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Large masses can show central areas of low density with distinct nonenhancing radial or fissured bands. Medication utilization and annual health care costs in patients with type 2 diabetes mellitus before and after bariatric surgery [published correction appears in Arch Surg 2011;146:659]. Yanagita S, Natsugoe S, Uenosono Y, et al: Morphological distribution of metastatic foci in sentinel lymph nodes with gastric cancer. Anticholinergic effects may be more pronounced in patients taking ipratropium or tiotropium. Benign tumors of the gallbladder include adenomas, villous papillomas, paragangliomas, and granular cell tumors. Benign lesions such as cysts (left hepatic lesions in C) also show lack of Eovist uptake. Therefore, it is not clear if obesity, level of glycemia, or treatment modalities is independently or cumulatively responsible for fetal growth abnormalities. The retroperitoneal and mesenteric adenopathy in fungal infections such as histoplasmosis are often either of soft tissue attenuation or low attenuation. Clinical information such as stool culture, the immune status, and geographic location is helpful for a specific diagnosis. In the presence of persistent hyperglycemia and negative fluid balance, it may be worthwhile adding the amount of urine to the calculation of the fluids. As illustrated in this case, the fibrotic thickening of the liver capsule (arrows) is a frequent manifestation of cirrhosis but it is not always observed on imaging. In overdose the effects of both paracetamol (principally hepatotoxocity) and opioid toxicity (neurological and respiratory depression) may be evident. The study suggested that over 70% of the maternal glyburide was transferred through the placenta to the fetus. This is especially important if the patient is admitted to hospital (see Clinical tip). Doxazosin is an -blocker used in hypertension and benign prostatic hyperplasia; it has no role in atrial fibrillation. In cardiac arrest, restoration of output is often followed by adrenaline-induced hypertension. However, because a percentage of these polyps are adenomatous and cannot be distinguished from hyperplastic polyps, endoscopic removal is recommended to exclude premalignant lesions. Once hyperglycemia is identified, a disruption of the normal relationship between -cell function and insulin sensitivity is established. Barium studies show small bowel polyps that are too numerous to count and some gastric and colonic polyps. It can be partially overcome by increasing the dose and/or frequency, but this can generate the opposite effect: excessive and involuntary movements (dyskinesias) at the beginning of the dosage interval. G, the lesion exhibits an increased activity on technetium99m heat-damaged red blood cell scintiscan; this finding is diagnostic of splenosis. Bladder biopsy specimens may not be accurate in staging the lesion because samples may not include lamina propria to assess bladder muscle invasion. Once the affected part of the esophagus is localized, the surgeon will determine the technique. Because of the invasive nature of this examination, patients may require sedation. In nonpregnant individuals, repetition of the test showed a mean difference of 26 mg/dL at one-hour and 20 mg/dL at twohour levels. Nishimori I, Tamakoshi A, Otsuki M: Prevalence of autoimmune pancreatitis in Japan from a nationwide survey in 2002.

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Good communication with your patient about the aims and benefits of treatment, as well as its potential side effects, are therefore very important. A B will arise from the absolute value of the difference in number between fat protons and water protons. Microscopic examination shows extension of epithelium into the mucosal invaginations of the muscle. The doctor begins to prescribe clarithromycin, but is alerted to a possible interaction by the electronic prescribing system. Treatment duration should be as short as possible to limit toxicity, often a single dose and usually less than 7 days. Infectious Causes Infectious diseases of the small bowel can be caused by various organisms, including bacteria, viruses, parasites, and fungi. Loop diuretics such as furosemide are useful in patients with pulmonary edema or those that require a few days of antihypertensive medication. Multiple antiviral medications, such as zidovudine, efavirenz, didanosine, and protease inhibitors are known to cause acute and chronic pancreatitis, some by inducing hyperlipidemia. Combined hepatocellular-cholangiocarcinoma tumors share overlapping pathologic and imaging features of hepatocellular carcinoma and cholangiocarcinoma. At microscopic examination, the appearance of metastases varies depending on the tumor of origin. Central nervous system toxicity (including convulsions and coma) can occur with high doses of penicillin or where severe renal impairment delays excretion. Although the authors recommended postponement of delivery until 39 weeks, this endorsement was based on nondiabetic patients. Axial contrast-enhanced (A) and coronal reformatted (B) computed tomography images show the metastatic focus (arrows) appearing as a focal enhancing mass in the fundus protruding into the gallbladder lumen. Peritoneal deposits on serosal surfaces adhere through fibrinous exudation and may incite a desmoplastic response. The main modes of transmission are via unprotected sexual intercourse and needle sharing during intravenous drug use. Hypersensitivity reactions to phenytoin range from mild skin rash to the rare lifethreatening