Kana Angelica Z.

Mercado III - CB32

What is gastroscopy?
A gastroscopy is a test that allows doctor to examine the inner lining of the
upper gut(gastrointestinal tract) namely the oesophagus (swallowing tube),
stomach, and duodenum(first part of the small intestines). The doctor uses an
endoscope to look inside you gut. Thisis sometimes called an endoscopy.An
endoscope is a thin, flexible, fibreoptic telescope. It is about as thick as a
little finger. Theendoscope is passed through the mouth, into the oesophagus
and down towards the stomachand duodenum. The endoscope is equipped
with a light and a tiny video camera at the tip sothat the doctor can see
inside your gut.
Why is gastroscopy performed?
A gastroscopy is usually performed to investigate the following symptoms:
• Recurrent indigestion
• Recurrent heartburn
• Upper abdominal pain or discomfort
• Difficulty swallowing
• Repeated vomiting
• Vomiting blood or passing foul smelling black tarry stools
Below is a list of some of the conditions which can be confirmed with
gastroscopy:
• Oesohagitis (inflammation of the oesphagus)
• Gastritis or duodenitis ( inflammation of the stoamch or duodenum)
• Stoamch orduodenal ulcers
• Cancer of the stoamch or oesophagus
How is gastroscopy performed?
Gastroscopy is usually perofrmed as an outpatient ‘day case’. Patient will
need to be fasted 6hours before the procedure. Your doctor may numb the
back of your throat by spraying somelocal anaesthetic. To help you to relax,
your doctor may also give you an sedative givenintravenously. You will be
positioned on your side on a couch and a plastic mouth guard willbe put
between your teeth. This is to protect your teeth and prevents you from
biting theendoscope.
The endoscope will then be inserted into your mouth and gently pushed
further down to theoesopagus and subsequently into your stomach and
duodenum. The tiny video camera willsend real time images to a TV screen to
allow your doctor to look out for any abnormality. Airis also pump throgh the
endoscope to distend your stomach. This will make the stomachlining easier
to see. You may feel ‘full’ and wanting to belch.Your doctor may take
somebiopsies from the lining of the gut for laboratory testing. This is a
painless process. Oncecompleted, your doctor will withdraw the endoscope
gently until it is pulled out. The wholeprocedure usually takes about 10 mins.
It is recommended that you set aside at least 2 hoursfor the whole
appointment, to prepare, give time for the sedative to work (if you have one),
forthe gastroscopy itself, and to recover.
What are the potential complications from gastroscopy?
Gastroscopy is a very safe and effective test. It does not usually hurt but may
be a littleuncomfortable especially when the endoscope passes through the
back of your throat. Youmay experience a mild sore throat for a day or two.
There is also a very slight increase risk of chest infection, stroke or heart
attack after agastroscopy. This tend to happen in older people with poor
health. These seriouscomplications are very rare in majority who are
otherwise healthy.
The endoscope may rarely cause some damage to the gut. This may lead to
bleeding orperforation or tear in the gut (approximately 1 in 10,000 cases).
This will require urgenttreatment. Should you experience any of the following
symptoms within 48 hours of theprocedure, do seek medical attention
immediately:
• Severe abdominal pain
• Fever
• Difficulty breathing
• Vomiting blood or passing of black tarry stools
Rarely, some people may have an allergic reaction to the sedative.
Special precautions
If your doctor gives you an intravenous sedative, you may take a little longer
to be ready to gohome. It is preferably that an adult accompanies you home
and stays with you for 24 hours.You should not drive, operate machinery or
drink alcohol for at least 24 hours after thesedative is given. You can resume
your normal diet. Most people will be able to return tonormal activities after
24 hours.

What is colonoscopy?
Colonoscopy is a procedure used to see inside the colon and rectum.
Colonoscopy can detect inflamed tissue, ulcers, and abnormal growths. The
procedure is used to look for early signs of colorectal cancer and can help
doctors diagnose unexplained changes in bowel habits, abdominal pain,
bleeding from the anus, and weight loss.

