Control of pharyngeal gonorrhoea is particu- ommend ceftriaxone as the only first‐line antibiotic larly important as most antibiotic resistance develops at remaining to treat gonorrhoea effectively (including this site  cheap cytotec online american express symptoms checker. An equivalent the most pressing problem of gonorrhoea control is contribution to other lower or upper genital tract infec- the likelihood that the infection will become untreata- tion in women purchase cytotec on line treatment 197 107 blood pressure, over and above that of gonorrhoea and/or ble within the next decade . The organism can chlamydia, has been less widely researched because of its evade host immune responses by having a widely vari- relatively recent discovery and the limitations of diagnostic able surface structure and rapidly evolves resistance expertise confined to a small number of centres. Antibiotic concentrations are higher mucosal surfaces, and other members of the genus (e. Complete resistance to ceftriaxone is currently mucopurulent cervicitis, with one group showing a 3. The pharynx was the nition of cervicitis hamper accurate comparisons between site of all resistant strains in the last European‐wide studies , and characterizing its role in vaginal discharge report . High‐level azithromycin resistance in the has remained elusive for similar methodological reasons. The first dual failure of ceftriaxone and azithro- major study showed a lack of association of M. A recent meta‐analysis suggests niques , necessitating ever closer working between that the association is statistically significant , but gynaecologists, sexual health clinicians and microbiolo- might be only marginally clinically relevant due to the low gists to achieve therapeutic success. This suggests that only a small minority of infected women are susceptible to significant damage while most are unaf- Untreated or untreatable gonorrhoea fected. For obvious ethical reasons, no modern data are availa- ble on the long‐term course or duration of untreated Mycoplasma genitalium in pregnancy gonorrhoea in women but, in the worst‐case scenario, the possibility of untreatable infection may prompt a In the antenatal setting, a large London study found a return to heroic surgical intervention for chronic disease. Treatment of Mycoplasma genitalium ● Complicated Consult microbiologist and/or sexual (see also Summary box 64. European guidelines recommend extended azithromycin ● Third line (after azithromycin and moxifloxacin regimens for 3 or 5 day as first‐line choice . However, over offensive vaginal discharge accompanied by pruritis, the next decade, the true relevance of M. In men it can cause overt urethritis widespread exposure to single‐dose azithromycin treat- but typically remains asymptomatic and clears sponta- ment of chlamydial infection, will become clearer as neously within only a few weeks. Black Caribbean compared with Caucasian origin  ● Second line Ofloxacin 200 mg b. Trichomonas vaginalis was more preva- lent than chlamydia or gonorrhoea at all ages except Unlike T. A fivefold mon in sexually active women and after male partner higher prevalence of T. Standard doses of metro- stain and wet‐mount microscopy, using a consistent ref- nidazole are safe to use at all stages of pregnancy but, erence standard – the Amsel method, Nugent score or likewise, treatment of T. Most formal research Treatment options and metronidazole has concentrated on one or other therapeutic method in resistance isolation, whereas tailored combinations of treatment may be required to achieve individual success, making Metronidazole 400 or 500 mg b. In cases of continued treatment failure, sims, including Atopobium vaginae, Prevotella spp. These associated bacteria and Mobiluncus curtisii, predominant include intravaginal dosage of paromomycin, furazo- among which is Gardnerella vaginalis, which is main- lidone, acetarsol, nonoxynol‐9 or povidone‐iodine. Each tained in a vaginal wall biofilm that persists despite met- has had limited success in small series or individual cases ronidazole treatment . After exclusion of other This has prompted alternative approaches to treat- causes of vulvo‐vaginal itch such as T. Newer edly during the luteal phase of the cycle, many on a intravaginal antiseptics have also failed to disrupt the specifically predictable day each month. Anectodal success has been have gross inflammation and pruritis by day 15 or 16 reported with this approach , which attempts to until gradual remission starts on the day of menstruation. A further tal or disseminated herpes; encouraging finding is a proven lower candidal relapse 3) management of first presentation and previously rate when adjunctive Lactobacillus therapy was used diagnosed genital herpes in pregnancy; with a conventional extended fluconazole regimen 4) management of frequently recurrent genital herpes in , but this has yet to reach robust guideline evi- perimenopausal women. Most vulvo‐vaginal candidiasis [207,209,210] will be unaware of their infection or have had such