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Please explain what and when the procedure was performed. Has the patient been seen since surgery by the physician? What was the reason provided for not seeing the patient?There is a patient abandonment issue. The person doing the surgery should do follow up for any complication related to the procedure he/she performed. Is it because of noncompliance, schedule conflict, non-payment etc?[Edit: Per additional history provided in the Comments section. The article below addresses medical management after bariatric surgery. The physician has tried to work up surgical complications. This is the section regarding nausea and vomiting. The authors mention antiemetic unless there are other issues. I hesitate to second guess what the surgeon’s train of thought is. I do think there should be response to the patient’s communications. I understand the frustration and the cost of repeat emergency room visits. Someone here has suggested contacting the chief of surgery. Post bariatric surgery recuperation can be problematic and I hope the symptoms resolve in time.Nausea and vomitingNausea and vomiting can often be helped by antiemetic or prokinetic drugs, however, some patients have chronic functional nausea and/or vomiting that does not fit the pattern of cyclic vomiting syndrome or other gastrointestinal disorders, hence particular attention should be directed to potential psychosocial factors post bariatric surgery. Therefore, low dose antidepressant medications and psychotherapy should be addressed. On demand CT scan and Gastroscopy could be the gold standard investigations in chronic situations[39,40].]World J Gastrointest Surg. 2014 Nov 27; 6(11): 220–228.Published online 2014 Nov 27. doi: 10.4240/wjgs.v6.i11.220PMCID: PMC4241489Medical management of patients after bariatric surgery: Principles and guidelinesAbd Elrazek Mohammad Ali Abd Elrazek, Abduh Elsayed Mohamed Elbanna, and Shymaa E BilasyAuthor information ► Article notes ► Copyright and License information ►This article has been cited by other articles in PMC.Go to:AbstractObesity is a major and growing health care concern. Large epidemiologic studies that evaluated the relationship between obesity and mortality, observed that a higher body-mass index (BMI) is associated with increased rate of death from several causes, among them cardiovascular disease; which is particularly true for those with morbid obesity. Being overweight was also associated with decreased survival in several studies. Unfortunately, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. All obese patients (BMI ≥ 30 kg/m) should receive counseling on diet, lifestyle, exercise and goals for weight management. Individuals with BMI ≥ 40 kg/m and those with BMI > 35 kg/m with obesity-related comorbidities; who failed diet, exercise, and drug therapy, should be considered for bariatric surgery. In current review article, we will shed light on important medical principles that each surgeon/gastroenterologist needs to know about bariatric surgical procedure, with special concern to the early post operative period. Additionally, we will explain the common complications that usually follow bariatric surgery and elucidate medical guidelines in their management. For the first 24 h after the bariatric surgery, the postoperative priorities include pain management, leakage, nausea and vomiting, intravenous fluid management, pulmonary hygiene, and ambulation. Patients maintain a low calorie liquid diet for the first few postoperative days that is gradually changed to soft solid food diet within two or three weeks following the bariatric surgery. Later, patients should be monitored for postoperative complications. Hypertension, diabetes, dumping syndrome, gastrointestinal and psychosomatic disorders are among the most important medical conditions discussed in this review.Keywords: Obesity, Bariatric surgery, Postoperative care, Body-mass index, El bannaCore tip: Obesity is a growing health concern worldwide that impacts the life of individuals both physically and psychologically. There are several well-established health hazards associated with obesity. Additionally, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. Bariatric surgery is one of the definite solutions for obesity. In this review, we will briefly discuss the general guidelines that should be considered before bariatric surgery. Also, we discuss the protocols of patients’ postoperative care and the management of medical disorders that must be considered after bariatric surgery.Go to:INTRODUCTIONObesity is a chronic disease that impairs health-related quality of life in adolescents and children. In 2010, overweight and obesity were estimated to cause 3.4 million deaths, 3.9% of years of life loss, and 3.8% of disability-adjusted life-years worldwide. Obesity is increasing in prevalence, currently, the proportion of adults with a body-mass index (BMI) of 25 kg/m or greater is 36.9% in men and 38.0% in women worldwide[1]. Attempts to explain the large increase in obesity in the past 30 years focused on several potential contributors including increase in caloric intake, changes in the composition of diet, decrease in the levels of physical activity and changes in the gut microbiome. More than 50% of the obese individuals in the world are located in ten countries (listed in order of number of obese individuals): United States, China, India, Russia, Brazil, Mexico, Egypt, Germany, Pakistan and Indonesia. Although age-standardized rates were lower in developing than in developed countries overall, 62% of the world’s obese individuals live in developing countries. Recently, United States accounted for 13% of obese people worldwide, the prevalence of obesity was 31.7% and 33.9% among adult men and women, respectively. In Canada 21.9% of men and 20.5% of women are obese. Reported prevalence rates of obesity include: 27.5% of men and 29.8% of women in Australia, 24.5% of men and 25.4% of women in the United Kingdom, in Germany 21.9% of men and 22.5% of women, in Mexico 20.6% of men and 32.7% of women, in South Africa 13.5% of men and 42% of women, in Egypt 26.4% of men and 48.4% of women, in Saudi Arabia 30% of men and 44.4% of women and in Kuwait 43.4% of men and 58.6% of women Figure ​Figure11)[2].There are several well-established health hazards associated with obesity, e.g., nonalcoholic steatohepatitis (NASH), type 2 diabetes, heart disease, chronic kidney disease, gastroesophageal reflux disease, gastrointestinal motility disorders, sexual disorders, cerebrovascular stroke, certain cancers, osteoarthritis, depression and others[3-10]. The risk of development of such complications rises with the increase of adiposity, while weight loss can reduce the risk. Bariatric surgery could be the definitive clue in many situations[11-15]. Bariatric surgery is one of the fastest growing operative procedures performed worldwide, with an estimated > 340000 operations performed in 2011. While the absolute growth rate of bariatric surgery in Asia was 44.9% between 2005 and 2009, the numbers of procedures performed in the United States plateaued at approximately 200000 operations per year[16,17]. Starting in 2006, the Center for Medicare and Medicaid Services, United States, restricted the coverage of bariatric surgery to hospitals designated as “Centers of Excellence” by two major professional organizations[18]. Medical management and follow up of patients who have undergone bariatric surgery is a challenge due to post operative complications.GENERAL GUIDELINES FOR SURGEONS/GASTROENTEROLOGISTSA well skilled physician or a surgeon has to consider the followings:(1) as the prevalence of obesity increases so does the prevalence of the comorbidities associated with obesity. Losing weight means overcoming illness at the present, complications in future and alleviating the economic burden in the present and future;(2) Overweight; BMI between 25 and 30, technically refers to excessive body weight, whereas “obesity” BMI ≥ 30 kg/m refers excessive body fat, “Severe obesity”, BMI ≥ 35 kg/m, or “morbid obesity” refers to individuals with obesity-related comorbidities. Furthermore, severe obesity and morbid obesity groups who failed dietary and medical regimens are candidates for bariatric surgery;(3) Children obesity; refers to children with BMI > 95th percentile for their age and sex and “overweight” refers to children with BMI between the 85th and 95th percentile for their age and sex;(4) Patients undergoing a bariatric operation should have a nutritional assessment for deficiencies in macro and micronutrients, also with no contraindication for such a major operation;(5) Most of bariatric procedures are performed in women (> 80%) and approximately half of these (> 40% of all bariatric procedures) are performed in reproductive aged women, accordingly, pregnancy planning and contraception options should be discussed in details with women who will undergo bariatric procedures. Fertility improves soon after bariatric surgery, particularly in middle-aged women, who were anovulatory. Additionally, oral contraceptives may be less effective in women who have undergone malabsorptive bariatric procedure. Therefore, it is better to delay pregnancy for 6-12 mo following bariatric surgery. Risk of preeclampsia, gestational diabetes, and macrosomia significantly decrease post bariatric surgery, but the risk of intrauterine growth restriction/small infants for their gestational age may increase. Body contouring surgery is in high demand following bariatric surgery;(6) All bariatric operations are accompanied with restrictive and/or malabsorption maneuvers; less food intake and malabsorption concepts;(7) The most common types of bariatric surgeries performed worldwide are Sleeve gastrectomy (SG): This procedure involves the longitudinal excision of the stomach and thus shaping the remaining part of the stomach into a tube or a “sleeve” like structure. SG removes almost 85% of the stomach (Figure ​(Figure2);2); Roux-en-Y gastric bypass (RYGB): It reduces the size of the stomach to the size of a small pouch that is directly surgically attached to the lower part of the small intestine. In this procedure, most of the stomach and the duodenum are surgically stapled and therefore, bypassed (Figure ​(Figure3);3); The laparoscopic adjustable gastric band (AGB): This is one of the least invasive procedures, where the surgeon inserts an adjustable band around a portion of the stomach and therefore, patients feel fuller after eating smaller food portions (Figure ​(Figure4).4). Bariatric surgical procedures, particularly RYGB, plus medical therapy, are effective interventions for treating type 2 diabetes. Improvement in metabolic control is often evident within days to weeks following RYGB; and(8) Complications reported following bariatric surgery vary based upon the procedure performed. Cholilithiasis, renal stone formation and incisional hernia could be the delayed phase complications; on the other hand, bleeding, leaking, infection and pulmonary embolism could be the early phase complications following the bariatric procedure. The overall 30-d mortality for bariatric surgical procedures worldwide is less than 1%.Roux-in Y Gastrectomy, sleeve gastrectomy. and adjustable gastric band.POST OPERATIVE CARE AND FOLLOW UPEarly post operative period; (1-3) d post bariatric surgeryPatients undergoing a bariatric operation are admitted to the post-anesthesia care unit (PACU) immediately at the conclusion of the operation. Usually, on postoperative day (POD) one, we begin oral therapy in tablet or crushed-tablet and liquid form if there is a naso-gastric tube after the gastrografin leak test. A basic metabolic profile (e.g., complete blood count, electrolytes, renal function, liver function, prothrombin time and partial thromboplastin time) should be obtained every 12 h for the successive two PODs, then every 24 h for another 3 d. Oxygen is administered by nasal cannula and weaned thereafter. The likelihood that, early specific complication, will arise for a given patient is determined by the nature of the procedure, the anesthetic techniques used, and the patient’s preoperative diseases. Respiratory problems are common complication in the early postoperative period following bariatric surgery. Patients with significant comorbidities, particularly neuromuscular, pulmonary, or cardiac problems are at a higher risk for respiratory compromise, but any patient can develop hypoxemia following bariatric surgery. For prophylaxis against Deep Venous Thrombosis (DVT) following bariatric surgeries, ultrasound evaluation is recommended for all patients, D-dimer test should be applied for suspected patients with DVT, especially after long operative time, repeat ultrasound or venography may be required for those with suspected calf vein DVT and a negative initial ultrasound investigation[19,20].Late post operative monitoringAfter the PACU period, most patients are transferred to the inpatient surgical postoperative unit. For the next 24-72 h, the postoperative priorities include ruling out an anastomotic leak following laparoscopic RYGB or laparoscopic SG. If no leak is observed, patients are allowed to start a clear liquid diet and soft drinks. The postoperative care team cares for the following: control of pain, care of the wound, continuous monitoring of blood pressure, intravenous fluid management, pulmonary hygiene, and ambulation. Post-bariatric nausea and vomiting is directly correlated with the length of the surgery; it also increases in females, non-smokers, and those patients with prior history of vomiting or motion sickness. Prophylaxis with pharmacologic treatment before the development of post operative nausea and vomiting significantly reduces its incidence after surgery[21-23].After hospital dischargeDiet: Usually patients are discharged 4-6 d after surgery. Most patients are typically discharged from the hospital on a full liquid diet, patients should be taught to keep monitoring their hydration and urine output. Approximately two-three weeks after surgery, the diet is gradually changed to soft, solid foods. The average caloric intake ranges from (400) to (800) kcal/d for the first month, and thus the daily glycemic load is greatly reduced. We encourage patients to consume a diet consisting of salads, fruits, vegetables and soft protein daily.To control the epigastric pain and vomiting, patients should be taught to eat slowly, to stop eating as soon as they reach satiety and not to consume food and beverages at the same time. For most patients suffering chronic vomiting, prokinetic therapy and proton-pump inhibitors (PPIs) should be considered. Patients, who underwent SG, LAGB or RYGB, benefit from a well-planned dietary advancement. Patients should understand that the surgery has changed their body but not the environment, they have to choose healthy foods, do not skip meals and to visit the dietitian regularly in the first 12 mo after surgery. However, if food intolerance develops, patients may choose a more vegetarian-based diet. Nevertheless, fresh fruits and vegetables are usually tolerated without a problem. The daily protein intake should be between 1.0 to 1.5 g/kg ideal body weight per day[24]. The biliopancreatic diversion/duodenal switch (BPD/DS) is a malabsorptive procedure for both macro- and micronutrients. Hence, we encourage higher protein intake of 1.5 g to 2.0 g of protein/kg ideal body weight per day, making the average protein requirement per day approximately 90 g/d[25,26]. Alcohol is better prevented in the first 6-12 mo after surgery[27].Monitoring: Patients should generally have their weight and blood pressure measured weekly until the rapid weight loss phase diminishes, usually within 4-6 mo, then again at 8, 10 and 12 mo, and annually thereafter. Patients with diabetes are encouraged to check their blood glucose daily. Glycemic control typically improves rapidly following bariatric surgery. Patients maintained on antihypertensive or diabetic medications at discharge should be monitored closely for hypotension and hypoglycemia, respectively, and medications should be adjusted accordingly. We recommend that the following laboratory tests be performed at three, six, nine months and annually thereafter: (1) Complete Blood Count; (2) Electrolytes; (3) Glucose and Glucose Tolerance test; (4) Complete iron studies; (5) Vitamin B12; (6) Aminotransferases, alkaline phosphatase, bilirubin, GGT; (7) Total protein and Albumin; (8) Complete lipid profile; (9) 25-hydroxyvitamin D, parathyroid hormone; (10)Thiamine; (11) Folate; (12) Zinc; and (13) Copper.Complications following the surgical treatment of severe obesity vary based upon the procedure performed. Secondary hyperparathyroidism, Hypocalcemia, Gastric remnant distension, Stomal stenosis/Obstruction, Marginal ulcerations, Cholilithiasis, Ventral incisional hernia, Internal hernia, Hiatus Hernia, Short bowel syndrome, Renal failure, Gastric prolapse, infection, Esophagitis, Reflux, Vomiting, Hepatic abnormalities and dumping syndrome are common late-phase complications after bariatric surgery. However, the clinician should aware of complications specific for every bariatric procedure[28,29]. Before therapy, the clinician should understand that the impact of various bariatric surgeries on drug absorption and metabolism are scarce. On the other hand, RYGB and other malabsorptive procedures that significantly exclude the proximal part of the small intestine, decrease the surface area where most drug absorption occurs and may result in a reduction in systemic bioavailability[30-32].Go to:COMMON MEDICAL CONDITIONS FOLLOWING BARIATRIC SURGERYHypertensionHypertension is not always related to obesity, and dietary interventions do not assure the normalization of blood pressure. However weight loss, whether by an intensive lifestyle medical modification program or by a bariatric operation, improves obesity-linked hypertension. Patients should be monitored weekly until the blood pressure has stabilized, and patients may need to resume antihypertensive medications, but often at adjusted doses[33].DiabetesPatients with diabetes should have frequent monitoring of blood glucose in the early postoperative period and should be managed with sliding scale insulin. Many diabetic patients have a decreased need for insulin and oral hypoglycemic agents after bariatric surgery. Oral sulfonylureas and meglitinides should be discontinued postoperatively as these medications can lead to hypoglycemia after bariatric surgery. Metformin is the safest oral drug in the postoperative period, since it is not associated with dramatic fluctuations in blood glucose. RYGB is associated with durable remission of type 2 diabetes in many, but not all, severely obese diabetic adults. However those who underwent LAGB generally exhibit a slower improvement in glucose metabolism and diabetes as they lose weight in a gradual fashion[34,35].RefluxMedications for gastroesophageal reflux disease (GERD) may be discontinued after RYGB and Laparoscopic AGB, however, SG has been associated with an increased incidence of GERD in some procedures. Recurrent GERD symptoms after RYGB, particularly when accompanied by weight regain, should raise the possibility of a gastrogastric fistula between the gastric pouch and remnant, and should be investigated by an upper GI contrast study or CT scan and referred to the bariatric surgeon. Upper endoscopy is the best investigation to exclude other esophagogastroduodenal disorders. GERD may be associated with esophageal complications including esophagitis, peptic stricture, Barrett’s metaplasia, esophageal cancer and other pulmonary complications. Failure of the PPI treatment to resolve GERD-related symptoms has become one of the most common complications of GERD after bariatric surgery. Most patients who fail PPI treatment have Non Erosive Reflux Disease and without pathological reflux on pH testing. In patients with persistent heartburn despite of medical therapy, it is reasonable to recommend avoidance of specific lifestyle activities that have been identified by patients or physicians to trigger GERD-related symptoms[36-38].Nausea and vomitingNausea and vomiting can often be helped by antiemetic or prokinetic drugs, however, some patients have chronic functional nausea and/or vomiting that does not fit the pattern of cyclic vomiting syndrome or other gastrointestinal disorders, hence particular attention should be directed to potential psychosocial factors post bariatric surgery. Therefore, low dose antidepressant medications and psychotherapy should be addressed. On demand CT scan and Gastroscopy could be the gold standard investigations in chronic situations[39,40].Marginal ulcerationDue to increased risk of ulcer formation from nonsteroidal anti-inflammatory drugs (NSAIDs), these medications should be discontinued postoperatively, especially after RYGB. NSAID use is associated with an increased risk of bleeding. If analgesic or anti-inflammatory treatment is needed, the use of acetaminophen is preferred in a dose of 1-2 g/daily[41-45]. Other