How to Prepare for Colonoscopy

The doctor usually provides written instructions about how to prepare for
colonoscopy. The process is called a bowel prep. Generally, all solids must be
emptied from the gastrointestinal tract by following a clear liquid diet for 1 to
3 days before the procedure. Patients should not drink beverages containing
red or purple dye. Acceptable liquids include
·fat-free bouillon or broth
·strained fruit juice
·water
·plain coffee
·plain tea
·sports drinks, such as Gatorade
·gelatin
A laxative or an enema may be required the night before colonoscopy. A
laxative is medicine that loosens stool and increases bowel movements.
Laxatives are usually swallowed in pill form or as a powder dissolved in
water. An enema is performed by flushing water, or sometimes a mild soap
solution, into the anus using a special wash bottle.
Patients should inform the doctor of all medical conditions and any
medications, vitamins, or supplements taken regularly, including
·aspirin
·arthritis medications
·blood thinners
·diabetes medications
·vitamins that contain iron
Driving is not permitted for 24 hours after colonoscopy to allow the sedative
time to wear off. Before the appointment, patients should make plans for a
ride home.
How is colonoscopy performed?
Examination of the Large Intestine
During colonoscopy, patients lie on their left side on an examination table. In
most cases, a light sedative, and possibly pain medication, helps keep
patients relaxed. Deeper sedation may be required in some cases. The doctor
and medical staff monitor vital signs and attempt to make patients as
comfortable as possible.

The doctor inserts a long, flexible, lighted tube called a colonoscope, or

scope, into the anus and slowly guides it through the rectum and into the
colon. The scope inflates the large intestine with carbon dioxide gas to give
the doctor a better view. A small camera mounted on the scope transmits a
video image from inside the large intestine to a computer screen, allowing
the doctor to carefully examine the intestinal lining. The doctor may ask the
patient to move periodically so the scope can be adjusted for better viewing.
Once the scope has reached the opening to the small intestine, it is slowly
withdrawn and the lining of the large intestine is carefully examined again.
Bleeding and puncture of the large intestine are possible but uncommon
complications of colonoscopy.

Removal of Polyps and Biopsy

A doctor can remove growths, called polyps, during colonoscopy and later
test them in a laboratory for signs of cancer. Polyps are common in adults
and are usually harmless. However, most colorectal cancer begins as a polyp,
so removing polyps early is an effective way to prevent cancer.
The doctor can also take samples from abnormal-looking tissues during
colonoscopy. The procedure, called a biopsy, allows the doctor to later look at
the tissue with a microscope for signs of disease.
The doctor removes polyps and takes biopsy tissue using tiny tools passed
through the scope. If bleeding occurs, the doctor can usually stop it with an
electrical probe or special medications passed through the scope. Tissue
removal and the treatments to stop bleeding are usually painless.
Recovery
Colonoscopy usually takes 30 to 60 minutes. Cramping or bloating may occur
during the first hour after the procedure. The sedative takes time to
completely wear off. Patients may need to remain at the clinic for 1 to 2
hours after the procedure. Full recovery is expected by the next day.
Discharge instructions should be carefully read and followed.
Patients who develop any of these rare side effects should contact their
doctor immediately:
·severe abdominal pain
·fever
·bloody bowel movements
·dizziness
·weakness

Points to Remember
- Colonoscopy is a procedure used to see inside the colon and rectum.
- All solids must be emptied from the gastrointestinal tract by following a
clear liquid diet for 1 to 3 days before colonoscopy.
- During colonoscopy, a sedative, and possibly pain medication, helps keep
patients relaxed.
- A doctor can remove polyps and biopsy abnormal-looking tissues during
colonoscopy.
- Driving is not permitted for 24 hours after colonoscopy to allow the sedative
time to wear off.

