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Postoperatively most patients with a fecal diversion are on a low residual diet while the stoma is edematous to prevent cramping or a possible bowel obstruction buy generic topiramate 100mg. Once the postoperative edema has subsided (usually 6 weeks after the surgical proce- dure) buy topiramate 100mg on-line, the patient is instructed to slowly reintroduce high fiber foods generic topiramate 100mg amex, chewing well and including liquids when eating high fiber foods purchase 100 mg topiramate amex. A normal diet for a person with a fecal diversion will depend upon the presence of active disease or strictures discount topiramate 200 mg fast delivery. For some patients with active inflammatory bowel disease or strictures, a low residual diet is recommended. Patients with a temporary loop ileostomy following the creation of an 18 Managing the Patient with a Fecal Diversion 289 ileal anal anastomosis may encounter high liquid output that can lead to dehydration. These patients are advised to include foods that thicken the output such as complex carbohydrates, pretzels, bread products, bananas, cheeses, and applesauce. They are further advised not to drink without eating some of the aforementioned products, as a significant increase in fluid intake without eating can cause an increase in output. The frequency of reported complications varies between 6 and 77%, and this variation appears to be a result of inconsistent reporting of definitions, types of stoma, and the time frame of complications [1, 5, 6]. The known risk factors for the occurrence of complications include obesity, the presence of inflammatory bowel disease, and emergently created stomas [2, 3]. It is therefore likely that a person with inflammatory bowel disease and a fecal diversion will at some point encounter a peristomal or stomal complication. Selected Peristomal Complications Irritant Contact Dermatitis The most common peristomal complication is the loss of skin around the stoma: irritant contact dermatitis, seen in 30–40% of patients [3]. The skin is exposed to the fecal output for a prolonged period of time, causing epidermal erosion. The skin damage can result from an inadequate pouch to skin seal that allows stool to remain in prolonged contact with the skin. Assessment of the peristomal area finds the loss of epidermis in the area of leakage, resulting in a moist area, and the patient notes frequent leak- age under the pouching system seal. The cause of the inadequate seal is usually not matching the opening on the skin barrier exactly to the stoma (the opening should be the same size and shape as the stoma to prevent the effluent form contacting the skin), allowing the skin barrier to be worn for an excessive amount of time causing the skin barrier to erode, or not matching the shape of the skin barrier to the shape of the peristomal skin [7]. When evaluating a patient for the proper shape of the skin barrier, the peristomal area is visualized while the patient is sitting to see if the skin barrier shape should be flat or convex. The shape is matched to the shape of the peristomal skin, if when the patient is sitting the skin is flat, a flat skin barrier is chosen, and if the skin around the stoma is concave a convex skin barrier is used. The fitting of the shape and size of the skin barrier is best done by a certified ostomy care nurse. Once the correct shape and size of skin barrier is determined, the denuded peristomal skin should be treated using a skin barrier powder. The skin barrier powder is a hydrocolloid and will absorb the skin moisture, drying the area 290 J. The powder is liberally applied to the affected skin, rubbed into the skin with a gauze pad, and the excess powder is wiped off leaving a light dusting on the skin. Peristomal Candidiasis Peristomal Candidiasis is an overgrowth of a Candida organism of sufficient mag- nitude that causes an inflammation or infection of the peristomal skin. The patient may complain of itching, pain, or excessive moisture in the skin around the stoma. Assessment of the area finds papules, erythema, and maceration with satellite lesions at the edges of the advancing Candidiasis. Location is generally limited to the area of the skin barrier as moisture is trapped under the skin barrier. Risk factors for development include long-term antibiotic administration, diabetes mellitus, use of immunosuppressive drugs, and a moist environment. The moist environment may be caused by an improper pouch seal, from cutting the skin barrier larger than the stoma or prolonged wear time, both of which can cause a moist environment. A topical antifungal preparation that will not interfere with the pouch adhesion is recommended, such as nystatin powder. The involved area is cleansed with warm water, dried, and powder rubbed into the area and the excess is removed. The powder is applied at pouch change until the peristomal area appears dry and intact. Peristomal Pyoderma Gangrenosum Peristomal pyoderma gangrenosum is a rare, ulcerative skin condition of unknown etiology that occurs in the area surrounding the stoma. The majority of patients with peristomal pyoderma have been diagnosed with inflammatory bowel disease, more often with Crohn’s disease than ulcerative colitis [6, 8, 9]. Full thickness ulcers with irregular ragged overhanging edges occur in the area covered by the skin barrier. The skin around the ulcers have a distinct purple hue, and the patients report the area to be very painful. Healing results in a cribriform scar that can cause pouch seal problems after the area is healed.