factors associated with increased risk of ulcer formation are smoking, alcohol, spicy food, gastrogastric fistulas, ischemia at the site of surgical anastomosis, poor tissue perfusion due to tension, presence of foreign material, such as staples and/or Helicobacter pylori infection. Diagnosis is established by upper endoscopy. According to our strategy, all patients should undergo diagnostic upper endoscopy to exclude congenital or GI diseases prior to bariatric procedures. Medical management is usually successful and surgical intervention is rarely needed[46-48].Go to:DUMPING SYNDROMEDumping syndrome or rapid gastric emptying is a group of symptoms that most likely occur following bariatric bypass. It occurs when the undigested contents of the stomach move too rapidly into the small intestine. Many patients who underwent bariatric bypass experienced postprandial hypoglycemia. However, the dumping syndrome usually occurs early (within one hour) after eating and is not associated with hypoglycemia. It is presumed to be caused by contraction of the plasma volume due to fluid shifts into the gastrointestinal tract. Dumping syndrome may result in tachycardia, abdominal pain, diaphoresis, nausea, vomiting, diarrhea, and sometimes, hypoglycemia. The late dumping syndrome is a result of the hyperglycemia and the subsequent insulin response leading to hypoglycemia that occurs around 2-3 h after a meal. Dumping syndrome is a common problem that occurs in patients who have undergone RYGB and when high levels of simple carbohydrates are ingested. Accordingly, patients who have experienced postgastric bypass bariatric surgery should avoid foods that are high in simple sugar content and replace them with a diet consisting of high fiber and protein rich food. Eating vegetables and salad is encouraged; beverages and alcohol consumption are better avoided[49].Go to:PSYCHOSOMATIC DISORDERS/DEPRESSIONMany patients usually experience enhanced self esteem and improved situational depression following weight loss. Depression often requires continued treatment, specially that, many patients with severe obesity often use food for emotional reasons. Therefore, when those patients experience a small gastric pouch postoperatively they may grieve the loss of food. Many studies documented the relationship between eating disorder and anxiety disorder, depression or schizophrenia[50,51]. Displaced emotions can result in somatization with symptoms of depression and psychosomatic disorders. It is important that clinicians recognize the psychological aspect of food loss after bariatric surgery, and reassure patients that the symptoms are related to the small gastric pouch size. Antidepressants often help to decrease the anxiety related to grieving associated with food loss, although the use of antidepressants needs to be approached with an empathetic style. Behavioral and emotive therapies are reported to be very helpful[52,53].Go to:OUTCOMEBariatric surgery remains the only effective sustained weight loss option for morbidly obese patients. The American Society for Metabolic and Bariatric Surgery estimated that in 2008 alone, about 220000 patients in the United States underwent a weight loss operation. The optimal choice for type of bariatric procedure, i.e., RYGB, SG, AGB or the selected surgical approach, i.e., open versus laparoscopic depends upon each individualized goals, i.e., weight loss, glycemic control, surgical skills, center experience, patient preferences, personalized risk assessment and other medical facilities. Laparoscopic sleeve gastrectomy is the most common bariatric procedure. However weight re-gain after long-term follow-up was reported[54-58]. Prospective studies and reviews report a general tendency for patients with metabolic disorders to improve or normalize after bariatric surgery. However weight loss is highly variable following each procedure. Recent studies have evaluated the potential impact of obesity on outcomes in organ-transplant recipients, for example bariatric surgery may be an important bridge to transplantation for morbidly obese patients with severe heart failure[59-63].Go to:RECENT ADVANCES IN BARIATRIC SURGERYA modified intestinal bypass bariatric procedure (Elbanna operation), reported a novel surgical technique designed to maintain good digestion, better satiety, and selective absorption with less medical and surgical complications (Figure ​(Figure5).5). This procedure preserves the proximal duodenum and the terminal ileum and thus preserving the anatomical biliary drainage and enterohepatic circulation[64,65].Figure 5Novel ElBanna surgical procedure.Recently, a novel bariatric technique dedicated; Modified Elbanna technique in childhood bariatric, showed promising success in pediatric surgeries (non published data).Go to:CONCLUSIONThe rising prevalence of overweight and obesity in several countries has been described as a global pandemic. Obesity can be considered like the driving force towards the pre-mature deaths. It increases the like hood for the development of diabetes, hypertension and NASH. The American Heart Association identified obesity as an independent risk factor for the development of coronary heart disease. In order to minimize post-surgical cardiovascular risk, surgical weight loss may become a more frequently utilized option to address obesity. Currently, bariatric surgery passes through a plateau phase, hence medical management and follow up of patients who have undergone bariatric surgery is a challenge.Go to:FUTURE RECOMMENDATIONSChildren obesity has become one of the most important public health problems in many industrial countries. In the United States alone, 5% of children have severe obesity. It is imperative that health care providers should identify overweight and obese children so as to start early counseling and therapy. To establish a therapeutic relationship and enhance effectiveness, the communication and interventions should be supported by the entire family, society, school, public media and primary health care. Bariatric surgery could be considered in complicated cases that failed all other options.Go to:FootnotesP- Reviewer: Amiya E, Firstenberg MS, Narciso-Schiavon JL S- Editor: Tian YL L- Editor: A E- Editor: Lu YJGo to:References1. Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, Pothier CE, Thomas S, Abood B, Nissen SE, Bhatt DL. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366:1567–1576. [PMC free article] [PubMed]2. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, Mullany EC, Biryukov S, Abbafati C, Abera SF, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:766–781. [PMC free article] [PubMed]3. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJ. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010;375:1609–1623. [PubMed]4. Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer L, Costa M, Lopez AD, Murray CJ. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970-2010: a systematic analysis of progress towards Millennium Development Goal 4. Lancet. 2010;375:1988–2008.[PubMed]5. Bleich S, Cutler D, Murray C, Adams A. Why is the developed world obese? Annu Rev Public Health. 2008;29:273–295. [PubMed]6. Food and Agriculture Organization Corporate Statistical Database. Food balance sheets. Available from:http://faostat3.fao.org/faostat-gateway/go/to/home/E.7. UN Department of Economic and Social Affairs, Population Division. World population prospects: the 2010 revision. Volume 1: Comprehensive tables. New York: United Nations; 2011.8. Astrup A, Brand-Miller J. Diet composition and obesity. Lancet. 2012;379:1100; author reply 1100–1101. [PubMed]9. Drewnowski A, Popkin BM. The nutrition transition: new trends in the global diet. Nutr Rev. 1997;55:31–43. [PubMed]10. Briefel RR, Johnson CL. Secular trends in dietary intake in the United States. Annu Rev Nutr. 2004;24:401–431. [PubMed]11. Swinburn B, Sacks G, Ravussin E. Increased food energy supply is more than sufficient to explain the US epidemic of obesity. Am J Clin Nutr. 2009;90:1453–1456. [PubMed]12. Popkin BM. The nutrition transition and obesity in the developing world. J Nutr. 2001;131:871S–873S.[PubMed]13. Ng M, Freeman MK, Fleming TD, Robinson M, Dwyer-Lindgren L, Thomson B, Wollum A, Sanman E, Wulf S, Lopez AD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA. 2014;311:183–192. [PubMed]14. Ben-Menachem T. Risk factors for cholangiocarcinoma. Eur J Gastroenterol Hepatol. 2007;19:615–617. [PubMed]15. Younossi ZM, Stepanova M, Negro F, Hallaji S, Younossi Y, Lam B, Srishord M. Nonalcoholic fatty liver disease in lean individuals in the United States. Medicine (Baltimore) 2012;91:319–327. [PubMed]16. American Society for Metabolic and Bariatric Surgery. Fact Sheet: Metabolic and Bariatric Surgery. Available from: http://www.asbs.org/ Newsite07/media/asbs_presskit.htm.17. Nguyen NT, Masoomi H, Magno CP, Nguyen XM, Laugenour K, Lane J. Trends in use of bariatric surgery, 2003-2008. J Am Coll Surg. 2011;213:261–266. [PubMed]18. Dimick JB, Nicholas LH, Ryan AM, Thumma JR, Birkmeyer JD. Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence. JAMA. 2013;309:792–799. [PMC free article] [PubMed]19. Chen KN. Managing complications I: leaks, strictures, emptying, reflux, chylothorax. J Thorac Dis. 2014;6 Suppl 3:S355–S363. [PMC free article] [PubMed]20. Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, Heinberg LJ, Kushner R, Adams TD, Shikora S, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & amp; Bariatric Surgery. Obesity (Silver Spring) 2013;21 Suppl 1:S1–27. [PMC free article] [PubMed]21. Tucker ON, Szomstein S, Rosenthal RJ. Nutritional consequences of weight-loss surgery. Med Clin North Am. 2007;91:499–514, xii. [PubMed]22. Sjöström L, Peltonen M, Jacobson P, Sjöström CD, Karason K, Wedel H, Ahlin S, Anveden Å, Bengtsson C, Bergmark G, et al. Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307:56–65. [PubMed]23. Bouldin MJ, Ross LA, Sumrall CD, Loustalot FV, Low AK, Land KK. The effect of obesity surgery on obesity comorbidity. Am J Med Sci. 2006;331:183–193. [PubMed]24. Schweiger C, Weiss R, Keidar A. Effect of different bariatric operations on food tolerance and quality of eating. Obes Surg. 2010;20:1393–1399. [PubMed]25. Ortega J, Ortega-Evangelio G, Cassinello N, Sebastia V. What are obese patients able to eat after Roux-en-Y gastric bypass? Obes Facts. 2012;5:339–348. [PubMed]26. Nelson WK, Fatima J, Houghton SG, Thompson GB, Kendrick ML, Mai JL, Kennel KA, Sarr MG. The malabsorptive very, very long limb Roux-en-Y gastric bypass for super obesity: results in 257 patients. Surgery. 