antiepileptic hypersensitivity syndrome (see Carbamazepine). This is followed by the functional and drainage phases that comprise 10- to 30-second images for at least 20 minutes. These terminologies were standardized by the 1992 International Symposium on Acute Pancreatitis3 and should be included in the radiology reports. In both groups, the counterregulatory growth hormone response diminished progressively during pregnancy. In a minority of cases, symptoms such as flank pain, nausea, vomiting, and fever are produced by mass effect and intratumoral or perirenal hemorrhage. The rationale for this treatment is the high frequency of multifocal tumor and ipsilateral recurrence and the low incidence of contralateral disease. The intensity of screening of patients at risk for the disease will affect the prevalence of the disease in a given population. Bacteria resist the actions of penicillins by making -lactamase, an enzyme which breaks the -lactam ring and prevents antimicrobial activity. They can typically manifest as multiple nodules (30% of cases), exophytic masses, or intramural masses. Kloppel G, Luttges J, Sipos B, et al: Autoimmune pancreatitis: pathological findings. Computed tomography image (C) after Nissen fundoplication demonstrates a curved apparent gastric wall thickening that represents the stomach fundus wrapped around the distal esophagus at the gastroesophageal junction. Intraarterial vasodilator therapy may be helpful in acute mesenteric ischemia to prevent or treat vasospasm.

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B, An intraoperative picture of partially resected liver tumor confirming the same finding (arrows). Furthermore, certain outcome variables will be influenced by physician behavior based on legal and social pressures. One problem with oral agents is the debate if these drugs can be used in the first trimester even if it appears safe to use glyburide and metformin throughout pregnancy. Long, smooth, benign-appearing stricture (A) involving the common duct, with multiple pancreatic duct strictures (B). This could be related to hormonal changes of pregnancy as well as to the effects of pregnancy on the gastrointestinal system. Lymphangiomas can be divided into three types according to the size of the vascular channels: capillary, cavernous, and cystic. The efficiency of scintigraphy in the detection of carcinoids is 75% to 80%, and the efficiency of scintigraphy followed by radio-guided surgery exceeds 90%. Solid food empties the slowest, followed by semisolid food, which empties slower than nutrient liquids. In longer-term treatment (which is more likely when they are used as an antipsychotic), other extrapyramidal syndromes such as tardive dyskinesia may occur (see Antipsychotics, first-generation [typical]). Gargouri L, Ponsot P, Viala J, et al: Recurrent autoimmune pancreatitis in a 10 year old boy. Sulphonylureas should be prescribed with caution for people at increased risk of hypoglycaemia, including those with hepatic impairment (reduced gluconeogenesis), malnutrition, adrenal or pituitary insufficiency (lack of counter-regulatory hormones) and the elderly. Molecules are adsorbed onto the surface of the charcoal as they travel through the gut, reducing their absorption into the circulation. A high index of suspicion is needed to facilitate early diagnosis and intervention and should be prompted when peritoneal signs are present. However, the rate of birth defects in infants of women with diabetes remains higher than that in the general population. Gray attenuation is the least specific of, and is common in, both benign and malignant diseases and is thickened bowel wall that shows attenuation comparable to that of enhanced muscle. A double-blind randomized comparison of meal-related glycemic control by repaglinide and glyburide in well-controlled type 2 diabetic patients. The limitation of this study is the small sample size; the results could have been affected by both alpha and beta errors. This helps in differentiation from chronic cholecystitis, in which the outer wall of enhancement is smooth. Gallstones and reflux of pancreaticobiliary enzymes are thought to result in chronic repetitive inflammation of the gallbladder mucosa that, over time, may undergo malignant transformation into invasive carcinoma. In itself, pregnancy does not appear to alter the course of retinopathy in women with diabetes. At macroscopic examination, concentric rings can be seen with the central necrotic hyphae; these rings are surrounded by viable hyphae and a rim of peripheral inflammation. The fetal insulin hypothesis: an alternative explanation of the association of low birthweight with diabetes and vascular disease. A second contrast-enhanced phase of imaging would potentially be useful in differentiating active arterial extravasation from a hypervascular mass lesion. As a folate antagonist, trimethoprim can impair haematopoiesis, causing haematological disorders such as megaloblastic anaemia, leucopenia and thrombocytopenia. Benign strictures are smoothly tapering and do not have an associated soft tissue mass. The involved gland appears hypointense or hyperintense on T1-weighted imaging and hyperintense on T2-weighted imaging. Additionally, the intestinal mucosa becomes hyperpermeable, perhaps related to reduced oncotic pressure; this may account for bacterial translocation from the gut to the peritoneal space, resulting in spontaneous bacterial peritonitis. As a result of portal hypertension and microvascular hepatic alterations, varices form, ascites develops, and hypersplenism occurs.

