant stricture of the bile duct is due to invasion from to pancreatic cancer. Cholangiocarcinoma, the most frequent primary biliary tract malignancy, is rather uncommon in the Western world.