Prevention of Gallstones

Ursodeoxycholic acid treatment can prevent gallstone formation. This has been demonstrated in the setting of rapid weight loss caused by very low-calorie diets or by bariatric surgery, which are associated with a high risk of new cholesterol gallstones (20-30% within 4 mo). Administration of ursodeoxycholic acid at a dose of 600 mg daily for 16 weeks reduces the incidence of gallstones by 80% in this setting. Recommending dietary changes of decreased fat intake is prudent; this may decrease the incidence of biliary colic attacks. However, it has not been shown to cause dissolution of stones.

Cholelitiasis a.k.a. gall stones are crystalline deposits that occur in the gall bladder. If gallstones are found in the bile ducts called choledocolitiasis. "Early detection of Cholelitiasis disorders is very important in order not to interfere with quality of life of patients, and this can be done through the liver function tests, ultrasound and CT scans. Even with a more sophisticated device, the most accurate diagnosis for gallbladder inflammation (acute cholecystitis) may be obtained from the examination skintigrafi hepatobilier, which gives a picture of the liver, bile duct, gall bladder and the upper small intestine ", expressed by Dr. Tjahyono Sigit, who is also as Chief of Medical Committee, Puri Indah Hospital, Jakarta. Generally there are 3 kinds of rocks that may occur, namely: 1. Cholesterol stones, which occurs when bile contains large amounts of cholesterol that usually remains as a liquid. When bile becomes saturated cholesterol, the cholesterol becomes insoluble and forms deposits. This case reaches 80 percent of cases of gallstone disease. 2. Bilirubin stone, occurs when unconjugated bilirubin consentration increased. Bilirubin has a tendency to bind with calcium, forming insoluble precipitates. With increasing concentration of bilirubin, calcium bilirubinate can crystallize and form stones. Over time, various types of oxidation that occurs resulting precipitate bilirubin. Because of its color, this stone is known as a black stone. 3. Mix Stone, a mixture of both types of stone above tesebut. To be aware of this disease can be used benchmark 4F: Women (Female) although men also was not susceptible to this disorder, because the pattern of unhealthy eating can also be a cholelitiasis trigger factor. Age 40 years (Forty) High-fat diet (Fatty) Still active in the reproductive (Fertile) Basically, this disease does not need to worry and unnecessary medical treatment for does not cause pain or discomfort such as a particular pain. But to know the early symptoms of deterioration are usually cholelitiasis will feel the symptoms: Pain in the upper right abdomen, sometimes like being blackmailed and intermittent, spread to the back right shoulder. May occur several minutes to several hours. Fever Nausea Vomiting Yellow (ikterik)

To determine whether a person has to be done cholelitiasis medical examination, because sometimes patients feel just like ulcer symptoms alone. Supporting examination to detect gallstones done by inspection: 1. Heart function tests 2. In gallbladder stones, generally Gamma GT and Alkaline Phosphatase increased. 3. USG Abdomen 4. Visible image of the gall-bladder stones, and sometimes can be seen in the bile ducts. 5. Other tests such as CT scans if the Abdomen ultrasound can not describe it clearly. If you have entered a stage of acute (Acute cholecystitis) there will be inflammation of the gallbladder wall, usually the result of gallstones in cystic duct, which causes sudden attacks of great pain. Approximately 95% of those with acute gallbladder inflammation, have gallstones. Sometimes, the inflammation that occurs is caused by bacterial infection. Before you feel the incredible pain in the upper abdomen of a sudden, the patient usually does not show signs of gallbladder disease. While acute cholecystitis without stones (5%) is a serious illness and tends to occur after the occurrence: Injuries resulting from a hematoma, etc.. Infections caused by burns Sepsis (infection that spreads throughout the body) The influence of infection from diseases severe (especially people who receive food intravenously in a long time). Acute gallstone symptoms include: Pain in upper right abdomen, intensified when the patient take a deep breath and often spread to the right shoulder. Nausea Vomiting Low-grade fever, the longer it tends to rise. Usually less pain attacks within 2-3 days and then disappeared within 1 week. In the event of complications, it will happen High fever, chills, increased number of leukocytes and the cessation of bowel movements (ileus) may indicate the occurrence of abscesses, gangrenous or perforated gallbladder. The attack is accompanied by jaundice (yellow fever), or backflow of bile into the liver suggests that bile duct has been blocked in part by gallstones or by inflammation. If blood tests show elevated levels of amylase enzyme, may have occurred inflammation of the pancreas (pancreatitis) caused by gallstone obstruction of pancreatic duct (pancreatic duct) For the treatment of the patient will be required to be hospitalized and given intravenous fluids and electrolytes and is not allowed to eat or drink. Likely the doctor will put the pipe to keep nasogastric remained empty stomach so that the stimulation of the gall bladder can be reduced. If suspected acute cholecystitis, the patient will be given antibiotics as soon as possible. If the diagnosis is certain and the stakes are small, usually surgery to remove the gall bladder will be done on the first day or two since the patients treated. If patients suffering from other diseases that can increase the risk of surgery, the surgery will be postponed until the treatment of these illnesses are going well. If the attack subsided, gall bladder can be removed at least 6 weeks later. But if there are complications (eg abscesses, gangrene or perforation of the gall bladder), surgery should be done immediately.