mini- Severe vulval candidiasis mal symptoms that the condition has passed entirely ● First choice Fluconazole 150 mg p. The ● Alternative Flucytosine 17% cream with or with- relative proportions of those infected and (un)affected out Amphotericin B 3% cream p. The following Minimal Misdiagnosed account is gleaned from 40 years’ clinical experience of some one or two cases per year since observing the larger Nil Hidden initial series. Most women will be dehydrated and in severe pain, and will require rehydration, systemic and. Retention of urine may mary genital episode, and then wrongly blames them for last from around 4 days to 3 weeks, and although in prac- knowingly spreading the infection. Formal surgical separation is occasionally Severe primary genital herpes required , but has been anecdotally avoided by topi- Most women with overtly symptomatic, true primary cal corticosteroid treatment  or awaiting spontane- anogenital herpes present first with a flu‐like illness, fol- ous remission . Symptoms typically commence 2–20 signs of ulceration, but with S2 neurology, inguinal lym- days after exposure, but the interval may be considerably phadenopathy and acute distress as above. Speculum longer if initial symptomless infection of sacral nerve examination (rarely performed in acute vulval herpes ganglia is followed by delayed primary recrudescence because of severe external pain) may reveal an acute . For those women with more severe signs of menin- sympathetic supply from S3 ± S4 which controls bladder gism, frank meningitis  or severe cutaneous or intra‐ and bowel function. Although the majority of women abdominal dissemination, which classically occurs in the presenting to sexual health clinics can be managed as immunocompromised, assistance from other specialists outpatients with oral aciclovir (400–800 mg t. Outcome after intravenous aciclovir: Complete recovery without scarring and healthy infant delivered near term. A combination of sup- appearance of herpes is post‐primary infection, in all but pressive and episodic treatments can be offered to cover the severest presentations. This represents the first visi- times of extra stress or holiday travel in those with less ble appearance of infection covertly acquired in the dis- frequent episodes, provided the temporary suppression tant past, caused by maternal immunosuppression, is started a few days beforehand. In greater control and a degree of freedom from the stress the pre‐aciclovir era, true primary herpes occurring in of recurrence. Transmission in discordant couples can the second trimester was usually disseminated and often be reduced by long term suppression and condom use fatal for the infant and mother . Nowadays, even , but most seronegative partners will eventually primary disseminated infection in a doubly‐immuno- acquire infection in the long term. These recurrences can be successfully sup- women at the fourchette, which is the principal area pressed by giving aciclovir in the luteal phase only . The As many of these women appeared to have their herpes lesions grow at and near the sites of healed micro‐ recurrences every month at the same time as their epi- lacerations. Perianal warts often occur in the absence of sodes of mood change in severe premenstrual syndrome any reported anal sex due to local inoculation by wiping. The rarest differential diagnosis is that of condy- fully prevented almost all herpes recurrences in a series lomata lata occurring in secondary syphilis, further of 12 women observed over a 9‐month follow‐up . Although overt external genital warts rarely ● First choice Aciclovir 5–10 mg/kg per 24 hours i. Multiple non‐keratinized vulval warts are usually first treated with podophyllotoxin 0.
Absolute contraindications to cardiac transplantation include: ongoing substance abuse cytotec 100mcg with mastercard medicine in ancient egypt, refractory psychiatric conditions buy 200mcg cytotec mastercard symptoms gonorrhea, suicidal behavior, severe personality disorder, issues with ongoing medical noncompliance, inadequate neurocognitive ability, irreversible hepatic or renal dysfunction, severe peripheral or cerebral vascular disease, systemic disease that limits rehabilitation, insulin-dependent diabetes with severe end-organ damage, or evidence of severe, fixed, secondary pulmonary hypertension [8–10]. With an assist device implanted, patients who would otherwise not survive long enough to receive a heart transplantation are now living independently at home with reasonably good quality of life until a suitable organ becomes available. This has impacted the number of patients reliant on inotropes at the time of transplant, with a decrease from 43. There are two broad categories of devices in use based on pump mechanism: pulsatile devices that employ some type of pneumatic pump, and continuous, or axial flow devices that involve a spinning propeller. The cycles of the pulsatile device are measured in beats per minute (bpm) and that of the continuous-flow pumps in revolutions per minute (rpm). Each