What is a cholecystectomy?
Cholecystectomy is a surgical procedure to remove your gallbladder — a
pear-shaped organ that sits just below your liver on the upper right side of
your abdomen. Your gallbladder collects and stores bile — a digestive fluid
produced in your liver.
Cholecystectomy may be necessary if you experience pain from gallstones
that block the flow of bile. Cholecystectomy is a common surgery, and it
carries only a small risk of complications. In most cases, you can go home the
same day of your cholecystectomy.
Open cholecystectomy
In this method, a 4 to 6 inch incision is made in the right upper portion of the
abdomen, just below the ribs. The liver is retracted to allow better access to
the gallbladder and the organ is removed. The abdominal layers are closed
by sutures.
Laparoscopic cholecystectomy
In this method, a tiny incision is made just below the umbilicus, through
which the laparoscope is inserted into the abdomen. The laparoscope is a
thin, flexible scope with a camera at the end, which projects a magnified
image of the area to be operated, onto a monitor. A surgeon skillfully guides
the scope to the site and three tiny incisions are made at the upper right side
of the abdomen to insert the minute surgical instruments necessary for the
procedure.
If available, a laparoscopic gallbladder removal surgery is usually the
procedure of choice, due to the lower risk of complications, quicker procedure
with faster healing time and less scarring.

Why is it done?

Cholecystectomy is used to treat gallstones and the complications they

cause. Your doctor may recommend cholecystectomy if you have:
·Gallstones in the gallbladder (cholelithiasis)
·Gallstones in the bile duct (choledocholithiasis)
·Gallbladder inflammation (cholecystitis)
·Pancreas inflammation (pancreatitis)

Risks
Cholecystectomy carries a small risk of complications including:
- Bile leak
- Bleeding
- Blood clots
- Death
- Heart problems
- Infection
- Injury to nearby structures, such as the bile duct, liver and small intestine
- Pancreatitis
- Pneumonia
Your risk of complications depends on your overall health and the reason for
your cholecystectomy. Emergency cholecystectomy carries a higher risk of
complications than does a planned cholecystectomy.

Before Surgery
If you and your doctor decide that surgery is the best option for you, there
are some things you should know:
- A low-fat diet can reduce the frequency and severity of attacks.
- Tell your doctor about all medications you are taking, including vitamins,
supplements, and blood thinners.
- Call your doctor if you experience a high fever or changes in your skin color
(jaundice).
- Do not eat or drink anything after midnight the night before your surgery.
- Make sure that you have someone to give you a ride home from the
hospital.
During Surgery
- You will be put to sleep by the anesthesiologist before the procedure begins.
- If the procedure is to be done laparascopically, a gas is used to inflate the
belly and lift the abdominal wall away from the internal organs.
- Four incisions are made to allow a camera and the surgical instruments into
the abdomen.
- Small clips are used to close the bile duct and blood vessels to the
gallbladder. These clips are left inside, but are not harmful to the body.
- The gallbladder is detached from the liver bed and removed.
- You will wake up in the operating room or in the recovery room, where
nurses will monitor you. If your procedure was done laparascopically, you will
return to your family in the short stay unit.
- Patients undergoing the surgery laparascopically will be required to stay a
night in the hospital if your gallbladder is infected, if the surgery is done late
at night, if you require a drain tube to remove excess fluid, or if you have
other medical conditions that require monitoring as you recover from the
surgery.
- Patients having an open cholecystectomy may need 3 to 7 days in the
hospital for recovery.

Childbirth includes both labor (the process of birth) and delivery (the birth
itself); it refers to the entire process as an infant makes its way from the
womb down the birth canal to the outside world.
Description
Childbirth usually begins spontaneously, about 280 days after conception, but
it may be started by artificial means if the pregnancy continues past 42
weeks gestation. The average length of labor is about 14 hours for a first
pregnancy and about eight hours in subsequent pregnancies. However, many
women experience a much longer or shorter labor.
Labor can be described in terms of a series of phases.
First stage of labor
During the first phase of labor, the cervix dilates (opens) from 0-10 cm. This
phase has an early, or latent, phase and an active phase. During the latent
phase, progress is usually very slow. It may take quite a while and many
contractions before the cervix dilates the first few centimeters. Contractions
increase in strength as labor progresses. Most women are relatively
comfortable during the latent phase and walking around is encouraged, since
it naturally stimulates the process.
As labor begins, the muscular wall of the uterus begins to contract as the
cervix relaxes and expands. As a portion of the amniotic sac surrounding the
baby is pushed into the opening, it bursts under the pressure, releasing
amniotic fluid. This is called “breaking the bag of waters.”