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If they are regularly passing more than two or three soft stools per day, the dose should definitely be reduced or the laxative stopped. Treatment When lesions are small, asymptomatic, and discovered incidentally, no treatment is necessary. Thus, failure to achieve successful outcome is not due to the questionable need for treatment but may suggest an inappropriate treatment approach. The incidence of hypoglycemia in women with type 1 diabetes increases during pregnancy, particularly during the first half of pregnancy. A liver profile should be measured before starting statin treatment and again at 3 months. A well-described presentation in men is new unilateral (usually left) varicocele secondary to compression or obstruction of the ipsilateral renal vein by tumor or thrombus. B, Arteriogram of the gastroduodenal artery demonstrates a pseudoaneurysm (arrow) originating from the gastroduodenal artery. Microscopic findings of anisonucleosis and distended intracytoplasmic lumina support the diagnosis of bile duct cancer. The other drugs have no role in secondary prevention following myocardial infarction. Is early-pregnancy proteinuria associated with an increased rate of preeclampsia in women with pregestational diabetes mellitus Bergquist A, Lindberg G, Saarinen S, et al: Increased prevalence of primary sclerosing cholangitis among first-degree relatives. Spot film from a dedicated small bowel follow-through shows multifocal sites of angulation and tenting consistent with adhesions. The long-term antihypertensive effect is probably mediated by vasodilatation, the mechanism of which is incompletely understood. Clinical presentation includes abdominal pain in 66%, obstruction in 40%, and gross intestinal hemorrhage in 24% of patients. Encourage the patient to return if he is having a lot of trouble with side effects, as other treatments for his enlarged prostate could be considered. This can occur in up to one third of benign tumors and cause symptoms such as early satiety, nausea, vomiting, constipation, abdominal distention, and a palpable mass. High-grade dysplasia represents the interface between benign adenoma and invasive cancer. Mechanisms of action Important adverse effects Warnings Important interactions 232 sodium chloride 0. A lateral abdominal radiograph may show calcified plaques at the origins of the mesenteric arteries. The end stage of this process is cirrhosis, in which dense fibrous bands divide the liver into parenchymal nodules. Rarely, but more seriously, they may cause faecal impaction and gastrointestinal obstruction. When administered in nebulised form as a mucolytic, acetylcysteine may cause bronchospasm. Betablockers and aspirin can also increase the potassium concentration, but this effect is not usually significant. You may therefore need to provide this artificially by increasing the dose of exogenous corticosteroid. Unfortunately, this leaves one-third to two-thirds of women at risk for type 2 diabetes undiscovered. Based on imaging studies, gastric outlet obstruction is a relatively straightforward diagnosis to make. The embolus is usually of cardiac origin; hence, myocardial infarction, arrhythmia, valvular disease, and ventricular aneurysm are important risk factors.