2006;140:517–522, discussion 522-523. [PubMed]27. Shen Z, Li Y, Yu C, Shen Y, Xu L, Xu C, Xu G. A cohort study of the effect of alcohol consumption and obesity on serum liver enzyme levels. Eur J Gastroenterol Hepatol. 2010;22:820–825. [PubMed]28. Koenig SM. Pulmonary complications of obesity. Am J Med Sci. 2001;321:249–279. [PubMed]29. Holes-Lewis KA, Malcolm R, O’Neil PM. Pharmacotherapy of obesity: clinical treatments and considerations. Am J Med Sci. 2013;345:284–288. [PubMed]30. Sakcak I, Avsar FM, Cosgun E, Yildiz BD. Management of concurrent cholelithiasis in gastric banding for morbid obesity. Eur J Gastroenterol Hepatol. 2011;23:766–769. [PubMed]31. Herrara MF, Lozano-Salazar RR, González-Barranco J, Rull JA. Diseases and problems secondary to massive obesity. Eur J Gastroenterol Hepatol. 1999;11:63–67. [PubMed]32. Lassailly G, Caiazzo R, Hollebecque A, Buob D, Leteurtre E, Arnalsteen L, Louvet A, Pigeyre M, Raverdy V, Verkindt H, et al. Validation of noninvasive biomarkers (FibroTest, SteatoTest, and NashTest) for prediction of liver injury in patients with morbid obesity. Eur J Gastroenterol Hepatol. 2011;23:499–506. [PubMed]33. Hofsø D, Nordstrand N, Johnson LK, Karlsen TI, Hager H, Jenssen T, Bollerslev J, Godang K, Sandbu R, Røislien J, et al. Obesity-related cardiovascular risk factors after weight loss: a clinical trial comparing gastric bypass surgery and intensive lifestyle intervention. Eur J Endocrinol. 2010;163:735–745.[PMC free article] [PubMed]34. Service GJ, Thompson GB, Service FJ, Andrews JC, Collazo-Clavell ML, Lloyd RV. Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med. 2005;353:249–254. [PubMed]35. Arterburn DE, Bogart A, Sherwood NE, Sidney S, Coleman KJ, Haneuse S, O’Connor PJ, Theis MK, Campos GM, McCulloch D, et al. A multisite study of long-term remission and relapse of type 2 diabetes mellitus following gastric bypass. Obes Surg. 2013;23:93–102. [PMC free article] [PubMed]36. Fass R, Shapiro M, Dekel R, Sewell J. Systematic review: proton-pump inhibitor failure in gastro-oesophageal reflux disease--where next? Aliment Pharmacol Ther. 2005;22:79–94. [PubMed]37. Löfdahl HE, Lane A, Lu Y, Lagergren P, Harvey RF, Blazeby JM, Lagergren J. Increased population prevalence of reflux and obesity in the United Kingdom compared with Sweden: a potential explanation for the difference in incidence of esophageal adenocarcinoma. Eur J Gastroenterol Hepatol. 2011;23:128–132.[PubMed]38. Fornari F, Madalosso CA, Farré R, Gurski RR, Thiesen V, Callegari-Jacques SM. The role of gastro-oesophageal pressure gradient and sliding hiatal hernia on pathological gastro-oesophageal reflux in severely obese patients. Eur J Gastroenterol Hepatol. 2010;22:404–411. [PubMed]39. Aasheim ET. Wernicke encephalopathy after bariatric surgery: a systematic review. Ann Surg. 2008;248:714–720. [PubMed]40. Salgado W, Modotti C, Nonino CB, Ceneviva R. Anemia and iron deficiency before and after bariatric surgery. Surg Obes Relat Dis. 2014;10:49–54. [PubMed]41. Klockhoff H, Näslund I, Jones AW. Faster absorption of ethanol and higher peak concentration in women after gastric bypass surgery. Br J Clin Pharmacol. 2002;54:587–591. [PMC free article] [PubMed]42. Maluenda F, Csendes A, De Aretxabala X, Poniachik J, Salvo K, Delgado I, Rodriguez P. Alcohol absorption modification after a laparoscopic sleeve gastrectomy due to obesity. Obes Surg. 2010;20:744–748. [PubMed]43. Woodard GA, Downey J, Hernandez-Boussard T, Morton JM. Impaired alcohol metabolism after gastric bypass surgery: a case-crossover trial. J Am Coll Surg. 2011;212:209–214. [PubMed]44. King WC, Chen JY, Mitchell JE, Kalarchian MA, Steffen KJ, Engel SG, Courcoulas AP, Pories WJ, Yanovski SZ. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA. 2012;307:2516–2525. [PMC free article] [PubMed]45. Sasse KC, Ganser J, Kozar M, Watson RW, McGinley L, Lim D, Weede M, Smith CJ, Bovee V. Seven cases of gastric perforation in Roux-en-Y gastric bypass patients: what lessons can we learn? Obes Surg. 2008;18:530–534. [PubMed]46. Capella JF, Capella RF. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg. 1999;9:22–27; discussion 28. [PubMed]47. Abd Elrazek AE, Mahfouz HM, Metwally AM, El-Shamy AM. Mortality prediction of nonalcoholic patients presenting with upper gastrointestinal bleeding using data mining. Eur J Gastroenterol Hepatol. 2014;26:187–191. [PubMed]48. Abd Elrazek AE, Yoko N, Hiroki M, Afify M, Asar M, Ismael B, Salah M. Endoscopic management of Dieulafoy’s lesion using Isoamyl-2-cyanoacrylate. World J Gastrointest Endosc. 2013;5:417–419.[PMC free article] [PubMed]49. Ukleja A. Dumping syndrome: pathophysiology and treatment. Nutr Clin Pract. 2005;20:517–525.[PubMed]50. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA. 2012;307:491–497. [PubMed]51. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303:235–241. [PubMed]52. García-García ML, Martín-Lorenzo JG, Campillo-Soto A, Torralba-Martínez JA, Lirón-Ruiz R, Miguel-Perelló J, Mengual-Ballester M, Aguayo-Albasini JL. [Complications and level of satisfaction after dermolipectomy and abdominoplasty post-bariatric surgery] Cir Esp. 2014;92:254–260. [PubMed]53. Wyatt SB, Winters KP, Dubbert PM. Overweight and obesity: prevalence, consequences, and causes of a growing public health problem. Am J Med Sci. 2006;331:166–174. [PubMed]54. Lamers F, van Oppen P, Comijs HC, Smit JH, Spinhoven P, van Balkom AJ, Nolen WA, Zitman FG, Beekman AT, Penninx BW. Comorbidity patterns of anxiety and depressive disorders in a large cohort study: the Netherlands Study of Depression and Anxiety (NESDA) J Clin Psychiatry. 2011;72:341–348.[PubMed]55. de Graaf R, Bijl RV, Smit F, Vollebergh WA, Spijker J. Risk factors for 12-month comorbidity of mood, anxiety, and substance use disorders: findings from the Netherlands Mental Health Survey and Incidence Study. Am J Psychiatry. 2002;159:620–629. [PubMed]56. Cesana G, Uccelli M, Ciccarese F, Carrieri D, Castello G, Olmi S. Laparoscopic re-sleeve gastrectomy as a treatment of weight regain after sleeve gastrectomy. World J Gastrointest Surg. 2014;6:101–106.[PMC free article] [PubMed]57. Lee WJ, Ser KH, Chong K, Lee YC, Chen SC, Tsou JJ, Chen JC, Chen CM. Laparoscopic sleeve gastrectomy for diabetes treatment in nonmorbidly obese patients: efficacy and change of insulin secretion. Surgery. 2010;147:664–669. [PubMed]58. Mechanick JI, Youdim A, Jones DB, Timothy Garvey W, Hurley DL, Molly McMahon M, Heinberg LJ, Kushner R, Adams TD, Shikora S, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & amp; Bariatric Surgery. Surg Obes Relat Dis. 2013;9:159–191. [PubMed]59. Adams PL. Long-term patient survival: strategies to improve overall health. Am J Kidney Dis. 2006;47:S65–S85. [PubMed]60. Gore JL, Pham PT, Danovitch GM, Wilkinson AH, Rosenthal JT, Lipshutz GS, Singer JS. Obesity and outcome following renal transplantation. Am J Transplant. 2006;6:357–363. [PubMed]61. Meier-Kriesche HU, Arndorfer JA, Kaplan B. The impact of body mass index on renal transplant outcomes: a significant independent risk factor for graft failure and patient death. Transplantation. 2002;73:70–74. [PubMed]62. Wikiel KJ, McCloskey CA, Ramanathan RC. Bariatric surgery: a safe and effective conduit to cardiac transplantation. Surg Obes Relat Dis. 2014;10:479–484. [PubMed]63. DiCecco SR, Francisco-Ziller N. Obesity and organ transplantation: successes, failures, and opportunities. Nutr Clin Pract. 2014;29:171–191. [PubMed]64. Elbanna A, Tawella N, Neff K, Abd Elfattah A, Bakr I. Abstracts from the 18th World Congress of the International Federation for the Surgery of Obesity & Metabolic Disorders (IFSO), Istanbul, Turkey 28-31 August 2013. Obes Surg. 2013;23:1017–1243.65. Elbanna A, Taweela NH, Gaber MB, Tag El-Din MM, Labib MF, Emam MA, Khalil OO, Abdel Meguid MM, Abd Elrazek MAA. Medical Management of Patients with Modified Intestinal Bypass: A New Promising Procedure for Morbid Obesity. GJMR. 2014;14:8–19.Articles from World Journal of Gastrointestinal Surgery are provided here courtesy of Baishideng Publishing Group Inc

Teens browse this list for services in your area. Don’t run away, call for help.NEW YORK AMERICAN CIVIL LIBERTIES UNION (ACLU) : YRights As a Pregnant Or Parenting Teen (2007)]Pregnant or Parenting? Title IX Protects You From Discrimination At SchoolGuttmacher Data: Minors’ Rights as ParentsIf you are facing abuse or threats because of your pregnancy here is a crisis line. http://www.thursdayschild.org/html/about.htm 800-USA-KIDSRESOURCES STATE BY STATE:ALABAMA: Babies First: United Methodist Children's HomeFor teen mothers in foster care.If you are a pregnant teen in Alabama in foster care, ask your case manager, counselor or CASA worker if this program could be right for you.ALASKA Passage House: Passage House907-272-1255 (Call to get help now.)Ages 17–21ARIZONA: Girls Ranch Scottsdale: Girls Ranch - Florence Crittenton.Ask a school counselor, case manager, or CASA Advocate about Girls Ranch Scottsdale.An adult needs to help arrange admission if this program is right for you.Most but not all pregnant teens at Girls Ranch Scottsdale are in Arizona state custody.ARIZONA:The House of El-Elyon:HousingParenting ClassesAges 12–18ARIZONA: Starting Out Right: Starting Out Right | Free Pregnancy Test | Arizona Youth PartnershipCall 520–719–2014 or email [email protected] suppliesARIZONA: Tempe. TeenAge Pregnancy Program (TAPP) / APPP👩‍🎓Educational support.Case management.Counseling.Parenting preparation.ARKANSAS: Compassion House: Get Help - Compassion House479-419-9100 (Call for help.)HousingChristian orientation.Ages: 19 and underARKANSAS: Hanna House: Hannah House of Fort Smith Arkansas479–782–5683 phone or email: [email protected] 13–29CALIFORNIA: (Alameda County) Bay Area Youth Center: Real AlternativesEmail: [email protected] SkillsAges 16–25CALIFORNIA: El Nido Programs - El Nido Family Centers: Teen Family ServicesHome Visits help teens connect to healthcare, education, counseling, financial help employment and childcare.Several locations in Los Angles areaAntelope Valley: Pacoima office at: 818.896.7776CALIFORNIA:Maternity Shelter Program - Home [email protected] Diego AreaAges 18–24CALIFORNIA : (Lake County) Lake Family Resource Center. Teen Parenting/Adolescent Family Life ProgramServices for Pregnant and Parenting teensMust enroll before 19th birthdaCalifornia: Welcome to Mary's Pregnant Teen Shelter .Housing.CALIFORNIA: (Sacramento) Waking the VillageHome Infograph — Waking the VillageContact us about our housing programs: 916-601-2979HousingEducational SupportIntensive