If not found symptoms, it usually does not require treatment, only require dietary changes. But when gallstones are causing recurrent pain attacks despite a diet is set up properly, patients are encouraged to undergo gall bladder removal (cholesystektomi). Cholesistektomi can be done in a conventional or laparoscopic. Since laparoscopic dipekenalkan in 1990, then laparoscopic cholecystectomy began much done and now about 90% done in laparoscopic cholecystectomy. Laparoscopic cholecystectomy is raised gallbladder surgery through the tube inserted through a small incision in the abdominal wall. This type of surgery has the following advantages: reduces discomfort after surgery shorten the period of hospitalization.

Cholelithiasis is the presence of stones in the gallbladder. Cholecystitis is acute or chronic inflammation of the gallbladder. Choledocholithiasisis the presence of stones in the common bile duct. Most gallstones result from supersaturation of cholesterol in the bile, which acts as an irritant, producing inflammation in the gallbladder, and which precipitates out of bile, causing stones. Risk factors include gender (women four times as like to develop cholesterol stones as men), age (older than age 40), multiple parity, obesity, use of estrogen and cholesterol-lowering drugs, bile acid malabsorption with GI disease, genetic predisposition, rapid weight loss. Pigment stones occur when free bilirubin combines with calcium. These stones occur primarily in patients with cirrhosis, hemolysis, and biliary infections. Acute cholecystitis is caused primarily by gallstone obstruction of the cystic duct with edema, inflammation, and bacterial invasion. It may also occur in the absence of stones, as a result of major surgical procedures, severe trauma, or burns. Chronic cholecystitis results from repeated attacks of cholecystitis, presence of stones, or chronic irritation. The gallbladder becomes thickened, rigid, fibrotic, and functions poorly. Complications of gallbladder disease include cholangitis; necrosis, empyema, and perforation of gallbladder; biliary fistula through duodenum; gallstone ileus; and adenocarcinoma of the gallbladder.

There is no sure way to prevent gallstones. But you can reduce your risk of forming gallstones that can cause symptoms. Maintain a healthy weight Stay close to a healthy weight. If you need to lose weight, do so slowly and sensibly. When you lose weight by dieting and then you gain weight back again, you increase your risk for gallstones, especially if you are a woman. If you diet, aim for a weight loss of only 1 lb (0.5 kg) to 1.5 lb (0.7 kg) a week. For more information, see the topic Weight Management.
Recommended Related to Digestive Disorders
Gallbladder Diet Most people never give a thought to the health of their gallbladder. The pear-shaped organ does have an important job, collecting and storing bile -- the fluid that helps the body digest fats. But unlike the heart, liver, and kidneys, the gallbladder isn't necessary to keep the body healthy and functioning. Even when it isn't working as well as it should and gallstones develop, most people are unaware that there is a problem. Yet in a small percentage of people, gallstones can trigger a variety... Read the Gallbladder Diet article > >