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The delivery of a baby by cesarean delivery has been suggested to be associated with increased risk of allergies and atopic diseases in the child buy topiramate 100mg online, most probably because of a lower bacterial exposure for the child buy topiramate 200mg with amex. However generic topiramate 200mg online, a randomized trial revealed quite contrary that promoted and prolonged (exclusive) breast-feeding is not able to prevent development of allergy or asthma in children at the age of about 6 years 88 In addition cheap topiramate 200 mg mastercard, a systematic review of several studies found no clear negative association between early solid food introduction and the development of asthma buy topiramate 200 mg low cost, food allergy, AR, or animal dander allergy 89. Regarding the nutrition of the baby, reduced breast-feeding and early introduction of solid food have been discussed as confounders to allergy development. It has long been proposed that the mother should avoid such foods containing potential allergens during pregnancy and lactation to prevent food sensitization in the child. According to a directive of the Commission of European Communities from 2005, the most allergenic foods have to be labeled because of their potency of eliciting severe allergic reactions: these are crustacean, fish, nuts, milk, egg, wheat/gluten, peanuts, soy, sesame, mustard, and celery. A diet higher in n-6 PUFAs-as present, for example, in margarine and vegetable oils-seems to be more likely to induce eczema than n-3 PUFAs, which are for instance found in fish 79 Accordingly, another study showed that fish consumption decreased eczema 80 However, it may not be the absolute content but the ratio of n-6 to n-3 PUFAs that may influence the development of either tolerance or sensitization to food, as a high ratio of 9 of n-6/n-3 in the diet of the mother prevented the induction of oral tolerance to ovalbumin in the offspring in a rat study 81 Celery and citrus fruits seem to increase the risk of food sensitization, whereas vegetable oils, raw sweet pepper, and again citrus fruit increase sensitization to respiratory antigens 79 Interestingly, apples consumed during pregnancy were able to decrease wheezing in children 80. Alcohol consumption by the mother during pregnancy is associated with higher total IgE levels in cord blood 76 Alcohol consumption in adults is also a risk factor for elevated specific IgE levels against food antigens 77 , 78. This seems to be important because allergen-specific T cells transferred from 1 mouse mother to another can transmit asthma risk to the offspring of the recipient mouse mother 69 Trafficking of cells could therefore be responsible for the passing of allergy risk from mother to feThis. The degree of risk seems to be directly related to the family history of allergy and especially to maternal atopy, 53 particularly when the mother has diagnosed atopic eczema and has elevated IgE levels. Many women experience type I allergies during pregnancy. For patients who were already on immunotherapy before the pregnancy, maintenance treatment may be continued safely during pregnancy. Hyposensitization (immunotherapy), which may be selectively indicated in certain patients with AR, bee venom sensitivity, and asthma should not be initiated during pregnancy because of the risk of systemic reactions. Examples include the occurrence of generalized eczema requiring identification of the cause before treatment or a suspected allergy to a drug needed for therapy of the mother (eg, penicillin for treating syphilis) 50 Importantly, when performing in vivo testing such as skin tests or provocation test, the exceptional immunologic staThis accompanying pregnancy should be considered when interpreting test results. Only in situations where in vitro diagnosis is not conclusive and the mother is at risk for developing allergy symptoms should in vivo skin tests be used. The diagnosis of allergy in pregnant women should focus on a detailed medical history and symptom analysis. The diagnosis and treatment of drug allergy are the same in pregnant as in nonpregnant patients. A unique form of urticaria associated with pregnancy, which tends to recur in subsequent pregnancies (pregnancy urticaria), has been reported 45 The pathogenesis of this condition is unknown, although there is speculation that it may be caused by allergic sensitization to endogenous hormones 46 , 47 The first step in treatment of urticaria and angioedema in pregnancy is identification and avoidance of causative factors. The recently introduced topical calcineurin inhibitors (pimecrolimus and tacrolimus), although effective in the treatment of atopic eczema, are not recommended for use in pregnant patients because of the lack of safety data. The importance of an exacerbation of eczema and dermatitis during pregnancy should not be underestimated as readout of the atopic state, being of interest for the genetic predisposition of the newborn 42 Most women with atopic dermatitis have lived with their condition long before becoming pregnant. A cohort study on the Isle of Wight, United Kingdom, found adverse reactions to food in approximately 20% of 969 pregnant women 38 The results of this observational study were based on questionnaires filled out by the mothers after childbirth. As with asthma, preexisting AR can worsen, improve, or remain unchanged during pregnancy 27 Furthermore, during pregnancy, nasal congestion can worsen, although the exact mechanism for this is not defined. Allergic rhinitis is often preexisting but may occur or be recognized for the first time during pregnancy. Treatment of acute asthma is similar to that recommended for nonpregnant patients including inhaled β2 agonists, oxygen (essential), and corticosteroids (oral or parenteral) 22 It is also reasonable to add nebulized ipratropium bromide in patients who do not respond to β2 agonists. The goals of management during pregnancy are the same as those for asthma in general, including prevention of severe exacerbations, improvement of quality of life (no interference with sleep or daily activities), and maintenance of normal lung function. Thus, optimal asthma treatment is crucial, as the risk of preeclampsia, premature birth, low birth weight, 19 and maternal and neonatal hypoxia and morbidity 10 , 20 posed by undertreated asthma may be greater than that from the use of oral steroids for the treatment of asthma. In general, patients with severe asthma are more likely to experience worsening of their disease during pregnancy. Potential side effects of any drug taken during pregnancy by the mother must be balanced againts the risk of the mother of the infant suffering from inadequately treated symptoms. Preexisting asthma symptoms may worsen, improve, or remain unchanged during pregnancy. In the case of asthma, the risk of uncontrolled severe asthma (which may include maternal or fetal mortality) would usually be the greater risk, suggesting that oral corticosteroids must still be used when indicated for the management of severe gestational asthma. However, the reality is that medications must be considered for pregnant patients with medical disorders, based on a thorough appreciation of the potential deleterious effects of untreated disease. Any drug may carry a small risk that must be balanced against the benefits of keeping the mother and baby healthy. Specific pharmacological agents for treatment of asthma or allergic diseases must be cautiously selected. Pregnancy itself may also affect the course of asthma and other diseases 10 Optimal management of these disorders during pregnancy is vital to ensure the welfare of the mother and the baby. Asthma and allergic disorders can affect the course and outcome of the pregnancy.

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