During a contraction, the infant experiences intense pressure that pushes it

against the cervix, eventually forcing the cervix to stretch open. At the same
time, the contractions cause the cervix to thin. During this first stage, a
woman’s contractions occur more and more often and last longer and longer.
The doctor or nurse will do a periodic pelvic exam to determine how the
mother is progressing. If the contractions aren’t forceful enough to open the
cervix, a drug may be given to make the uterus contract.
As pain and discomfort increase, women may be tempted to request pain
medication. If possible, though, administration of pain medication or
anesthetics should be delayed until the active phase of labor begins—at
which point the medication will not act to slow down or stop the labor.
The active stage of labor is faster and more efficient than the latent phase. In
this phase, contractions are longer and more regular, usually occurring about
every two minutes. These stronger contractions are also more painful.
Women who use the breathing exercises learned in childbirth classes find
that these can help cope with the pain experienced during this phase. Many
women also receive some pain medication at this point—either a short-term
medication, such as Nubain or Numorphan, or an epidural anesthesia.
As the cervix dilates to 8-9 cm, the phase called the transition begins. This
refers to the transition from the first phase (during which the cervix dilates
from 0-10 cm) and the second phase (during which the baby is pushed out
through the birth canal). As the baby’s head begins to descend, women begin
to feel the urge to “push” or bear down. Active pushing by the mother should
not begin until the second phase, since pushing too early can cause the
cervix to swell or to tear and bleed. The attending healthcare practitioner
should counsel the mother on when to begin to push.
Second stage of labor
As the mother enters the second stage of labor, her baby’s head appears at
the top of the cervix. Uterine contractions get stronger. The infant passes
down the vagina, helped along by contractions of the abdominal muscles and
the mother’s pushing. Active pushing by the mother is very important during
this phase of labor. If an epidural anesthetic is being used, many practitioners
recommend decreasing the amount administered during this phase of labor
so that the mother has better control over her abdominal muscles
When the top of the baby’s head appears at the opening of the vagina, the
birth is nearing completion. First the head passes under the pubic bone. It fills
the lower vagina and stretches the perineum (the tissues between the vagina
and the rectum). This position is called “crowning,” since only the crown of
the head is visible. When the entire head is out, the shoulders follow. The
attending practitioner suctions the baby’s mouth and nose to ease the baby’s
first breath. The rest of the baby usually slips out easily, and the umbilical
cord is cut.
Episiotomy
As the baby’s head appears, the perineum may stretch so tight that the
baby’s progress is slowed down. If there is risk of tearing the mother’s skin,
the doctor may choose to make a small incision into the perineum to enlarge
the vaginal opening. This is called an episiotomy. If the woman has not had
an epidural or pudendal block, she will get a local anesthetic to numb the
area. Once the episiotomy is made, the baby is born with a few pushes.
Third stage
In the final stage of labor, the placenta is pushed out of the vagina by the
continuing uterine contractions. The placenta is pancake shaped and about
10 inches in diameter. It has been attached to the wall of the uterus and has
served to convey nourishment from the mother to the fetus throughout the
pregnancy. Continuing uterine contractions cause it to separate from the
uterus at this point. It is important that all of the placenta be removed from
the uterus. If it is not, the uterine bleeding that is normal after delivery may
be much heavier.