Eat regular, balanced meals Try not to skip meals. Eat on a regular schedule. And eat meals that contain some fat (which causes the gallbladder to empty). This can help prevent gallstones. Eat plenty of whole grains and fiber. And be sure to often have servings of foods that contain calcium(milk products and green, leafy vegetables). Limit saturated (animal) fat and foods high incholesterol. Exercise regularly If you exercise more, you may be able to reduce your risk for gallstones. Along with eating a low-fat diet, exercise is also an effective way to help you stay close to ahealthy weight and lower your cholesterol andtriglyceride levels. Deciding whether to take estrogen Some evidence shows that taking hormones such as estrogen after menopause or taking highdose birth control pills may increase a woman's risk of gallstones that cause symptoms. If you are taking such hormones, talk with your doctor.

Complete Blood Count (CBC) It is a basic screening test and is one of the most frequently ordered laboratory procedures. The findings in the CBC give valuable diagnostic information about the hematologic and other body systems, prognosis, response to treatment, and recovery. The CBC consists of a series of tests that determine the number, variety, percentage, concentration and quality of blood cells. Tests 1. White blood cell count (WBC): presence of infection 2. Differential white blood cell count: specific patterns of WBC 3. Red blood cell count (RBC): carries oxygen and carbon dioxide from lungs to tissue and vice versa 4. Hematocrit (Hct): measures RBC mass 5. Hemoglobin (Hgb): main component of RBC 6. Red blood cell indices: calculated values of size and Hgb content of RBCs, important in anemia evaluation 7. Platelet count: necessary for clotting and control of bleeding 8. Red blood cell distribution width (RDW): indicates degree variability and abnormal cell size 9. Mean platelet volume (MPV): index of platelet production Normal Values in Adults WBC: 5.0 10.0 x 103/mm3 RBC: 4.0 5.5 x 106/mm3 Hgb: 12.0 17.4 g/dL Hct: 36 52% Platelet: 140 400 x 103/mm3 RDW: 11.5 14.5% MPV: 7.4 10.4 fL Nursing Considerations 1. Explain test procedure. Explain that slight discomfort may be felt when the skin is punctured. 2. Encourage to avoid stress if possible because altered physiologic status influences and changes normal hematologic values. 3. Explain that fasting is not necessary. However, fatty meals may alter some test results as a result of lipidemia. 4. Apply manual pressure and dressings over puncture site on removal of dinner. 5. Monitor the puncture site for oozing or hematoma formation. 6. Instruct to resume normal activities and diet.

Blood typing
Blood typing is a method to tell what specific type of blood you have. What type you have depends on whether or not there are certain proteins, called antigens, on your red blood cells. Blood is often grouped according to the ABO blood typing system. This method breaks blood types down into four categories:

Type A Type B Type AB Type O

Your blood type (or blood group) depends on the types that are been passed down to you from your parents. How the Test is Performed Blood is drawn from a vein, usually from the inside of the elbow or the back of the hand. The puncture site is cleaned with a germ-killing product. An elastic band is placed around the upper arm to apply pressure, which causes the vein to swell with blood. A needle is inserted into the vein, and the blood is collected into a tube. During the procedure, the elastic band is removed to restore circulation. Once the blood has been collected, the needle is removed, and a band-aid or gauze is applied. In infants or young children, the area is cleansed with antiseptic and punctured with a sharp needle or a lancet. The blood may be collected in a pipette (small glass tube), on a slide, onto a test strip, or into a small container. A bandage may be applied if there is any bleeding. The test to determine your blood group is called ABO typing. Your blood sample is mixed with antibodies against type A and B blood, and the sample is checked to see whether or not the blood cells stick together (agglutinate). If blood cells stick together, it means the blood reacted with one of the antibodies. The second step is called back typing. The liquid part of your blood without cells (serum) is mixed with blood that is known to be type A and type B. Persons with type A blood have anti-B antibodies, and those with type B blood have anti-A antibodies. Type O blood contains both types of antibodies. These two steps can accurately determine your blood type.