MentoringCase ManagementArt, Friendship, Community, CreativityChild Development CenterTravel, Recreation, CampingAges 18–24CALIFORNIA (HOUSING) (North Hollywood.) Youth Volunteers of America Los Angeles. (VOALA) Women’s Care Cottage. Women’s Care Cottage is an Independent/Transitional living program assisting homeless young women coming out of emergency shelters, foster care and probation. Admits women with one infant up to the age of 1 year. Provides up to 18 months – 3 years of housing, case management, counseling, social and cultural activities. Ages 18–21.COLORADO: options for Pregnant or Parenting Teens. Jefferson County Adolescent Pregnancy and Parenting Program (JCAPPP) Jeffco Public Schools. Non-residential. Specialized curricula, job-training, social support. Onsite childcare for teen parents.COLORADO: ttp://ttps://obgyn.coloradowomenshealth.com/health-info/teens/teen-pregnancy-programs Non-residential. University of Colorado/Colorado Adolescent Maternity Program. (CAMP) Specialized obstetrical care for teens. Emotional and social support.COLORADO: (HOUSING) Hope House of Colorado Quote from the website: “Hope House is metro-Denver's only resource providing free self-sufficiency programs to parenting teen moms, including Residential, GED, and College & Career Support programs. Additional supportive services include parenting and life skills classes, healthy relationship classes, and certified counseling, all designed to prepare them for long-term independence.” (ages 16 to 24)COLORADO: Yampah Mountain High School Non-residential, public School-based support for pregnant and parenting teens. High quality Infant and toddler childcare onsite.CONNECTICUT: Noank Community Support Services Clift House. Shelter care for ages infant to 18, either gender. Pregnant and Parenting teens.CONNECTICUT: Young Parents Program Public school-based services for pregnant and parenting teens. High School completion support and ONSITE childcare at High Schools for teen parents. Districts offering the Young Parents Program: Bridgeport, Griswold, New Britain, Torrington, Waterbury, Windham. Contact: Shelby Pons, MSW, [email protected] (860) 807-2126DISTRICT OF COLUMBIA: (Non-Residential) Teen Alliance for Prepared Parenting Specialized Pre-natal care. Education support. Counseling. Teen fathers also served. Ages Served: Adolescents who are pregnant and aged 21 or younger are eligible to enroll at any time during their pregnancy. Young fathers may enroll if they are expecting a child, or if they have a child under the age of five years. Once enrolled, youth may continue to participate in the program until 23 years of age.DISTRICT OF COLUMBIA: http://tps://dcps.dc.gov/page/expectant-and-parenting-students (Non-residential). Expectant and Parenting Students. New Heights. “Supportive case management and assistance with securing services, such as a childcare voucher, WIC, housing, TANF, employment, job training opportunities, college/university admissions and more.” Public High School Programs: The following schools have the New Heights program in their buildings, and can be reached at the following phone numbers:Anacostia, (202) 645-4040Ballou, (202) 645-3400Ballou STAY, (202) 727-5344Cardozo, (202) 671-1995CHEC, (202) 939-7700 ext. 5063Coolidge, (202) 282-0081Dunbar, (202) 698-3762Luke C. Moore, (202) 678-7890Roosevelt, (202) 576-8899Roosevelt STAY, (202) 576-8399Washington MET, (202)727-4985Wilson, (202) 282-0120Woodson, (202) 939-20324. DISTRICT OF COLUMBIA (HOUSING) Perennial Transitional House for Teen Parent23.DISTRICT OF COLuMBIA: HBP Teens Non-residential. Support services and structured classes for pregnant and parenting teens. Case Management and Home Visiting. Centered particularly on the needs of young African-American parents. Multi-phase program. Ages Served:12–2124.DISTRICT OF COLUMBIA: DC Social Innovation Project Non-residential. Teens to Doulas: This innovative program trains teens who are already parenting to serve as doulas for women in the community. The goal is for successful teen mothers to share their skills to reduce the risk factors in the community for other mothers.25. DISTRICT OF COLUMBIA: Teen Parent Assessment Program (TPAP)(Non-residential) Financial Issues: This is an assessment program that evaluates teens for independent living in the D.C. area. Usually, teens can apply for TANF (Temporary Assistance for Needy Families) in D.C. , but must be living with their parents to receive this aid. The Teen Assessment program determines on a case by case if the pregnant/parenting teen in an independent or other living situation qualifies for the aid. Service Contact: Teen Parent Assessment Program Contact Phone: (202) 698-6671Contact TTY: 711. If you are unable to get an appointment for the Teen Parent Assessment Program, you may need to get a referral from your school guidance counselor or other social services.26.DELAWARE: Diocese of Wilmington Bayard House27.FLORIDA: (HOUSING) Group Home, Bellview FL, Hands of Mercy Everywhere Hands of Mercy Everywhere. Christian-oriented residence that also offers diverse practical, educational, and therapeutic services to teen mothers. Ages served not specified28.FLORIDA: Hannah's Transitional Living || ANCHORAGE CHILDREN'S HOME || (850) 763-7102 Transitional living apartments for pregnant and parenting young women. Ages 16–2229.FLORIDA: Home Our Mother’s Home. Keeps teen mothers who are in foster care with their children.30.FLORIDA: (Pinellas County) Transitional Living Programs - Family Resources SafePlace2BTOO-Young Moms. (Scroll down the page for maternity services. The first program listed on the page has the same name but is for LGBT youth.) Housing and support. 18 month program. Ages 16–21.31.FLORIDA: Woman to Woman - Children & Family Services Gulf CoasJewish Children & Family Services. Non-residential mentoring and goal-setting for pregnant and parenting teens. No age range specified.GEORGIA: House of Dawn: Changing Lives, Changing Generations770–477–2385Housing👩‍🎓Educational SupportCareer and Life skillsCounselingAges 13–23GEORGIA: Home | The Living Vine Christian Maternity Home.HousingProgram emphasizes strict Christian environment, so possibly suitable only for committed Christians.Hawaii: Hale Kipa: Independent Living Program808.754.9844Emergency ShelterAges 12–17HAWAII: Neighborhood Helping Pregnant and Parenting Teens Neighborhood Place of Puna. Non-residential. Practical, material and emotional support.37.HAWAII: (HOUSING) Mary Jane Home | Catholic Charities Hawaii The Mary Jane Home. Ages Served: 18 and over.38. IDAHO: (and Eastern Washington) Alexandria's House | Volunteers of America Ages Served: 16–20.39.IDAHO: (Burley) Cassia High School Alternative Public High School. Serves teens who would benefit from an alternative school, including pregnant and parenting teens. Childcare for teen parents provided.40.IDAHO: Marian Pritchett School Marian Pritchett School. (Serving pregnant teens since 1964) Public High School for pregnant and parenting teens. Includes Giraffe Laugh Childcare for students attending Marian Pritchett School. Marian Pritchett - Giraffe Laugh.41.ILLINOS: (HOUSING) (Chicago) response-Ability Pregnant and Parenting Program (RAPPP) The Night Ministry operates 120-day housing programs for youth and for pregnant and parenting young mothers and their children. Call toll-free 877-286-2523. Ages 14–19.42.ILLINOIS: http://theharbour.org/successful-teenseffective-parents.html The Harbour. STEPS Program. Individual subsidized apartments for teens and their children. Parenting classes, counseling and case management. Age range served: not specified.43.INDIANA: Maternity Home With A Heart Hannah’s House. (HOUSING.) Faith-based/Christian. Parenting classes, counseling, referrals to community resources, emotional support. Serves ages 13 up. (Website states youngest resident they have served was 13 and the oldest was 43.)44. Indiana: Project Home IndyResidency for Teenage Mothers (Link leads to application page)HousingMedical CareEducational SupportParenting ClassesLife Skills ClassesAges 15 -19 at admission.45.INDIANA: Young Families of Indiana Network Future Promises. Non-residential school-based support for pregnant and parenting teens.46.INDIANA: (South Bend) Youth Service Bureau of St. Joseph County Young Mom’s Self-Sufficiency Program. (YMSSP) Non-residential support services.47. IOWA: Ruth Harbor - Pregnant? Christian orientation. Counseling, midwife care, doula services, recreation, outings. Ages ?-24. Does not specify minimum age.48.IOWA: Transitional Living for Teen Parents United Action for Youth. (UAC) Housing and other supports. Ages 17–21.49. IOWA: Transitional Living Services - Youth & Shelter Services, Inc. - Iowa50..KANSAS: About Us | Wichita Children's Home 1. Bridges. Housing for pregnant and parenting teen mothers 2. Moving on to Motherhood (MOM-Non-residential case management and support.)52. KENTUCKY: (HOUSING)Mother & Baby Home All God’s Children Mother & Baby Home. Faith-based. Nationally Accredited Childcare program onsite provides care for resident’s babies so they can attend school. Support, therapy, classes. Ages 13–21.53.KENTUCKY: (Louisville) Teenage Parent Program Georgia Chaffee Teenage Parent Program (TAPP). Non-residential. Provides support and services to help pregnant and parenting teens complete their high school educations.54. KENTUCKY: 👩‍⚕️ Young Parents Program (YPP.) Non-residential. Specialized obstetrical care, support and counseling. Ages served: Under age 18.55. LOUISIANA: I'm Pregnant. Now What?Phone : (318) 925-4663Crisis Line : (318) 277-9506Email : [email protected] Sanctuary for Women. Faith-based/Christian. Counseling, goal-setting, career planning, parenting classes, life skills and recreation. Participation in religious activities may be required. Onsite accredited education/certified teacher for High School completion or GED. Ages served: 13–23.56. LOUISIANA: Parenting Jus4me. Non-residential. Support and parenting classes for pregnant and parenting teens. No age range specified.57. LOUISIANA: http://ttp://www.lighthouseministriesinc.org/ The Lighthouse Child Residential Center. Faith-based. Cares for pregnant and parenting teens and their children. Licensed to care for children from birth through age 18.MAINE: FINANCIAL HELP: TANF and Teen Parents58. MAINE: rgh Rumford Group Homes Teens are housed in several different apartments supervised by the program and are provided with various services. Ages 16–21.59. MAINE: Crisis Center | Bangor, ME Shepherd’s Godparent Home. Ages served: teens to thirties.60. MARYLAND: Programp=s for Pregnant Teens and Teen Mothers | Hearts & Homes for Youth Damamli. This program is for pregnant and parenting teens in the foster care or juvenile justice system. The program starts the teen in a specialized foster home and later she lives independently with her child, with support from the program in her own apartment. Age range: 16–20.61. MARYLAND: Housing & Support Saint Ann’s: Grace House, Hope House and Faith House. Residence with onsite High School. Ages 13–21.62. MASSACHUSETTS: Programs Bridge Over Troubled Waters. Single Parent Housing. Transitional Housing for teen parents. Does not specify age range served.63. MASSACHUSETTS: (Boston) St. Mary’s Home Faith-based history but apparently no religious requirements or programming for participants. Housing. Case management, onsite high school completion, parenting classes, therapy. Ages 13–21.64. MICHIGAN: Shelter - Alternatives For Girls Provides emergency shelter for homeless teens and their children. Transitional housing program also available. Website did not mention specific maternity care programs offered. Ages 15—MICHIGAN: Eastpointe. Gianna House now open, but the website isn’t up currently. RESIDENTIAL. Ages 13–17. Contact information will be posted here ASAP>65. MICHIGAN: MI Health Family - MOASH Websites provide information on help for pregnant and parenting teens in Michigan. Michigan Organization on Adolescent Sexual Health. (MOASH) PREGNANT & PARENTING TEENS Ages served not specified.66. MICHIGAN: Michigan Adolescent Pregnancy and Parenting Program (MI-APPP) Case Management for pregnant and parenting teens. No are range specified.MINNESOTA: LEGAL RIGHTS OF TEENS: The Rights of Teen ParentsMINNESOTA: A School for Pregnant and Parenting Teens Longfellow High School. Non-residential public high school.MINNESOTA: The Nest: A Maternity Home The Nest. Focuses on ages 18–25 but may accept minors placed by parents. More information soon.MISSISSIPPI: http://mchms.org/pdfs/MCH_Two_of_Us_Brochure_032314_RGB.pdf Two of Us Therapeutic Maternity Home. Full-time licensed nursing staff. Highly specialized intensive care and education for mothers and infants. Ages 10–18.MISSOURI: 👩‍⚕️ https://www.barnesjewish.org/Medical-Services/Obstetrics-Gynecology/Women-Infants/Childbirth-at-Barnes-Jewish/Teen- Pregnancy-Center Barnes Jewish Hospital. Non-residential services, including specialized obstetrical care, classes and support. Ages 17 and under.MISSOURI: Mother's Refuge - Supporting Young Mother (HOUSING). Ages 12-21. Does not appear to focus on excessive religious pressureMISSOURI: Nativity House KC Faith-based. Roman Catholic.MISSOURI: Youth Services - reStart reStart Youth Services. Four transitional housing units for pregnant and parenting teens. Ages 16–21.MISSOURI: Home The Sparrow's Nest. (HOUSING) Ages 19 and under.MONTANA: Blackfeet Teen Pregnancy/Parenting Coalition Teen Pregnancy Parenting Coalition. Non-residential. GED tutoring. Case Management. Peer support. Nutritional Counseling. Childcare. Ages Served not specified.MONTANA: Mountain Home Montana Non-religious, comprehensive program. Housing. Bonnie Hamilton Home. (Group living) Mountain Home Apartments. (Individuals living with child.) Licensed Therapy. 24–7 mental health crisis line. Other resources. Ages 16–29.MONTANA: Nurtured baby, Healthy adult, Strong community Florence Crittenton . (Needs updating)NEBRASKA: CARES. ( info needs updating-program may be closed.)NEBRASKA: Center for Healthy Families Nebraska Mental Health/Project Harmony. Non-residential. Support services for pregnant and parenting teens. No age range specified. (Omaha residents only).NEBRASKA:Teen & Young Parent Program - Nebraska Early Childhood CollaborativeNNEVADA: “Living Grace” website is not available as of 8/15/2019. Will update as I get more information.NEVADA: Pregnant and Parenting Teen Saint Jude’s Ranch. Most residents are youth placed here by state social service and juvenile justice agencies.NEVADA: Contact Casa De Vida. (HOUSING) —More information available soon.NEW HAMPSHIRE: (Littleton)TRANSITIONAL LIVING PROGRAM (HOUSING). Case management, GED/Highschool completion, parenting classes and other services for pregnant and parenting teens and young adults. Ages served 18–21.NEW HAMPSHIRE: Our Place | Catholic Charities New Hampshire Our Place. Non-residential Faith-based. (Roman Catholic) Prenatal, breastfeeding, parenting and other classes and resources for parents of all ages.NEW JERSEY: http://ttps://www.cge-nj.org/program-offerings/adolescent-program/ The Center for Great Expectations (Adolescent Program) (HOUSING) AOther programs for women also available. Licensed Clinical Staff. Ages served: 13–18,NEW JERSEY: Capable Adolescent Mothers Crossroads Programs. (HOUSING) Intensive Long-term program. For General Program Information regarding Crossroads’ programs and services, please contact Michelle Wright at 609 880 0210, ext 109. Ages: 16–21.NEW JERSEY:services and Programs that help young homeless mothers and pregnant women Raphael’s Life House, Inc. Housing, licensed counseling, parenting classes, GED completion and career development. Ages served: Not specified.NEW MEXICO: Catholic Charities of Gallup NM (HOUSING)Casa San Jose. Residential care for pregnant and parenting teens. Ages Served: Not specified.NEW MEXICO: 14 to 17 Information Page Information from Pegasus Legal Services for Children about legal rights of minors in New Mexico, including teen pregnancy and parenting.NEW YORK: Residential Services Catholic Charities Community Maternity Services. Multiple programs: Heery Center-Ages 12–21, focuses on pregnant and parenting girls placed by juvenile and state agencies. Joyce Center is the transitional living maternity home.NEW YORK: Pregnant/Parenting Teens Children’s Village-Inwood House. Age range served not specified.NEW YORK: (Rochester) http://ttp://centerforyouth.net/index.php?cID=89 The Center For Youth. Chrysalis Program. 18 month program. Residential setting for pregnant or parenting young women. Ages 16–21.NEW YORK: Supportive Housing (Brooklyn) Diaspora Community Services/ “Mother’s Gaining Hope”. Federally funded “Maternity Group Home”. (MGH) I have not further details on ages served or its programs at this writing.NEW YORK: SERVICES SUSPENDED DUE TO BUDGET. (Concerned readers please consider donating. )(Niagara region) https://hannahhouse.ca/ Ages: through age 24. No lower age limit stated.NEW YORK: Regina Maternity Services Catholic Charities of Rockville Centre. Housing For pregnant teens and their children. Regina Residence is a structured program with case management. Mary Residence is supported independent living for graduates of Regina Residence. Ages 11–24.NORTH CAROLINA: http://www.angelhousematernityhome.org/admission_information0.aspx Angel House Maternity Home. Minimum Age: 17NORTH CAROLINA: Services for single, pregnant, & non-pregnant teens, women and their families | Florence Crittenton Services | Charlotte, NC Multiple residential programs. Ages 10 and up.NORTH DAKOTA: St. Gianna Maternity Home (HOUSING) Residents required to participate in prayers and attend Mass. Ages Served: Serves minors but does not specify age range.NORTH DAKOTA: Home | The Perry Center Serves minors placed by parents, but does not give age-range. Christian oriented services, apparently placing emphasis on evangelism but also offering life-skills and other practical services.OHIO: (Franklin County) The Center for Healthy Families The Center for Healthy Families. Non-residential. School and Community based services for pregnant and parenting teens offered at four high schools. Services for teen fathers also included. Ages: 13–19.OHIO: (Mentor, Ohio) Pregnancy - Hannah’s Home. Minimum age 18. More information available soon.OHIO: The Highlands - Shelter Care (HOUSING) Residential care for pregnant and parenting teens and their children. Ages 14–20.OHIO: (Columbus) 👩‍⚕️Teen and Pregnant Program Nationwide Children’s (Hospital). TaP. Non-residential. Comprehensive medical care, classes, counseling, referrals for pregnant girls and women ages 21.5 and under.OHIO: WIC (Supplemental food for Women, Infant Children) WIC - American Pregnancy Association\http://file:///C:/Users/17074/AppData/Local/Pa/TempState/Downloads/158843%20(1).pdfOKLAHOMA: Broken Arrow Public Schools Mentoring Healthy Parents (Formerly Margaret Hudson Program). Non-residential. Support for pregnant and parenting teens. Age range not specified.OKLAHOMA: J.A.M.E.S., INC. WEBSITE CURRENTLY DOWN> CHECK BACK SOON> Educational support and college scholarships for pregnant and parenting teens. High School seniors and college students.OKLAHOMA: http://s://www.choctawnation.com/tribal-services/member-services/choctaw-support-expectant-and-parenting-teens-sept Choctaw Support for Expectant and Parenting Teens. (SEPT) Services for teens pregnant with or parenting a Native American child under the age of one year. Must live within the 10.5 county service area of Choctaw Nation. Ages 13–21.OKLAHOMA: (Owassa) Oklahoma Baptist Homes for Children . (HOUSING) (Owassa) Maternity Cottage and transitional living apartments for Mother and Child Program. Participants must attend Southern Baptist church while in residence. Age range served not specified.OKLAHOMA: Transitional Living Program (HOUSING) Housing offered to youth, including pregnant and parenting teens and their children. Ages 16–21.OREGON: Safe Haven Maternity Home Safe Haven Maternity Home.OREGON: Dedicated to helping young mothers Saint Child. Housing for pregnant girls and women and their infants. May stay for up to a year after birth of baby. Faith-based (Christian). Counseling, education, job training, life skills and other supports. Participants are offered bible study and other Christian activities but are apparently not coerced. Ages 14–24.Pennsylvania: (Lansdale) (HOUSING) Home Morning Star Maternity Home. Ages 13–25.Pennsylvania: Maternity & Pregnancy Services - Catholic Charities of Harrisburg PAPENNSYLVANIA: http://ttps://www.valleyyouthhouse.org/programs/transitional-housing/maternity-group-home-mgh/RHODE ISLAND: (HOUSING) (may be for 18 and above only) Little Flower Home - Serving RI & Southern MA - Housing for 'Pregnant Homeless' WomenRHODE ISLAND: About Nowell Leadership Academy (Public Charter High School) For Pregnant and Parenting teens.SOUTH CAROLINA: Help for pregnant and parenting young women in South CarolinTENNESSEE: Comprehensive Resource Center The Hagar Center. Non-residential. Classes, support and material assistance.102. TENNESSEE: http://ttps://mercymultiplied.com/about-us/ Mercy Multiplied. Faith-based/Non-denominational Christian. Residential programs are located in four states for girls including a facility in Nashville, Tennessee. The programs are designed to work with on many issues, including pregnancy. The website states that the program does not demand that the pregnant mother relinquish her child to adoption, however, neither is there any indication of housing or services offered for the mother/child family. Adoption services prominently noted on website. Counseling is strongly centered on Christian teachings, although Mercy Multiplied states that its counselors are Master’s Level or graduate student interns. Counseling process includes/demands “commitment to Christ”. This program might be appropriate for young women who of their own free will wish to pursue Christianity. Ages Served: Unknown at this writing.107. TEXAS: Annunciation House: Apply for Services108. TEXAS: Apply | LifeHouse Houston. Housing and other support. Strong focus on Christian evangelizing. Ages 12 and up. (Other services for non-residential clients also available.)109. TEXAS: Teen Parenting Help - Jane's Due Process Information and support for pregnant teenagers concerning Texas legal rights.110.TEXAS: Viola's House111. UTAH: 👩‍🎓Horizonte Instruction and Training Center. Young Parent Program. Programs Non-residential. High School completion and vocational education with onsite childcare provided by Head Start. Parenting and other skills. Flexible scheduling. Contact Person: Kathy Williams (801) 578-8574 ext. 233.112. UTAH: Teen Mother & Child Program Non-residential. University of Utah/Teen Mother and Child Program. Obstetrical care/Nurse-Midwives. Social and psychological support and referrals for other needed services. Ages served: 19 and younger.113. UTAH: YWCA Of Salt Lake City. Referrals to Transitional Housing. No other details as of this writing.114. VERMONT: Family Literacy Center (Non-residential) Educational center for pregnant and parenting teens and young adults. Infants may attend classes with parents until they are four months old and after that Onsite Nationally Accredited childcare is available full-time. Onsite licensed therapy, parenting and nutrition classes and other social supports. Ages served: High school freshmen age through age 25.115. VIRGINIA: Grace Home Ministries. (HOUSING) Program is long-term and residents encouraged to stay for as long as two years with their babies. Faith based/Christian. Program includes participation in Christian experiences. However, Grace Home states: “We believe religion is a matter of personal conviction; therefore, we don’t put any pressure on program participants in matters of personal faith or beliefs. Mentoring, childcare classes, case management. Ages 1–20.116. VIRGINIA: (Lynchburg) ADOPTION-ORIENTED! Liberty Godparent Maternity Home. Services | Liberty Godparent Home If you have decided for adoption AND you are a Baptist or of a similar faith, you might consider this facility, as its emphasis is on adoption. The program does offer “Mommy and Me” support if you decide on raising your baby yourself, however, the emphasis is clearly adoption. Faith-based. (Baptist) Residents attend Thomas Road Baptist church. Other services from their website: All residents are required to attend school, pursue a GED, or participate in vocational training. Classes are offered off site at Liberty Christian Academy through Liberty University Online Academy (grades 6-12). Tutoring services for GED and SAT exams are available as needed. To help each young lady build a positive future, the LGH staff is committed to educating the residents on Life Skills and other topics such as Decision-Making, Parenting, Adoption, and Nutrition. About Us Overview | Liberty Godparent Home Ages Served: Not specified.VIRGINIA: (Fairfax County) Second Story for Young Mothers - assistance for mothersSecond Story for Young Mothers. (HOUSING) Residential services offered through independent living in townhouses for young mothers between the ages of 18–21. Pregnant and parenting teens between the ages of 16 and 18 receive non-residential community based support, education and services. Follow-up support and case management also offered. 24/7 Crisis Hotline - Call 1-800-SAY-TEEN or text “TEENHELP” to 855-11 TTY 711VIRGINIA: (Alexandria) Keep it 360 | The Alexandria Campaign on Adolescent Pregnancy (ACAP) T.C. Futures. (Non-residential.) From website: The T.C. Futures Group provides parenting meetings and developmental playgroups specifically for Alexandria’s teenage parents and their children. Parents learn about positive parenting skills, child development, and local resources. The group meets every other week after school at T.C. Williams High School. Participation is not limited to T.C. Williams students; all teenage parents in Alexandria are invited to attend. Participation is free, and Spanish translation is available. For more information, contact David Wynne, TC Williams Social Worker, at 703.824.6800.VIRGINIA (Fredricksburg) Mary's Shelter Mary’s Shelter. (HOUSING) Faith-based. Provides residential care for up to three years. Minimum Age: 18.VIRGINIA: Mommy and Me Program. ( A program component of “Youth For Tomorrow”.). (RESIDENTIAL/HOUSING) Faith based/Christian. Intensive program for pregnant teens and their infants. Education for teens at accredited school on campus, health care, parenting classes, in-house therapy and nursing staff. ) Admissions are either by court placement or social service agency referral. Teens may stay until their child is four-years-old. Ages: 12–18.VIRGINIA: (Winchester.) About | New Eve Maternity Home New Eve Maternity Home. (HOUSING). Faith-based/Roman Catholic. Help with education, employment, life skills. Ages served: 18 and above. (?)VIRGINIA: (Norfolk) THIS LISTING NOT ACTIVE CURRENTLY. WILL UPDATE ASAP. Eastern Virginia Medical School. Non-residential. Specialized obstetrical care. Classes, parenting skills, emotional support, transportation to prenatal appointments.WASHINGTON: (Seattle area.) Housing Cocoon House. (HOUSING) Housing for pregnant and parenting teens and their children. (Short -term and long-term.) Support for education, life skills and employment. Ages 12–17.WASHINGTON: (Spokane) Alexandria's House | Volunteers of America (HOUSING). “Spacious historic home”. Mentoring, support, doulas, other services. Ages: 16–20.WASHINGTON: (Spokane)http://ttp://gracesonhousingfoundation.org/ Hope and Housing for Teen Moms and their Children Graceson Housing Foundation. (Housing.) Faith-based/Christian but spiritual activities are left up to choice. This program is strong on community and nurturing. Classes, life skills, and employments skills also offered. Ages 13-18.WASHINGTON (Seattle) 👩‍⚕️ "Family Medicine Residency Teen Pregnancy and Parenting Clinic. (A program of Kaiser Permanente but you DO NOT have to be a Kaiser Permanente member to receive services.) Non-residential. Accepts Medicaid and other insurance. Prenatal care with delivery at Swedish First Hill Hospital. Offers help getting medical care coverage, nutritious food, childbirth classes, parenting classes and well-child care for the baby until two years of age. (Well-child care is only for the babies whose mothers used the Teen Pregnancy and Parenting Clinic for their prenatal care and delivery.) Open Tuesdays and Thursdays. Drop by or call: Kaiser Permanente Capitol Hill Campus, West Building 206-326-2656. On the bus line. Ages served: Not specified.WEST VIRGINIA: Crittenton Services, Inc. A Florence Crittenton program. (More information to follow)WISCONSIN: (Milwaukee) Pregnant and Parenting Youth Program (PPYP). Non-residential public school-based support.WISCONSIN: (Sheboygan) 👩‍🎓 Sheboygan Area School District Non-residential. TAPP/Parenting Lab. School-based support for pregnant and parenting teens. Guidance counselor assists pregnant students with educational plan/ONSITE childcare/parenting lab for teen parents. Classes designed/flexible to accommodate pregnancy related issues. Pregnant or parenting students in Sheboygan contact your school guidance counselor to access these services.

This answer may contain sensitive images. Click on an image to unblur it.Gynecomastia is a common disorder of the endocrine system in which there is a non-cancerous increase in the size of male breast tissue.Most adolescent boys, up to 70%, have some breast development duringpubertyNewborn and adolescent males often experience temporary gynecomastia due to the influence of maternal hormones and hormonal changes during puberty, respectively.The development of gynecomastia is usually associated with benign pubertal changes; in adolescent boys, the condition is often a source of psychological distress. However, 75% of pubertal gynecomastia cases resolve within two years of onset without treatment.In rare cases, gynecomastia has been known to occur in association with certain disease states.Gynecomastia may be seen in individuals with Klinefelter syndrome or certain cancers, with disorders involving theendocrine system or metabolic dysfunction, with the use of certain medications, or in older males due to a natural decline in testosteroneproduction.Disturbances in the endocrine system that lead to an increase in the ratio ofestrogens/androgens are thought to be responsible for the development of gynecomastia.This may occur even if the levels of estrogens and androgens are both appropriate but the ratio is altered.Diagnosis is based on symptoms. Conservative management of gynecomastia is often appropriate as the condition commonly resolves on its own. Medical treatment of gynecomastia that has persisted beyond two years is often ineffective. Medications such as aromatase inhibitors have been found to be effective in rare cases of gynecomastia from disorders such as aromatase excess syndrome or Peutz–Jeghers syndrome, but surgical removal of the excess tissue is usually required.SIGNS AND SYMPTOMS :classic feature of gynecomastia is male breast enlargement with soft, compressible, and mobile subcutaneouschest tissue palpated under the areola of the nipple in contrast to softer fattytissue.This enlargement may occur on one side or both.Dimpling of the skin and nipple retraction are not typical features of gynecomastia.Milky discharge from the nipple is also not a typical finding, but may be seen in a gynecomastic individual with a prolactin secreting tumor.Males with gynecomastia may appear anxious or stressed due to concerns about the possibility of having breast cancer.An increase in the diameter of the areola and