Breech presentation
Approximately 4% of babies are in what is called the “breech” position when
labor begins. In breech presentation, the baby’s head is not the part pressing
against the cervix. Instead the baby’s bottom or legs are positioned to enter
the birth canal instead of the head. An obstetrician may attempt to turn the
baby to a head down position using a technique called version. This is only
successful approximately half the time.
The risks of vaginal delivery with breech presentation are much higher than
with a head-first presentation. The mother and attending practitioner will
need to weigh the risks and make a decision on whether to deliver via a
caesarean section or attempt a vaginal birth. The extent of the risk depends
to a great extent on the type of breech presentation, of which there are
three. Frank breech (the baby’s legs are folded up against its body) is the
most common and the safest for vaginal delivery. The other types are
complete breech (in which the baby’s legs are crossed under and in front of
the body) and footling breech (in which one leg or both legs are positioned to
enter the birth canal). These are not considered safe to attempt vaginal
delivery.
Even in complete breech, other factors should be met before considering a
vaginal birth. An ultrasound examination should be done to be sure the baby
does not have an unusually large head and that the head is tilted forward
(flexed) rather than back (hyperextended). Fetal monitoring and close
observation of the progress of labor are also important. A slowing of labor or
any indication of difficulty in the body passing through the pelvis should be
an indication that it is safer to consider a cesarean section.
Cesarean sections
A cesarean section, also called a c-section, is a surgical procedure in which
incisions are made through a woman’s abdomen and uterus to deliver her
baby.
Cesarean sections are performed whenever abnormal conditions complicate
labor and vaginal delivery, threatening the life or health of the mother or the
baby. In 2002, just over 26% of babies were born by c-section, an increase of
7% from the previous year. The procedure may be used in cases where the
mother has had a previous c-section and the area of the incision has been
weakened. Dystocia, or difficult labor, is the another common reason for
performing a c-section.
Difficult labor is commonly caused by one of the three following conditions:
abnormalities in the mother’s birth canal; abnormalities in the position of the
fetus; abnormalities in the labor, including weak or infrequent contractions.
Another major factor is fetal distress, a condition where the fetus is not
getting enough oxygen. Fetal brain damage can result from oxygen
deprivation. Fetal distress is often related to abnormalities in the position of
the fetus, or abnormalities in the birth canal, causing reduced blood flow
through the placenta.
Other conditions also can make c-section advisable, such as vaginal herpes,
hypertension (high blood pressure) and diabetes in the mother. Some parents
choose to have a c-section because they fear the pain or unpredictability of
labor or they want to avoid pelvic damage.
- Surgical delivery of an infant through the abdominal and uterine wall. Often
performed as an emergency for abruptio placentae, placenta previa, or
cephalopelvic disproportion. May be scheduled for “previous c-section.”
- Performed when safe vaginal delivery is questionable or immediate delivery
is crucial because the well-being of the mother or fetus is threatened

Indications
·Abnormal presentations (breech, transverse, etc.)
·Abruptio Placenta
·Carcinoma of the Cervix
·Cephalopelvic Disporportion (CPD)
·Cervix will not dilate
·Fetal distress** Most common reason
·Habitual death of the fetus during the course of labor
·Placenta Previa
·Preeclamptic toxemia in pts where difficult labor is anticipated
·Presence of STDs such as genital herpes
·Previous cesarean section
·Prolapse of the umbilical cord

Surgical Intervention: Special precautions

- Patient Factors
- Psychological status
- Significant other present or not
- Room Set-up: all preparations are made before the anesthetic is
administered. If regional anesthesia is planned, the set-up, counts, and
preliminary routines can be performed simultaneously w/anesthesia
procedures. If general, the set-up, prep, catheterization, gowning & gloving
of all personnel and draping are performed before anesthesia induction.
Why?