device has an inflow cannula through which the patient’s blood is drawn from the heart and into the pump and an outflow cannula that directs the blood back into the patient’s circulation. For both pulsatile pumps and continuous-flow pumps, there are two more classifications that can be described on the basis of the location of the pump when implanted: intracorporeal, wherein the entire pump is implanted inside the body with the exception of the drive-line that powers the device and passes through an exit site on the abdomen; the other is paracorporeal, or extracorporeal, wherein the pump sits outside the body and the inflow and outflow cannulae enter and exit the skin on the upper abdomen just below the costal margin. The Levitronix CentriMag (now owned by Thoratec) is approved for temporary right ventricular assistance up to 30 days and its inflow cannula may be placed in either the right atrium or the right ventricle. Bridge to recovery refers to the patient who is expected to recover from heart failure and the device is used to sustain life until the time when it can be weaned off and explanted. It will be important not to begin administration of plasma and cryoprecipitate until the plan to proceed with the transplant is certain. The local organ-procurement agency will obtain consent for donation from the family and proceed with the donor evaluation and support. The donor evaluation consists of taking a general history of any illnesses or risk factors such as heart disease, hypertension, diabetes, or cigarette smoking. Specifics are gathered surrounding the time and mode of death to determine whether there is any potential cardiac injury, down time, cardiopulmonary resuscitation, or cardioversion. This consists of measuring central venous pressures and, potentially, full hemodynamic profiles if pulmonary artery catheter measurement capability exists at the hospital caring for the donor. The initial stabilization phase should include endocrine support with the administration of levothyroxine and corticosteroids, reduction of inotropic support if it is appropriate, and, potentially, diuresis or transfusion when indicated. A surface echocardiogram is then performed to make sure the heart is structurally normal and that function is normal. It is generally accepted that a cardiac catheterization will be necessary in male donors more than 40 years old and female donors more than 45 years old, but catheterization should also be performed in younger donors when the donor has a significant history of hypertension, cigarette smoking, diabetes, or alcohol abuse. Cardiac enzymes need to be carefully evaluated and correlated to any severe hemodynamic instability, the use of cardiopulmonary resuscitation, as well as the time of herniation . A number of studies have demonstrated correlations between elevations of troponin and early graft failure [19,20]. These data should be analyzed closely with the patient’s hemodynamic function and echocardiographic findings. A transplant center may request that a second echocardiogram be performed if the first echocardiogram was performed shortly after herniation. Catecholamine-induced left ventricular dysfunction can improve significantly in a short period of time and not preclude excellent short-and long-term outcomes. One must also take into consideration the ischemic time that will be incurred with procurement and travel time. The majority of transplant centers are willing to accept an ischemic time up to 4 hours for adult donors but no more than 6 hours. The advent of ex vivo perfusion offers the possibility of warm perfused preservation of thoracic organ grafts. Ex vivo perfusion uses warm oxygenated blood and an extracorporeal pump to perfuse organs during transport and preservation. This technology offers the potential for longer extracorporeal periods and possibly altering the paradigm of cold preservation. During this inspection, one should palpate the coronary arteries to discern any calcifications and also palpate the aortic root for calcifications. External evaluation of the heart is not a reliable evaluation of function unless there is something grossly abnormal, such as severe bruising from a myocardial contusion or a dilated right ventricle. Once it is determined that the heart is appropriate for transplantation and all of the other organ teams are ready, the donor is heparinized and cannulated. If the lungs are being harvested, a pulmonary artery cannula will be placed in the main pulmonary artery. The heart is vented via the left atrial appendage, excised, and is then submerged in ice slush saline, packaged sterilely, and placed in a cooler for rapid transport to the center caring for the recipient. Recipient Operation Once the recipient is prepared and draped, the median sternotomy incision is made and the heart is dissected free of any adhesions, and then cardiopulmonary bypass is established. The recipient is placed on total cardiopulmonary bypass, before the cross-clamp is applied to the aorta, and the heart is excised along the atrioventricular