asymmetry of chest tissue are other possible signs of gynecomastia.CausesGynecomastia is thought to be caused by an altered ratio of estrogens toandrogens mediated by an increase in estrogen production, a decrease in androgen production, or a combination of these two factors.Estrogen acts as a growth hormone to increase the size of male breast tissue.The cause of gynecomastia is unknown in around 25% of cases.Drugs are estimated to cause 10–25% of cases of gynecomastiaCertain health problems in men such as liver disease, kidney failure or low testosterone can cause breast growth in men. Drugs and liver disease are the most common cause in adults.Other medications such as methadone, aldosterone antagonists (spironolactone & epelerenone), HIV medication, cancer chemotherapy, hormone treatment for prostate cancer, heartburn and ulcer medications, calcium channel blockers, antifungal medications such as ketoconazole, antibiotics such as metronidazole, tricyclic antidepressants such as amitriptyline, herbals such aslavender, tea tree oil, and dong quai are also known to cause gynecomastia.Phenothrin, an insecticide, possessesantiandrogen activity, and has been associated with gynecomastia.PhysiologicMany newborn infants of both sexes show breast development at birth or in the first weeks of life.During pregnancy, the placenta converts the androgenic hormones DHEA and DHEA sulfate to the estrogenic hormonesestrone and estradiol, respectively; after these estrogens are produced by the placenta, they are transferred into thebaby's circulation thereby leading to temporary gynecomastia in the baby.In some infants neonatal milk (also known as "witch's milk") can be secretedThe temporary gynecomastia seen in newborn babies usually resolves after two or three weeks.Gynecomastia in adolescents usually starts between the ages of ten and twelve and commonly goes away after eighteen months.Declining testosterone levels and an increase in the level of subcutaneousfatty tissue seen as part of the normal aging process can lead to gynecomastia in older men. This is also known as senile gynecomastia.Increased fatty tissue in these men leads to increased conversion of androgenic hormones such as testosterone to estrogens.When the human body is deprived of adequate nutrition, testosterone levels drop while the adrenal glands continue to produce estrogens thereby causing a hormonal imbalance.Gynecomastia can also occur once normal nutrition is restarted (this is known as refeeding gynecomastia)A small proportion of male gynecomastia cases may be inherited due to the very rare aromatase excess syndrome inherited in an autosomal dominant manner.Non-physiologicApproximately 10–25% of cases are estimated to result from the use of medications.This is known as non-physiologic gynecomastia.Medications known to cause gynecomastia include ketoconazole,cimetidine, gonadotropin-releasing hormone analogues, human growth hormone, human chorionic gonadotropin, 5α-reductase inhibitorssuch as finasteride and dutasteride,estrogens such as those used intransgender women and men withprostate cancer, and antiandrogens such as bicalutamide, flutamide, andspironolactone.Medications that are probably associated with gynecomastia include calcium channel blockers such as verapamil, amlodipine, and nifedipine; risperidone, olanzapine,anabolic steroids,alcohol, opioids,efavirenz, alkylating agents, andomeprazole.Certain components of personal care products such aslavender or tea tree oil and certain supplements such as dong quai andTribulus terrestris have been associated with gynecomastia.Chronic diseasePatients with kidney failure are often malnourished, which may contribute to gynecomastia development. Dialysismay attenuate malnutrition of kidney failure. Additionally, many kidney failure patients experience a hormonal imbalance due to the suppression of testosterone production and testicular damage from high levels of urea also known as uremia-associated hypogonadism.In individuals with liver failure or cirrhosis, the liver's ability to properly metabolize hormones such as estrogen may be impaired. Additionally, those with alcoholic liver disease are further put at risk for development of gynecomastia; ethanol may directly disrupt the synthesis of testosterone and the presence of phytoestrogens in alcohol may also contribute to a higher estrogen to testosterone ratio.Conditions that can cause malabsorptionsuch as cystic fibrosis or ulcerative colitis may also produce gynecomastia.TumorsTesticular tumors such as Leydig cell tumors or Sertoli cell tumor(such as in Peutz-Jeghers syndrome) or hCG-secreting choriocarcinomamay result in gynecomastia. Other tumors such as adrenocortical tumors, pituitary gland tumors (such as a prolactinoma), or bronchogenic carcinoma, can produce hormones that alter the male–female hormone balance and cause gynecomastia.Individuals with prostate cancer who are treated with androgen deprivation therapy may experience gynecomastia.DiagnosisTo diagnose gynecomastia, a thorough history and physical examination are obtained by a physician. Important aspects of the physical examination include evaluation of the male breast tissue with palpation to evaluate for breast cancer and pseudogynecomastia(male breast tissue enlargement solely due to excess fatty tissue), evaluation ofpenile size and development, evaluation of testicular development and an assessment for masses that raise suspicion for testicular cancer, and proper development of secondary sexual characteristics such as the amount and distribution of pubic and underarm hair.Gynecomastia usually presents with bilateral involvement of the breast tissue but may occur unilaterally as well.A review of the medications or illegal substances an individual takes may reveal the cause of gynecomastia.Recommended laboratory investigations to find the underlying cause of gynecomastia include tests for aspartate transaminase and alanine transaminaseto rule out liver disease, serumcreatinine to determine if kidney damage is present, and thyroid-stimulating hormone levels to evaluate for hyperthyroidism. Additional tests that may be considered are markers of testicular, adrenal, or other tumors such as urinary 17-ketosteroid, serum betahuman chorionic gonadotropin, or serum dehydroepiandrosterone. Serum testosterone levels (free and total),estradiol, luteinizing hormone, andfollicle stimulating hormone may also be evaluated to determine if hypogonadism may be the cause of gynecomastia.Differential diagnosisOther causes of male breast enlargement such as mastitis,breast cancer, pseudogynecomastia,lipoma, sebaceous cyst, dermoid cyst,hematoma, metastasis, ductal ectasia,fat necrosis, or a hamartoma are typically excluded before making the diagnosis.Another condition that may be confused with gynecomastia isenlargement of the pectoralis muscles.ImagingMammography is the method of choice for radiologic examination of male breast tissue in the diagnosis of gynecomastia when breast cancer is suspected on physical examination.However, since breast cancer is a rare cause of breast tissue enlargement in men, mammography is rarely needed.If mammography is performed and does not reveal findings suggestive of breast cancer, further imaging is not typically necessary.If a tumor of the adrenal glands or the testes is thought to be responsible for the gynecomastia,ultrasound examination of these structures may be performed.HistologyEarly histological features expected to be seen on examination of gynecomastic tissue attained by fine-needle aspirationbiopsy include the following: proliferation and lengthening of the ducts, an increase in connective tissue, an increase in inflammation andswelling surrounding the ducts, and an increase in fibroblasts in the connective tissue.Chronic gynecomastia may show different histological features such as increased connective tissuefibrosis, an increase in the number of ducts, less inflammation than in the acute stage of gynecomastia, increased subareolar fat, and hyalinization of the stroma.When surgery is performed, the gland is routinely sent to the lab to confirm the presence of gynecomastia and to check for tumors under a microscope. The utility of pathologic examination of breast tissue removed from male adolescent gynecomastia patients has recently been questioned due to the rarity of breast cancer in this population.ClassificationThe spectrum of gynecomastia severity has been categorized into a grading system:Grade I: Minor enlargement, no skin excessGrade II: Moderate enlargement, no skin excessGrade III: Moderate enlargement, skin excessGrade IV: Marked enlargement, skin excessTreatmentMild cases of gynecomastia in adolescence may be treated with advice on lifestyle habits such as proper diet and exercise with reassurance. In more severe cases, medical treatment may be tried including surgical intervention.MedicationMedical treatment of gynecomastia is most effective when done within the first two years after the start of male breast enlargement.Selective estrogen receptor modulators (SERMs) such as tamoxifen or raloxifene may be beneficial in the treatment of gynecomastia but are not approved by the Food and Drug Administration for use in gynecomastia.Tamoxifen may be used for painful gynecomastia in adults.Aromatase inhibitors (AIs) have been used off-label for cases of gynecomastia occurring during puberty.A few cases of gynecomastia caused by the rare disorders aromatase excess syndrome and Peutz-Jeghers syndrome have responded to treatment with AIs such as anastrozole.Surgery.If chronic gynecomastia is treated, surgical removal of glandular breast tissue is usually required.Surgical approaches to the treatment of gynecomastia include subcutaneousmastectomy, liposuction-assisted mastectomy, laser-assisted liposuction, and laser-lipolysis without liposuction. Complications of mastectomy may include hematoma, surgical wound infection, breast asymmetry, changes in sensation in the breast, necrosis of the areola or nipple, seroma, noticeable or painful scars, and contour deformities.OtherRadiation therapy and tamoxifen have been shown to help prevent gynecomastia and breast pain from developing in prostate cancer patients who will be receiving androgen deprivation therapy. The efficacy of these treatments is limited once gynecomastia has occurred and are therefore most effective when used prophylactically.Many insurance companies deny coverage for surgery for gynecomastia treatment or male breast reduction on the basis that it is a cosmetic procedureHOPE SO IT WILL HELP YOU.THANKS.!!!