- Method: Regional (Epidural preferred or Spinal) or Local or General

- Equipment: spinal or epidural tray
- Other meds: Oxytocin (Pitocin) 10-20 u per liter of IV fluids once infant is
delivered to minimize blood loss
- Oxytocin may be used to induce or continue labor, contract the uterus post
delivery; stimulate lactation
- Carbopost (Hemabate) parenteral oxytocic used to control uterine
hemorrhage following childbirth
- Ergonovine, Methylergononvine (Ergotrate, Methergine) causes uterine
muscle contraction
- Position during procedure
- Supine with roll at Rt hip to displace the uterus & prevent aortocaval
compression
- Supplies and equipment: rolled sheet for hip roll, safety belt
- Special considerations: high risk areas: bony prominences; assistance PRN
-awkward and in pain/between contractions
- Method of hair removal: wet prep or clippers
- Anatomic perimeters: Similar to laparotomy-table side to table side; to
xiphoid process extending down to mid thigh: NO Vaginal prep
- Solution options: Betadine or Duraprep or Hibiclens
- Insert foley before prep
- Types of drapes: C-Section pack includes laparotomy drape, which may
sticky clear plastic around fenestration and fluid-catching channels
- Order of draping: 4 towels, abd drape
- Special considerations
- State/Describe incision
- Skin: Low transverse Pfannenstiel (Most common) or low midline vertical;
length depends on estimated size of fetus
- Uterus: type depends on the need for the c-section
Supplies
- General: prep set, C-Section pack, basin set, gloves
- Specific
- Bulb syringe for infant suction
- Cord clamps, 2 per infant
- Delee suction device
- Cord blood tubes (2)
- Blood gas tubes on standby
- Suture/dressings of choice
- Medications on field (name & purpose)
- General: those for a major GYN laparotomy plus (below) or C-Section tray
(facility specific)
Specific
- Delivery forceps (in room), a cord clamp, mucus aspiration bulb, possible
Delee suction trap, Lister bandage scissors, Foerster ring forceps, Pennington
forceps, Delee retractor, (2) lab tubes for cord blood
- General: ESU, Suction
Specific:
- Infant radiant warmer mobile unit and possibly additional transport device
depending on location of procedure (OR vs L & D)
- Fetal monitor
PROCEDURE STEPS:
- Incision is made (#10 blade) and tissues of abdomen are divided w/usual
fashion: have goulet or army-navy ready for muscle separation at midline &
fascial incision and dissection
- Peritoneal covering over bladder is palpated (to ensure no inclusion of
bladder, bowel, or omentum) and incised (exposing distended uterus). 2 crile
hemostats are used to elevate the peritoneum about 2 cm apart.
- Bleeding sites will be clamped but not ligated until later (typically)
- The uterus is quickly palpated to determine fetal placement & position
- STSR: Be ready with dry lap sponges, bulb syringe, and suction
- Amniotic fluid is quickly evacuated from field
- Assistant retracts the bladder downward with the bladder blade or other
similar retractor
- Surgeon nicks the uterus w/deep knife and extends the incision w/bandage
scissors (blunt tips prevent injury to fetus)
- STSR may be asked to remove bladder retractor & simultaneously assistant
pushes firmly on upper abd while surgeon grasps infant’s head & rotates
upward
- Head is delivered from wound & airways immediately suctioned with bulb
(poss Delee)
- STSR: Once the head is controlled, all sharp and metal objects are removed
prior to elevating the infant’s head
- The umbilical cord is clamped and cut. Cord blood sample is collected
(surgeon may milk the cord)
- The infant is passed off to the pediatrician and into the warmed crib for
assessment and possible emergency resuscitation measures
- STSR: Protect your sterile field
- The placenta is delivered, inspected, & removed to back table (usually in a
basin)
- The uterine interior may be cleaned w/a moist lap sponge. Oxytocin MAY be
injected into the uterus to help with hemostasis
- The surgeon closes the uterus in 2 layers with 2-0 or 0 absorbable suture
(chromic catgut, Vicryl, or Dexon)-running stitch
- The bladder flap may be approximated or not-if so, a 2-0 or 3-0 absorbable
suture w/fine taper needle is often used
- The abdominal cavity is examined for bleeding, sponges, etc and is
irrigated.
- Surgeon closes abdominal wall and skin for low transverse incision;
subcuticular stitch or staples are used for closure.
- Blood clots are expressed from the uterus (STSR may be asked for basin at
perineum).
- Wound and vaginal area are cleaned
- Dressing & perineal pad applied

Dressing, Casting and Immobilizers

*Types & sizes
- Abdominal dressing and perineal pad
*Type of tape or method of securing
- Silk, paper, foam tape. Elastoplast for compression dressing as ordered.
Specimen and Care
- Identified as: Placenta is sent per surgeon request for evaluation
- Cord blood tubes x 2 filled
- Blood gasses of cord may be ordered and drawn by circulator or peds from
the artery within the umbilical cord
- Handled: Placenta is usually sent in formalin, if sent