groove. The anastomoses are performed in the following order: left atrial, inferior vena caval, pulmonary arterial, aortic, and superior vena caval . Isoproterenol is used to maintain an appropriate heart rate if bradycardia is a problem or the heart is paced. The pulmonary artery catheter should be floated through the new heart so that pulmonary artery pressures can be monitored closely and any signs of right heart failure can be detected early. Postoperative Care the immediate postoperative management of a heart transplant recipient is by and large not unlike that of other cardiac surgery patients. A pulmonary artery catheter is used with continuous mixed venous oximetry and preload is optimized with either volume or diuretic. Usually patients come out of the operating room on Isuprel (isoproterenol) to stimulate the heart rate and/or the temporary pacemaker set to a back-up rate of 90 to 100 bpm or higher. After the first several days, the heart rate is allowed to drift to its baseline as the cardiac index allows. Occasionally, patients exhibit a distributive shock immediately postoperatively characterized by low systemic vascular resistance and vasopressin or neosynephrine is used to treat it. The ideal patient who is hemodynamically stable and has no signs of surgical bleeding can be extubated within a few hours. Sometimes, patients with right ventricular failure owing to pulmonary hypertension need to be treated with inhaled nitric oxide or epoprostenol (Flolan) and thus mechanical ventilation is continued. These patients have a tendency to bleed more postoperatively and one should keep a low threshold to return to the operating room for exploration if bleeding persists. Serious ventricular failure after cardiac transplantation is unusual and can be related to poor donor-organ selection, poor graft preservation, a long ischemia time, or rejection owing to the presence of preformed antibodies. Early rejection is often heralded by atrial fibrillation and the manifestation of arrhythmias should prompt an immediate workup and treatment. Plasmapheresis can be very effective in removing preformed antibodies responsible for humoral rejection.
These have informed study entered a new phase cytotec 100mcg discount treatment norovirus, the enrolment of a third gen- and improved our obstetric practice in many areas generic cytotec 100mcg fast delivery 97140 treatment code, eration of participants, the grandchildren of the original including the management of severe pre‐eclampsia cohort. Specifically in observational studies the data many of the key research questions in the discipline. Descriptive studies are cross‐ sectional studies that report the incidence or prevalence Study design of health‐related states at a specific time point. They do not attempt to provide an association between the expo- the premise of any research question or hypothesis is sure and outcome. Observational studies which are ana- based on the relationship between an exposure and out- lytical in nature are focused on determining the come of interest. In epidemiology, exposures are poten- relationship between exposure and outcome through dif- tial causal characteristics. In contrast, interventional studies (pharmacological and non‐pharmacological behavioural are studies in which the investigator specifically provides interventions), behaviour (e. Outcome study design adopted by researchers will depend on the refers to either disease states (e. All types of phenotypes that have the potential to increase adverse observational and interventional studies are described in outcomes (e. Study design is defined as the process in which a researcher or research team translates the hypothesis of Cross‐sectional studies interest through a detailed project plan into an opera- tional study. The types of research conducted are broadly Cross‐sectional studies involve observation of a total divided into observational and interventional research population, or a random subset of it, at a defined time. An observational study is when research is They provide information on an entire population under focused on the collection of health and socio‐demo- study and can describe absolute risks and not just rela- graphic variables related to exposure and outcome. They can also describe the prevalence of dis- variables can range from population‐based data (e. National audits of maternal and perinatal deaths sus data) to specifically designed health‐related question- are variants of cross‐sectional surveys . Study design Observational Interventional research research Descriptive Analytical Analytical Cross-sectional Ecological Case–control Cohort studies Clinical trials survey study studies Individual Community based based Perinatal Epidemiology and Statistics 461 or prospectively (the preferred method). Both cohorts are focused on identifying predictors Multiple pregnancies are counted only once. The cohort can also be selected by a specific causes but which was aggravated by the physiological event such as year of birth (a birth cohort). The