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Secondary (acquired) causes of hepatic iron overload include the iron-loading anemias (thalassemia major, sideroblastic anemia, chronic hemolytic anemia, and spur cell anemia), long-term hemodialysis, and dietary iron overload. Coagulopathy is probably due to sequestration of red blood cells and platelets and to consumption of clotting factors in hemangiomas. Intravenous valproate can be used temporarily where oral administration is not possible. Furthermore, weight reduction is not recommended in pregnancy even in obese patients. Women with long-standing type 2 diabetes who have diminished endogenous production of insulin and who are dependent on exogenous insulin or certain oral hypoglycemic agents are also at risk for hypoglycemia, although the incidence and severity of hypoglycemia in this population is lower. Cariati A, Piromalli E, Cetta F: Gallbladder cancers: associated conditions, histological types, prognosis, and prevention. Ensure that both you and the patient are clear on the intended duration of therapy. Its age-adjusted incidence rate is 11 in 100,000, and it constitutes more than 90% of the malignant tumors of the pancreas. The Brazelton scale has gained wide acceptance as one of the premier instruments for integrative characterization of nervous system function in the newborn period. However, these protocols are only general guidelines and the therapeutic regimen is tailored to the individual patient on the basis of her prominent clinical features. Thus, the media rely on the structural changes in bowel, to recognize abnormalities. Relatively inexpensive non-proprietary formulations are available and should be preferred in most cases. In accord with earlier studies, these pregnancies were complicated by an excess of hypertension and premature delivery, but not by accelerated progression of nephropathy. Three conditions need to be met for early detection: (1) the results must provide clinically important gains, (2) the benefits must exceed the negative effects of testing, and (3) the net benefit (total benefit less the total harm) must justify the economic costs of testing and treatment. Although her wrist has now healed, she is keen to continue taking the codeine, as not having to open her bowels so regularly has considerably improved her quality of life. Therefore, patients with renal compromise Glimeperide Glimeperide is a sulfonylurea drug. It is, however, still available in the oral form, both in short-acting and extended release. It is responsible for 10% of new cancer cases and 9% of cancer-related deaths annually in the United States, representing an estimated 146,970 new cases and 24,680 deaths each year. However, without adequate evidence-based research findings, we will not know if improved perinatal outcomes can be achieved with modification of glucose-loading test thresholds. To understand the related imaging, it is important to be familiar with the postoperative anatomy. The stomach may be right-sided or left-sided in both polysplenia and asplenia syndromes. The normal jejunum wall thickness measures approximately 2 mm and the ileum 1 mm on enteroclysis. With invasive techniques, such as those just mentioned, the evaluation of the pancreatic exocrine function is performed by measuring bicarbonate output and concentration in the pure pancreatic juice collected after secretin stimulation. Diffuse mesenteric arterial narrowing on angiography without evidence of occlusion suggests nonocclusive mesenteric ischemia, although vasculitis also may be considered. A and B, Double-contrast barium radiography demonstrates limited distensibility and thickened gastric folds (arrows). Pancreatic necrosis is defined as focal or diffuse areas of nonviable pancreatic parenchyma and is typically associated with peripancreatic fat necrosis.

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The criteria for a good liquid-phase marker includes the ability to equilibrate rapidly and be nonabsorbable. Barium studies of the colon used to be the primary noninvasive imaging technique to evaluate the colon in case of colonic inflammation. Explain that you are offering a treatment to make their airways relax, which should therefore improve their breathing. Circumferentially infiltrated lymphoma causing irregular narrowing of a jejunum segment (arrows). Ampullary biopsy with IgG4 staining may be helpful in diagnosis if other imaging and clinical features are less clear. Its major effect is to decrease hepatic glucose output and lower fasting glycemia. Safety of glyburide for gestational diabetes: a meta-analysis of pregnancy outcomes. Maternal obesity is associated with dysregulation of metabolic, vascular, and inflammatory pathways. Using the maximum dose of insulin that could be tolerated by the mother, they carried 94% of the pregnancies to 38 weeks or more, 10% not being delivered until after 40 weeks. Acute abdominal series in a 38-year-old woman with abdominal distention and vomiting. As they reduce uric acid excretion, they may precipitate acute attacks in patients with gout. Unless their use is essential, quinolones should be avoided in pregnancy and in children as they may cause arthropathy. Aldosterone antagonists can cross the placenta during pregnancy and appear in breast milk so should be avoided where possible in pregnant or lactating women. Prescribe nicorandil using its generic name as this will allow the pharmacist to dispense the non-proprietary formulation rather than the branded preparation, which is about twice as expensive. It is understandable that shock and anxiety at the news of such a diagnosis may make it harder for patients to fully absorb the implications of the condition. Surgery remains the mainstay in the treatment of hepatoblastoma, with prognosis directly related to tumor stage. If a cutoff of 4000 g is used, then 169 cesarean sections would be required in diabetic versus 654 in nondiabetic women. Mention that, very rarely, this medicine can cause effects similar to severe allergic reactions; they should stop taking it and seek urgent medical advice if they develop facial swelling or stomach pains. With diffuse intrahepatic tumors, orthotopic liver transplantation may be considered. Biliary complications, which include bile leakage and bile duct stricture, occurring in 7% to 10% of donors, represent the most common cause of morbidity in living-donor liver transplantation. Before starting treatment, you should first exclude reversible causes, such as electrolyte disturbances and drug causes. Most benign tumors are clinically silent and may be discovered incidentally; however, large or soft lesions may act as a lead point for an intussusception and cause bowel obstruction. Differentiating among these various concerns requires careful history-taking and radiologic investigation. Symptoms of cholangiocarcinoma result from biliary obstruction with subsequent cholestasis and hyperbilirubinemia. The solid emptying demonstrates an initial lag phase, followed by a constant linear rate of gastric emptying. Alterations in fetal carbohydrate metabolism may also contribute to intrauterine asphyxia. One disadvantage of negative contrast agents are magnetic susceptibility artifacts by ferrous oxide on gradient-echo sequences. As the oral drops have greater bioavailability than tablets, they are prescribed at different doses.