Postoperative Care
*Destination
- Allow for bonding time with infant if possible
- PACU
- Expected prognosis (Good, Depends on Indication and any anesthetic
complications) * mortality is 4-6 times that assoc w/vaginal delivery
- Maternal: healing & care of surgical wound
increased risk of future C-section
Infant: prognosis depends on reason for C-section and extent of oxygen
deprivation
*Potential complications
- Hemorrhage: Fundus must be massaged just after delivery and become
firm to help stop bleeding
- Infection
- Other: Injury to surrounding structures
*Surgical wound classification: II

ARTERIOVENOUS FISTULA

An arteriovenous fistula is an abnormal channel between an artery and a

vein.
·Although doctors may be able to hear the distinctive sound of blood flow
though a fistula by using a stethoscope, imaging tests are often needed.
·Fistulas can be cut out or eliminated with laser therapy, or sometimes
substances are injected into the fistula to block the blood flow.
Normally, blood flows from arteries into capillaries and then into veins. When
an arteriovenous fistula is present, blood flows directly from an artery into a
vein, bypassing the capillaries. A person may be born with an arteriovenous
fistula (congenital fistula), or a fistula may develop after birth (acquired
fistula).
Congenital arteriovenous fistulas are uncommon. Acquired arteriovenous
fistulas can be caused by any injury that damages an artery and a vein that
lie side by side. Typically, the injury is a piercing wound, as from a knife or
bullet. The fistula may appear immediately or may develop after a few hours.
The area can swell quickly if blood escapes into the surrounding tissues.
Some medical treatments, such as kidney dialysis, require that a vein be
pierced for each treatment. With repeated piercing, the vein becomes
inflamed and clotting can develop. Eventually, scar tissue may develop and
destroy the vein. To avoid this problem, doctors may deliberately create an
arteriovenous fistula, usually between an adjoining vein and artery in the
arm. This procedure widens the vein, making needle insertion easier and
enabling the blood to flow faster. Faster flowing blood is less likely to clot.
Unlike some large arteriovenous fistulas, these small, intentionally created
fistulas do not lead to heart problems, and they can be closed when no longer
needed.
Symptoms and Diagnosis
When congenital arteriovenous fistulas are near the surface of the skin, they
may appear swollen and reddish blue. In conspicuous places, such as the
face, they appear purplish and may be unsightly.
If a large acquired arteriovenous fistula is not treated, a large volume of
blood flows under high pressure from the artery into the vein network. Vein
walls are not strong enough to withstand such high pressure, so the walls
stretch and the veins enlarge and bulge (sometimes resembling varicose
veins). In addition, blood flows more freely into the enlarged veins than it
would if it continued its normal course through the arteries. As a result, blood
pressure falls. To compensate for this fall in blood pressure, the heart pumps
more forcefully and more rapidly, thus greatly increasing its output of blood.
Eventually, the increased effort may strain the heart, causing heart failure.
The larger the fistula, the more quickly heart failure can develop.
With a stethoscope placed over a large acquired arteriovenous fistula,
doctors can hear a distinctive “to-and-fro” sound, like that of moving
machinery. This sound is called a machinery murmur. Doppler
ultrasonography is used to confirm the diagnosis and to determine the extent
of the problem. For fistulas between deeper blood vessels (such as the aorta
and vena cava), magnetic resonance imaging (MRI) is more useful.
Treatment
Small congenital arteriovenous fistulas can be cut out or eliminated with laser
coagulation therapy. This procedure must be done by a skilled vascular
surgeon, because the fistulas are sometimes more extensive than they
appear to be on the surface. Arteriovenous fistulas near the eye, brain, or
other major structures can be especially difficult to treat.
Acquired arteriovenous fistulas are corrected by a surgeon as soon as
possible after diagnosis. Before the surgery, a radiopaque dye, which can be
seen on x-rays, may be injected to outline the fistula more clearly in a
procedure called angiography. If the surgeon cannot reach the fistula easily
(for example, if it is in the brain), complex injection techniques that cause
clots to form may be used to block blood flow through the fistula. For
example, coils or plugs may be inserted into the fistula at the various points
where the vein and the artery meet. This procedure is done using x-rays for
guidance and does not require open surgery.