cohort design, which can be ties during, but unrelated to, pregnancy or the either retrospective or prospective, allows the study of puerperium. It is costly and not to 1 year after abortion, miscarriage or delivery that is appropriate for rare diseases with a long latent period for the result of direct or indirect maternal causes. In a case–control study, partici- pants are selected on the basis of the outcome of interest. This can be further divided into: are selected without the outcome of interest to allow com- – Intrapartum stillbirth: a baby known to be alive at parisons to be made between exposures of interest. This can be For example, in the determinants of factors associated further divided into (i) early (0–6 completed days) with endometrial cancer in postmenopausal women and (ii) late (7–27 completed days). Data are ● Perinatal death: death of a fetus or a newborn in the then collected in both groups and factor(s) that are differ- perinatal period, which commences at 24 completed ent between the groups may demonstrate an association weeks’ gestation and ends before seven completed with the outcome of interest. Matching in case–control days after birth (total of stillbirths and early neonatal studies precludes the factor in which the groups are death). In the example cited, the effect of age on endometrial cancer cannot be determined. In common with all obser- vational studies, case–control studies do not prove causa- Cohort studies tion but instead demonstrate association. The strength of Cohort studies are a form of longitudinal observational association, coupled with biological plausibility, are some study used to analyse risk factors by studying groups of of the criteria used to suggest association as reported by people who do not have the disease either retrospectively the Bradford Hill Criteria (Table 33. The more specific an association between a factor and an effect, the bigger the probability of a causal relationship 4 Temporality the effect has to occur after the cause (and if there is an expected delay between the cause and expected effect, then the effect must occur after that delay) 5 Biological gradient Greater exposure should generally lead to greater incidence of the effect. In other cases, an inverse proportion is observed: greater exposure leads to lower incidence 6 Plausibility A plausible mechanism between cause and effect is helpful 7 Coherence Coherence between epidemiological and laboratory findings increases the likelihood of an effect 8 Experiment Occasionally it is possible to appeal to experimental evidence 9 Analogy the effect of similar factors may be considered Inherent within the design of case–control studies, the numbers and to select cohorts of disease and non‐dis- selection of cases and controls by the investigator pre- ease, and they are less time‐consuming since the main cludes any estimation of disease incidence. In contrast, prospective studies follow populations selected because they do not have the disease. In population risk studies, a mine true population risk (incidence of the disease in a large number of negative controls will be collected population) a larger cross‐sectional study or cohort depending on the disease incidence. A variation of this method is the nested of these studies are significantly higher, they provide an case–control study, where cases with a disease in a opportunity to specifically tailor data collection. A well‐designed study does have the the same cohort who have not yet developed the disease. Confounding is defined the nested case–control design is easier and less expen- as the alternative explanation to the association found sive than a full cohort approach. A confounder must are also particularly useful for rare diseases and diseases be associated with both the exposure and the outcome with long latency periods. If well designed, this approach and not be on the causal pathway between the expo- will also allow examination of multiple exposures of sure and the outcome. The temporal sequence of exposure and disease the association between coffee drinking and cancer is can sometimes be difficult to study in a case–control smoking. It is recognized that coffee drinkers are more study and certainly the size of the study will need to be likely to smoke and smoking is certainly associated with sufficiently large to study rare exposures, which often cancer. Identifying potential confounders allows inves- limits this design in some settings. At the studied after all the events and outcomes have already design stage this includes restricting the study popula- occurred. The data are collected from a given popula- tion, matching in case–control studies and randomiza- tion. However, this is reliant on the data collected on conducted by starting with two groups that are selected potential confounders. Unfortunately, bias cannot be corrected Meta‐analysis through statistical analysis and can only be minimized by Independent trials although well powered and designed at appropriate study design. Often trials are also