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Less invasive alternatives to surgical resection include hepatic artery chemoembolization and percutaneous tumor ablation by using methods such as radiofrequency, cryosurgery, microwaves, ethanol, or interstitial laser thermotherapy. For example, in acute stroke, explain that part of the brain is being starved of blood and oxygen due to a blocked artery, which will cause long-term damage. Surgical Treatment Surgery is usually not indicated in the treatment of the diseases discussed in this section. Relapses are seen in 6% to 26% (average, 17%) of cases after tapering of corticosteroids or while on maintenance therapy, and these patients may require a second course with a higher dose or a longer maintenance dose of steroids or addition of immunomodulators such as mycophenolate mofetil or azathioprine. Normal Anatomy Anatomic variants of the biliary, hepatic arterial, hepatic venous, and portal venous anatomy are common. Most hyperplastic polyps appear as sharply defined, round or oval filling defects measuring less than 1 cm. The key and only essential biochemical marker of perinatal risk in diabetic pregnancies is the maternal glucose concentration. As a rule of thumb, the physician must always consider the efficacy of his treatment rather than censuring the drug for failure to achieve targeted levels of glycemic control and desired pregnancy outcome. The most common dose-related adverse events are gastrointestinal upset (such as nausea, gastric irritation and diarrhoea), neurological and psychiatric effects (including tremor, ataxia and behavioural disturbances), thrombocytopenia and transient increase in liver enzymes. The device and/or flow rate should be adjusted as necessary to keep the SpO2 within the target range. This would include sources of hemorrhage elsewhere, including intra-abdominal, retroperitoneal, or intramuscular locations. Larger lesions cause symptoms such as left upper quadrant pain, nausea, and abdominal distention. Measurements of skinfold thickness can provide reasonable assessment especially if taken at multiple sites. In patients with hematologic and autoimmune disorders, the presence of accessory spleens should be noted before planning splenectomy to guide surgeons to remove all functional splenic tissue at surgery, because a remnant accessory spleen after the surgery may evoke relapse of the disorder. As diltiazem has mixed vascular and cardiac actions, it can cause any of these adverse effects. Umemura T, Ota M, Hamano H, et al: Genetic association of Fc receptor-like 3 polymorphisms with autoimmune pancreatitis in Japanese patients. Medical treatment includes restriction of oral intake, intravenous fluid and electrolyte resuscitation, and parenteral (narcotic) analgesia. This leads to increased peristalsis both above and below the obstruction with frequent loose stools and flatus early in its course. As a rapid volume overload has also been implicated in the etiology of cerebral edema, the fluid replacement after the first hour is provided according to the sum of the maintenance amount of fluid (1. Hematogenous spread from distant sites is rare and is mainly caused by breast and lung cancer. Maternal exposure to angiotensin converting enzyme inhibitors in the first trimester and risk of malformations in offspring: a retrospective cohort study. In addition to constitutional risk factors such as previous macrosomia and parity, level of glycemic control, obesity, and treatment modality were found to be independent contributors to the outcome variable. The homogeneous form is the most common; the heterogeneous and focal forms may simulate perfusion abnormalities, diffusely infiltrative disease, nodular lesions, or masses. Explain that he may also notice some tenderness or growth in the tissue underneath his nipples. In addition, association with the thin section images makes it possible to detect the related morphologic modifications, such as parenchymal atrophy or focal enlargement of the pancreatic parenchyma. Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. Although obesity in and of itself portends potential adverse outcome in pregnancy, gestational diabetic women treated with insulin and possibly oral antidiabetic drugs who achieve targeted levels of glycemic control will have pregnancy outcomes comparable to those of normal-weight women. Cost is not usually a consideration when prescribing aminoglycosides for life-threatening infection. Short-acting nitrates, such as glyceryl trinitrate, are taken during an attack of angina to relieve chest pain. Elli L, Buscarini E, Portugalli V, et al: Pancreatic involvement in von Hippel-Lindau disease: report of two cases and review of the literature.