Blood typing is also done to tell whether or not you have a substance called Rh factor on the surface of your red blood cells. If you have this substance, you are considered Rh+ (positive). Those without it are considered Rh- (negative). Rh typing uses a method similar to ABO typing. How to Prepare for the Test No special preparation is necessary for this test. How the Test Will Feel Some people have discomfort when the needle is inserted. Others may only feel a tiny prick or stinging sensation. Afterward, there may be some throbbing or a bruise may develop. Why the Test is Performed This test is done to determine a person's blood type. Health care providers need to know your blood type when you get a blood transfusion or transplant, because not all blood types are compatible with each other. For example:

If you have type A blood, you can only receive types A and O blood. If you have type B blood, you can only receive types B and O blood. If you have type AB blood, you can receive types A, B, AB, and O blood. If you have type O blood, you can only receive type O blood.

Type O blood can be given to anyone with any blood type. That is why people with type O blood are called universal blood donors. Blood typing is especially important during pregnancy. If the mother is found to be Rh-, the father should also be tested. If the father has Rh+ blood, the mother needs to receive a treatment to help prevent the development of substances that may harm the unborn baby. See: Rh incompatibility If you are Rh+, you can receive Rh+ or Rh- blood. If you are Rh-, you can only receive Rhblood. Normal Results ABO typing: If your blood cells stick together when mixed with:

Anti-A serum, you have type A blood Anti-B serum, you have type B blood Both anti-A and anti-B serums, you have type AB blood

If your blood cells do not stick together when anti-A and anti-B are added, you have type O blood. Back typing:

If the blood clumps together only when B cells are added to your sample, you have type A blood. If the blood clumps together only when A cells are added to your sample, you have type B blood. If the blood clumps together when either types of cells are added to your sample, you have type O blood.

Lack of blood cells sticking together when your sample is mixed with both types of blood indicates you have type AB blood. RH typing:

If your blood cells stick together when mixed with anti-Rh serum, you have type Rhpositive blood. If your blood does not clot when mixed with anti-Rh serum, you have type Rh-negative blood.

Risks Risks associated with taking blood may include:

Fainting or feeling light-headed Multiple punctures to locate veins Excessive bleeding Hematoma (blood accumulating under the skin) Infection (a slight risk any time the skin is broken)

Considerations There are many antigens besides the major ones (A, B, and Rh). Many minor ones are not routinely detected during blood typing. If they are not detected, you may still have a reaction when receiving certain types of blood, even if the A, B, and Rh antigens are matched. A process called cross-matching followed by a Coombs' test can help detect these minor antigens and is routinely done prior to transfusions, except in emergency situations. Alternative Names Cross matching; Rh typing; ABO blood typing

asting blood glucose (FBG) is a blood test done to measure the amount of glucose present in the blood after an eight-hour fast. It is thus not affected by recent food intake. Purpose of the test The values obtained can

diagnose whether a person has diabetes mellitus (DM), or be used to monitor glucose control in those already known to have DM.

Most carbohydrates in the diet are converted into glucose. If the body's ability to use glucose is impaired, the levels in the blood rise, and the state of DM may exist. Establishing the diagnosis is important, because the complications of untreated DM can be fatal. Once diagnosed, treatment must be monitored to ensure optimum glucose control: good control delays the onset, and reduces the impact of, possible complications. Regular FBGs will show the effectiveness of treatment, or the need to change therapy. FBG measurement in newborn babies and pregnant women is a different category and must be interpreted by a specialist. FBG may also be used as part of the investigation of other conditions associated with abnormalities in glucose metabolism or fluctuations in glucose levels, like:

adrenal gland disorders, delirium/dementia, seizures, hormone-secreting tumours, transient ischaemic attacks, and trauma, heart attack and surgery.

How the test is done The patient must have nothing to eat or drink for at least eight hours before the blood sample is taken.

The normal routine for blood sampling is followed: a suitable vein is identified, and a tourniquet applied to distend the vein for puncture. The skin over the vein is antiseptically cleaned. A sterile needle and syringe are used to draw about 10ml of blood from the vein, the tourniquet is removed, the needle withdrawn, and the puncture site compressed for a few minutes, then covered with a clean dressing. The blood sample is usually sent to a laboratory for analysis. A hand-held glucometer may also be used, provided that it is correctly calibrated and has verifiable accuracy. Normal Values A FBG value of >7.0 mmol/L is diagnostic of DM, except in neonates or pregnancy. Abnormal results Results above 7mmol/L - called hyperglycaemia - could be due to a variety of causes, including:

Diabetes mellitus, Pre-diabetes, Too low a dose of insulin in a known diabetic, Hyperthyroidism, Rare conditions such as acromegaly, Cushing syndrome, phaeochromocytoma, or pancreatitis, or Drugs: o Steroids, o Diuretics, o Some antipsychotics and antidepressants, o Phenytoin, or o Excess paracetamol use.