repeated with con- Randomized controlled trials flicting results. This approach increases the power to potential for bias by random selection of participants to detect smaller differences that were not identified in indi- one intervention arm or to another intervention, non‐ vidual studies. The weighted average of the combined patients, health volunteers or communities (randomized effect size is estimated. This minimizes the possibility that con- the individual studies and the effect size observed. Down the left‐hand In some circumstances an open label trial is carried out, side are the trials included. The trial quoted above is the where it is not possible to blind either the clinician or the last of the four trials listed (first author Boulvain). On the patient but randomization is performed without bias at right‐hand side is a plot of the risk ratio for each of these time of therapy. Review: Induction of labour at or near term for suspected fetal macrosomia Comparison: I Induction versus expectant management Outcome: 3 Shoulder dystocia Study or subgroup Induction Expectant Risk Ratio Weight Risk Ratio n/N n/N M-H, Fixed, 95% Cl M-H, Fixed, 95% Cl Boulvain 2015 (I) 5/407 32/411 78.
Even when some component of nutritional support must be provided by parenteral nutrition purchase cytotec canada medications joint pain, feeding via the gut is desirable buy generic cytotec on-line symptoms low blood sugar. Several developments—including new techniques for placement of feeding tubes, availability of smaller caliber, minimally reactive tubes, and an increasing range of enteral formulas—have expanded the ability to provide enteral nutritional support to critically ill patients. Relative or absolute contraindications to enteral feeding include fistulas, intestinal obstruction, upper gastrointestinal hemorrhage, and severe inflammatory bowel disease or intestinal ischemia. Enteral feeding is not recommended in patients with severe malabsorption or early in the course of severe short-gut syndrome. Gastric feeding provides the most normal route for enteral nutrition, but may not be tolerated in the critically ill patient because of gastric dysmotility with delayed emptying . Enteral nutrition infusion into the duodenum or jejunum may decrease the incidence of aspiration because of the protection afforded by a competent pyloric sphincter; however, the risk of aspiration is not completely eliminated by feeding distal to the pylorus [8–10]. An advantage of this site of administration is that enteral feeding can be initiated early in the postoperative period, because postoperative ileus primarily affects the colon and stomach and only rarely involves the small intestine. If these procedures are contraindicated or unsuccessful, the tube may be placed by endoscopy, using endoscopic and laparoscopic technique, or surgically via a laparotomy . Nasoenteric Route Nasoenteric tubes are the most commonly used means of providing enteral nutritional support in critically ill patients. This route is preferred for short- to intermediate-term enteral support when eventual resumption of oral feeding is anticipated. It is possible to infuse enteral formulas into the stomach using a conventional 16- or 18-French (Fr) polyvinyl chloride nasogastric tube, but patients are usually much more comfortable if a small-diameter silicone or polyurethane feeding tube is used. Nasoenteric tubes vary in luminal diameter (6 to 14 Fr) and length, depending on the desired location of the distal orifice: stomach, 30 to 36 inches; duodenum, 43 inches; jejunum, at least 48 inches. Some tubes have tungsten-weighted tips designed to facilitate passage into the duodenum via normal peristalsis, whereas others have a stylet. The tip of the tube should be lubricated, placed in the patient’s nose, and advanced to the posterior pharynx. If the patient is alert and can follow instructions, the patient should be permitted to sip water as the tube is slowly advanced into the stomach. To avoid unintentional airway placement and serious complications, position of the tube should be ascertained after it has been inserted to 30 cm. Alternatively,2 commercial systems are now available to track tube progression from the esophagus through the stomach to the duodenum by electromagnetic means. Proper final placement of the tube in the stomach must be confirmed by chest or upper abdominal radiograph before tube feeding is begun. The following methods to assess final tube placement are unreliable and do not assess tube misdirection into the lower respiratory tract: auscultation over the left upper quadrant with air insufflation through the tube, assessment of pH with gastric content aspiration, and easy passage of the tube to its full length with the absence of gagging and coughing . Delayed gastric emptying has been confirmed in critically ill patients and may contribute to gastric feeding intolerance. Spontaneous transpyloric passage of enteral feeding tubes in critically ill patients is commonly unsuccessful, secondary to the preponderance of gastric