- Growth of endometrial tissue outside the uterine cavity, associated with infertility, abnormal uterine bleeding, and pain.

Causes and Incidence The cause of endometriosis is unclear, but the prevailing hypothesis suggests dissemination and implantation of endometrial cells at local ectopic sites via retrograde menstruation through the fallopian tubes and distant sites via the bloodstream or lymphatics. Sites can be anywhere in the body, but pelvic structures are most common. Another hypothesis suggests transformation of coelomic epithelium into endometrium-like glands. A familial history, late childbearing, and mullerian duct abnormalities are predisposing factors. Approximately 25% of women can expect to develop endometriosis. It is seen most commonly during the childbearing years.

Disease Process After implantation of endometrial cells, primarily on pelvic structures (e.g., the ovaries, ligaments, oviducts, and peritoneal surface of the uterus), the cells grow to form lesions. These lesions are subject to hormonal cycles and bleed during menstruation, causing irritation and inflammation of the surrounding tissue, leading to fibrosis and adhesions.

Symptoms The major symptom is secondary dysmenorrhea, although many individuals are asymptomatic. Other symptoms are abnormal uterine bleeding, dyspareunia, infertility, lower abdominal pain, nausea and vomiting, and pain associated with a full bladder or with defecation.

Potential Complications The primary complication is infertility or spontaneous abortion.

Diagnostic Tests Laparoscopy with biopsy allows visualization and histologic confirmation of the lesions.

Treatments

Surgery
Laparoscopy to remove or vaporize lesions; hysterectomy with bilateral salpingo-oophorectomy for intractable pain.

Drugs
Gonadotropin-releasing hormone agonists, progestins, and antigonadotropic agents to inhibit ovarian function and suppress endometrial growth; prostaglandin synthase inhibitors to relieve dysmenorrhea.

General
Emotional support for depression, altered body image, and possible infertility.

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- Bleeding from the nose.

Causes and Incidence Epistaxis may be caused by a variety of factors, such as irritation, trauma, underlying coagulation disorders, or localized or systemic infections. At least 10% of the population is thought to have suffered at least one episode of epistaxis. Children and men are more susceptible, and winter is the time of most frequent occurrence.

Disease Process Bleeding results when damage interferes with the vascular integrity of the superficial vessels in the fragile mucosa of the nasal passages. Most bleeding originates in the anterior portion of the nose from Kiesselbach’s plexus, a highly vascular network in the anterior nasal septum. Posterior bleeding usually originates from the turbinates or lateral nasal wall.

Symptoms Bleeding from the nostrils.

Potential Complications Pooled blood may cause sinusitis and otitis media. Large blood loss can cause anemia or interfere with cerebral and cardiopulmonary tissue perfusion. In individuals with an altered mental status, aspiration of blood also is a possible complication.

Diagnostic Tests Inspection with a nasal speculum to determine the site of bleeding; x-ray films to locate fracture if trauma is the cause.

Treatments

Surgery
Reduction and fixation of nasal fractures; ligation of the internal maxillary artery for uncontrolled posterior bleeding; split-thickness skin grafts to correct chronic bleeding in Rendu-Osler-Weber syndrome.

Drugs
Analgesics for pain; if posterior chamber is packed, antiinfective drugs to prevent sinusitis and otitis media; if a large amount of blood was swallowed, nonabsorbable antibiotics to prevent breakdown of blood and ammonia absorption.

General
Upright position; pinching of the nose with thumb and forefinger for 5-10 minutes (anterior bleeding); cauterization of site if pressure fails; packing of nasal cavity to apply pressure (posterior bleeding); blood replacement if anemia is evident.

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- Squamous cell carcinomas, which account for 60% of esophageal cancer, arise from the surface epithelium, most commonly in the middle and lower esophagus. Adenocarcinomas, which constitute the remaining 35%, arise from the gastric fundus and develop in the lower third of the esophageal tract.

Causes and Incidence The etiology is not well defined, but risk factors associated with chronic esophageal irritation include smoking and alcohol abuse. The incidence is low in the United States, but the disease is endemic in central China and Southeast Africa, with reports of 50 cases per 100,000. This cancer is most common in older adults, with blacks affected three times as often as whites and men three times as often as women.