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Hepatic venous variants relevant in donors and in recipients are summarized in Table 44-6. The normal increases in insulin response in early pregnancy are necessary for the anabolic changes in early pregnancy, that is, adipose tissue accretion is necessary for the caloric demands of the third trimester and lactation. The problem of diagnosing without an established diagnosis is putting the cart before the horse. The most significant ultrasound findings of chronic pancreatitis are pancreatic duct dilatation, intraductal calcifications, and pseudocysts. Villous polyps have a higher rate of malignancy (55%) and are removed endoscopically or surgically when found. Cross-sectional imaging can detect features of biliary dilatation and occasionally wall thickening and complications such as cholangiocarcinoma and cirrhosis. Does pregnancy increase the risk for development and progression of benign diabetic retinopathy Acquisition of both a supine radiograph of the abdomen and an upright view of the chest is performed to evaluate for free intraperitoneal air. Insulin and glucose requirements during the first stage of labor in insulin-dependent diabetic women. Using only the lower end of the spectrum was considered potentially unethical to withhold treatment of women with elevated fasting glucose levels. In addition, most secondary causes of hepatic iron overload are characterized histologically by iron deposition within Kupffer cells rather than hepatocytes. Although a history or radiographic evidence of pulmonary tuberculosis may be suggestive, nearly one fifth of patients with abdominal tuberculosis have no evidence of extraabdominal disease. Therefore, in addition to the change from whole blood to plasma (14%), the C& criteria subtracted 5 mg from the threshold created by the original conversion and rounded out the results. C, Transverse ultrasound image of a patient with known acute pancreatitis showing a pancreatic/peripancreatic pseudocyst (arrow). The identification of a site of transition in the small bowel and detection of change in caliber from dilated to nondilated bowel is important in identifying the cause of obstruction. When exposed to a brief (one hour) episode of hypoglycemia during an early and vulnerable period of embryogenesis, mouse48 and rat49 embryos had growth retardation and gross developmental anomalies. During the surgery, the splenic artery was ligated to increase blood flow to the hepatic artery. Blood glucose is a continuous variable; therefore, sensitivity and specificity are inversely related. This increases plasma concentrations and risk of adverse effects with drugs metabolised by P450 enzymes. Patients with blue rubber bleb nevus and Klippel-Trenaunay syndromes can have lesions anywhere in the gastrointestinal tract. It has become axiomatic, even with scant data to support it, that patients with poor glycemic control and especially fetal macrosomia are associated with higher fetal death rates in the final weeks of pregnancy. There are no clinically significant adverse drug interactions with bulk-forming laxatives. Ultrasonography Ultrasonography can be used to locate dilated loops as well as to assess peristalsis and thus differentiate a mechanical obstruction from paralytic ileus. However, the most common adverse effects of activated charcoal are black stools and vomiting. The technique can evaluate areas of bowel dilatation or narrowing and is especially helpful in distinguishing partial and complete small bowel obstructions, in which no distal oral contrast is identified in complete small bowel obstructions. The Small Lesion (6 to 9 mm) Two thirds of small polyps are adenomatous, and approximately 4% will have advanced histologic findings. Dose-dependent effects of glyburide on insulin secretion and glucose uptake in humans. For nondiabetic patients, as approximately 50% of shoulder cases occur below 4000 g, any threshold above 4000 g that requires cesarean delivery will result in fewer cases of shoulder dystocia. Portal hypertension increases portal venous pressure, which leads to hepatofugal venous flow through the coronary vein into a plexus of dilated esophageal and periesophageal veins.

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