atony. The addition of a tungsten weight to the end of enteral feeding tubes and the development of wire or metal stylets in enteral feeding tubes are aimed at improving the success rate for spontaneous transpyloric passage. Once the tube is documented to be in the stomach, various bedside techniques, including air insufflation, pH-assisted, magnet- guided and spontaneous passage with or without motility agents, may help facilitate transpyloric feeding tube passage. No matter which techniques are used to facilitate transpyloric passage of enteral feeding tubes, these tubes must be inserted by skilled practitioners using defined techniques. If the tube does not pass into the duodenum on the first attempt, placement can be attempted under endoscopic assistance or fluoroscopic or electromagnetic guidance. Endoscopic placement of nasoenteral feeding tubes is easily accomplished in the critically ill patient and can be performed at the bedside using portable equipment . Transnasal or transoral endoscopy can be used for placement of nasoenteral feeding tubes in critically ill patients. The patient is sedated appropriately (see Chapter 20), and topical anesthetic is applied to the posterior pharynx with lidocaine or benzocaine spray. A 43- to 48-inches-long nasoenteric feeding tube with an inner wire stylet is passed transnasally into the stomach. An endoscopy forceps is passed through the biopsy channel of the endoscope and used to grasp the tip of the enteral feeding tube. The endoscope, along with the enteral feeding tube, is advanced distally into the duodenum as far as possible. The endoscopy forceps and feeding tube remain in position in the distal duodenum as the endoscope is withdrawn back into the gastric lumen. The endoscopy forceps are opened, the feeding tube released, and the endoscopy forceps withdrawn carefully back into the stomach. The portion of the feeding tube that is redundant in the stomach is advanced slowly into the duodenum using the endoscopy forceps to achieve a final position distal to the ligament of Treitz. An abdominal radiograph is obtained at the completion of the procedure to document the final position of the nasoenteral feeding tube. Endoscopic placement of postpyloric enteral feeding tubes is highly successful, eliminates the risk of transporting the patient to the radiology department for fluoroscopic placement, and allows prompt achievement of nutritional goals, because enteral feeding can be initiated immediately after the procedure. A 90% success rate was documented with endoscopic procedure duration of approximately 13 minutes, shorter than fluoroscopic procedure duration, and without the need for additional sedation . A box with three receivers that is placed on the patient’s xiphoid process triangulates the position of the tube. The clinician is able to “view” the tip on a monitor as it passes down the esophagus through the stomach and into the duodenum. This procedure can be considered for patients who have normal gastric emptying and low risk for pulmonary aspiration, and can be performed in the operating room, in an endoscopy unit, or at the bedside in the intensive care unit with portable endoscopy equipment. A prophylactic antibiotic, usually a first- generation cephalosporin, is administered before the procedure. The lights are dimmed, and the assistant applies digital pressure to the anterior abdominal wall in the left subcostal area approximately 2 cm below the costal margin, looking for the brightest transillumination (light reflex). The endoscopist should be able to clearly identify the indentation in the stomach created by the assistant’s digital pressure on the anterior abdominal wall (digital reflex); otherwise, another site should be chosen. A small incision is made in the skin, and the assistant introduces a large-bore catheter–needle stylet assembly into the stomach and through the snare. The inner stylet is removed, and a looped insertion wire is introduced through the catheter and into the stomach. The end of the transgastric wire exiting the patient’s mouth is then tied to a prepared gastrostomy tube. The assistant pulls on the end of the wire exiting from the abdominal wall, whereas the endoscopist guides the lubricated gastrostomy tube into the posterior pharynx and the esophagus. With continued traction, the gastrostomy tube is pulled into the stomach so that it exits on the anterior abdominal wall. The gastroscope is reinserted into the stomach to confirm adequate placement of the gastrostomy tube against the gastric mucosa and to document that no bleeding has occurred. The intraluminal portion of the tube should contact the mucosa, but excessive tension on the tube should be avoided because this can lead to ischemic necrosis of the gastric wall. The gastroscope is inserted and a point on the anterior abdominal wall localized, as for the pull technique. Rather than introducing a looped insertion wire, however, a straight guidewire is snared and brought out through the patient’s mouth by withdrawing the endoscope and snare together.