Very low readings (hypoglycaemia) may be associated with:

Too much insulin used for treating DM, Insulinoma (rare tumour), Hypothyroidism, Starvation/excess dieting, or Drugs: o Alcohol,

o o

Anti-diabetic medication, or Some lipid-lowering agent.

Associated risks The risks of the test are those of drawing blood:

Bleeding from the puncture site, Bruising, Haematoma formation (lump due to bleeding under the skin), or Infection - important in diabetics.

by Raja Nandhini on March 20, 2013 at 4:23 AM

Gallstone disease and subsequent surgeries are potential risk factors for menopausal women on hormone replacement therapy (HRT), warns a new study published in the Canadian Medical Association Journal.

The study involved women enrolled in a large cohort study that examined factors affecting disease in women. Researchers analyzed the data obtained from 70,928 women who had reported about their health, diet and medical reports every two years from 1992 for an around 11.5 years. It was seen that nearly 64.8% of them were on HRT at least once. Analysts found about 2819 incident of cholecystectomies and 2608 of those patients were on HRT. Moreover, those were on oral HRT were at a much higher risk for gallbladder disease and consequent removal of gallbladder than those who took oral HRT. These findings fall in line with previous studies reporting the increased risk of gallbladder disease with HRT in menopausal women. Source-Medindia

http://www.nlm.nih.gov/medlineplus/ency/article/003345.htm

http://www.scribd.com/doc/122463872/pathophysiology-of-brain-abscess-secondary-to-chronic-otitismedia http://www.diabetes.co.uk/diabetes_care/fasting-blood-sugar-levels.html http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/cholecystectomy_92 ,P07689/

Cholecystectomy
(Gallbladder Removal, Open Cholecystectomy, Laparoscopic Cholecystectomy)

Procedure overview What is a cholecystectomy?

A cholecystectomy is the surgical removal of the gallbladder, an organ located just under the liver on the upper right quadrant of the abdomen. The gallbladder stores and concentrates bile, a substance produced by the liver and used to break down fat for digestion.

Types of cholecystectomies

Click Image to Enlarge

The gallbladder may be removed in one of two ways:

Open method. In this method, a two- to three-inch incision is made in the upper right-hand side of the abdomen. The surgeon locates the gallbladder and removes it through the incision. Laparoscopic method. This procedure uses at least three to four small incisions and three or more laparoscopessmall thin tubes with video cameras attachedto visualize the inside of the abdomen during the operation. The surgeon performs the surgery while looking at a TV monitor. The gallbladder is removed through one of the incisions.

A laparoscopic cholecystectomy is considered less invasive and generally requires a shorter recovery time than an open cholecystectomy. Occasionally, the gallbladder may appear severely diseased on laparoscopic examination or other complications may be apparent, and the surgeon may have to perform an open surgical procedure to remove the gallbladder safely.

Reasons for the procedure

A cholecystectomy may be performed if the gallbladder contains gallstones (cholelithiasis), is inflamed or infected (cholecystitis), or is cancerous. Gallbladder inflammation or infection may cause pain which may be described as follows:

Is generally located on the right side of the upper abdomen May be constant or may become more severe after a heavy meal At times, may feel more like fullness than pain May be experienced in the back and in the tip of the right shoulder blade

Other symptoms of gallbladder inflammation or infection include, but are not limited to, nausea, vomiting, fever, and chills.

The symptoms of gallbladder problems may resemble other medical conditions or problems. In addition, each individual may experience symptoms differently. Always consult your doctor for a diagnosis. There may be other reasons for your doctor to recommend a cholecystectomy.