Disease Process A squamous cell carcinoma begins as a small mucosal patch that grows, ulcerates, and extends into the esophageal lumen and then the recurrent laryngeal nerve and tracheobronchial tree. Extension to the aorta and other adjacent structures also occurs. Metastasis to local and abdominal lymph nodes and to most body organs follows.

Symptoms Dysphagia is the most common presenting symptom. Regurgitation and weight loss may also occur.

Potential Complications The prognosis is poor, with less than 5% long-term survival. Complications of advanced disease include esophageal obstruction, hemorrhage, and perforation.

Diagnostic Tests The tumor is diagnosed with visualization on esophageal x-ray followed by esophagoscopy with a brush biopsy.

Treatments

Surgery
Resection of tumor for palliation; esophagectomy with Dacron graft replacement; esophageal dilation to aid eating.

Drugs
Preoperative systemic, cisplatinbased chemotherapy.

General
Radiation for palliation and to control pain; head of bed propped up on 4-inch blocks to prevent reflux; treatment of esophagitis.

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- Dilated blood vessels in the esophagus.

Causes and Incidence The cause of esophageal varices is portal hypertension in association with cirrhosis, liver parenchymal disease, duodenal ulcer, or acute pancreatitis. About 50% of individuals with cirrhosis eventually develop bleeding esophageal varices.

Disease Process Portal veins narrow and become obstructed as a result of the underlying disease process. As the lumen narrows, the venous blood returning to the right atrium from the intestine and spleen seeks new routes through collateral vessels. These collateral vessels enlarge and become tortuous, and the mucosa ulcerates.

Symptoms Hematemesis and melena are common. However, bleeding may occur abruptly, with massive hemorrhage accompanied by blood coming out of the mouth.

Potential Complications Esophageal rupture, with massive hemorrhage and death, is the most common complication. With acute bleeding, the mortality rate is about 50%. Approximately 60% of individuals die within a year of the first episode of bleeding.

Diagnostic Tests History of underlying disease, plus hematemesis or melena. Hemorrhage with varices is confirmed by an upper gastrointestinal series, and bleeding site is confirmed by endoscopy or mesenteric angiography.

Treatments

Surgery
Portacaval, splenorenal, or mesocaval shunt to relieve portal pressure; ligation of bleeders.

Drugs
Vasopressin or beta-blocker to lower portal hypertension; antacids or histamine receptor antagonists to inhibit gastric acid; vitamin K; antibacterial agents.

General
Control of acute bleeding through ice water lavage and esophageal tamponade techniques; blood transfusions, fluid replacement; sclerotherapy to thrombose varices.

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• Medical Information

- Single or multiple cysts in the breast.

Causes and Incidence The cause is unclear but is thought to be related to a hormonal imbalance, with an excess estrogen production and a progesterone deficiency during the luteal phase of the menstrual cycle. Fibrocystic disease is the most common breast condition, occurs primarily during the childbearing years, and is estimated to be present in at least half of all women. It accounts for half of all breast surgery.

Disease Process The precise process of cyst formation is unknown. However, a wide variety of morphologic changes occur in fibrocystic disease, including fibrosis, cyst formation, sclerosing adenosis, and ductal hyperplasia. The cysts may be nonproliferative, proliferative without atypia, or atypically hyperplastic.

Symptoms Symptoms typically appear about 1 week before the onset of menstruation and subside about a week after menstruation stops. They include lumpy breast tissue; tender, burning, aching, heavy breasts; and nipple discharge.

Potential Complications Women with atypical hyperplasia have a greater risk of cancer. Infection is another possible complication.

Diagnostic Tests Clinical evaluation with mammography or ultrasound. The definitive diagnosis is made by biopsy and histologic examination of tissue.

Treatments

Surgery
Subcutaneous mastectomy for chronic disease.

Drugs
Progestin/estrogen injections in second half of cycle to correct hormonal imbalance.

General
Support bra, heat compresses to reduce breast pain; forgoing foods with methylxanthines (e.g., coffee, tea, chocolate), which increase metabolic breast activity.

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