Risks of the procedure

As with any surgical procedure, complications may occur. Some possible complications of cholecystectomy may include, but are not limited to, the following:

Bleeding Infection Injury to the bile ductthe tube that carries bile from the gallbladder to the small intestine

During laparoscopic cholecystectomy, insertion of the instruments into the abdomen may injure the intestines or blood vessels. There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Before the procedure

Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure. You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear. In addition to a complete medical history, your doctor may perform a physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood or other diagnostic tests. You will be asked not to eat or drink for eight hours before the procedure, generally after midnight. If you are pregnant or suspect that you may be pregnant, you should notify your health care provider. Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general). Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.

Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure. If your procedure is to be done on an outpatient basis, you will need to have someone drive you home afterwards because of the sedation given prior to and during the procedure. Based on your medical condition, your doctor may request other specific preparation.

During the procedure

Click Image to Enlarge

A cholecystectomy may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your doctor's practices. A cholecystectomy is generally performed while you are asleep under general anesthesia. Generally, a cholecystectomy follows this process: 1. You will be asked to remove any jewelry or other objects that may interfere with the procedure. 2. You will be asked to remove clothing and be given a gown to wear. 3. An intravenous (IV) line will be inserted in your arm or hand. 4. If there is excessive hair at the surgical site, it may be clipped off. 5. You will be positioned on the operating table on your back. 6. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. 7. The skin over the surgical site will be cleansed with an antiseptic solution.

Open method cholecystectomy:

1. An incision (open method) will be made. The incision may slant under the ribs on the right side of the abdomen, or it may be an up-and-down incision in the upper part of the abdomen. 2. The gallbladder is removed. 3. In some cases, one or more drains may be inserted through the incision to allow drainage of fluids or pus.

Laparoscopic method cholecystectomy:

1. Three to four small incisions will be made in the abdomen. Carbon dioxide gas will be introduced into the abdomen to inflate the abdominal cavity so that the gallbladder and surrounding organs can be more easily visualized. 2. The laparoscope will be inserted through one of the incisions and instruments will be inserted through the other incisions to remove the gallbladder. 3. When the procedure is completed, the laparoscope will be removed.

Procedure completion, both methods:

1. The gallbladder will be sent to the lab for examination. 2. The skin incision(s) will be closed with stitches or surgical staples. 3. A sterile bandage or dressing or adhesive strips will be applied.

After the procedure

In the hospital
After the procedure, you will be taken to the recovery room for observation. Your recovery process will vary depending on the type of procedure performed and the type of anesthesia that is given. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room. As a laparoscopic cholecystectomy procedure may be performed on an outpatient basis, you may be discharged home from the recovery room. You may receive pain medication as needed, either by a nurse or by administering it yourself through a device connected to your intravenous line. You may have a thin plastic tube inserted through your nose into your stomach to remove air that you swallow. The tube will be removed when your bowels resume normal function. You will not be able to eat or drink until the tube is removed.

You may have one or more drains in the incision if an open procedure was done. The drains will be removed in a day or so. You might be discharged with the drain still in your abdomen covered with a dressing. Follow your doctor's instructions for taking care of it. You will be encouraged to get out of bed within a few hours after a laparoscopic procedure or by the next day after an open procedure. Depending on your situation, you may be given liquids to drink a few hours after surgery. Your diet may be gradually advanced to more solid foods as tolerated. Arrangements will be made for a follow-up visit with your doctor, usually two to three weeks after the procedure.

At home
Once you are home, it is important to keep the incision clean and dry. Your doctor will give you specific bathing instructions. If stitches or surgical staples are used, they will be removed during a follow-up office visit. If adhesive strips are used, they should be kept dry and generally will fall off within a few days. The incision and the abdominal muscles may ache, especially after long periods of standing. Take a pain reliever for soreness as recommended by your doctor. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications. Walking and limited movement are generally encouraged, but strenuous activity should be avoided. Your doctor will instruct you about when you can return to work and resume normal activities. Notify your doctor to report any of the following:

Fever and/or chills Redness, swelling, or bleeding or other drainage from the incision site(s) Increased pain around the incision site(s) Abdominal pain, cramping, or swelling Pain behind the breastbone