MANUALUL

MERCK
EDIIA a XVIII-a

Ediia I
Ediia a II-a
Ediia a III-a
Ediia a IV-a
Ediia a V-a
Ediia a VI-a
Ediia a VII-a
Ediia a VIII-a
Ediia a IX-a
Ediia a X-a
Ediia a XI-a
Ediia a XII-a
Ediia a XIII-a
Ediia a XIV-a
Ediia a XV-a
Ediia a XVI-a
Ediia a XVII-a
Ediia a XVIII-a

1899
1901
1905
1911
1923
1934
1940
1950
1956
1961
1966
1972
1977
1982
1987
1992
1999
2006

MANUALUL MERCK. EDITIA A XVIII-A

MANUALUL MERCK. EDITIA A XVIII-A

EDITII N ALTE LIMBI

ale Manualului Merck
Arab Larike Publications Services, Cyprus
Ceh Egem, Prague
Chinez Peoples Medical Publishing House, Beijing
Coreean Hanwoori Publishing Co., Seoul
Croat Placebo, Split
Francez Editions dAprs, Paris
German Elsevier, Ltd., Munich
Greac Medical & Scientific Publishing, Athens
Italian Springer-Verlag Italia Srl (Medicom), Milan
Japonez Nikkei Business Publications, Tokyo
Polonez Elsevier, Ltd, Wroclaw
Portughez Editora Roca Ltda., So Paulo
Rus MIR Publishers, Moscow
Spaniol Elsevier Espaa, S.A., Madrid
Turc Yce, Istanbul
Ungar Melania, Budapest

ALTE CRI MERCK

THE MERCK INDEX
Ediia I, 1889
THE MERCK VETERINARY MANUAL
Ediia I, 1955
THE MERCK MANUAL OF GERIATRICS
Ediia I, 1990
THE MERCK MANUAL OF MEDICAL INFORMATION-HOME EDITION
Ediia I, 1997
THE MERCK MANUAL OF HEALTH & AGING

MANUALUL MERCK. EDITIA A XVIII-A

Ediia I, 2004
Crile Merck sunt publicate fr a obine profit, ca un serviciu adus comunitii
tiinifice i publicului.

MANUALUL MERCK. EDITIA A XVIII-A

EDIIA A XVIII-A

MANUALUL
MERCK
DE
DIAGNOSTIC I TRATAMENT

MARK H. BEERS, MD, Edittor ef

ROBERT S. PORTER, MD, Edittor
THOMAS V. JONES, MD, MPH, Edittor asociat
JUSTIN L. KAPLAN, MD, Edittor asistent MICHAEL
BERKWITS, MD, MSCE, Edittor asistent

Comittett edittorial
Richard K. Albert, MD
Marjorie A. Bowman, MD, MPA
Sidney Cohen, MD
Jan Fawcett, MD
Eugene P. Frenkel, MD
Susan L. Hendrix, DO
Michael Jacewicz, MD
Gerald L. Mandell, MD, MACP
John E. Morley, MB, BCh
H. Ralph Schumacher, Jr., MD
David A. Spain, MD
Peter G. Szilagyi, MD, MPH

MANUALUL MERCK. EDITIA A XVIII-A

Paul H. Tanser, MD, FRCP(C), FRCP (Glasgow)

Publicatt de MERCK RESEARCH LABORATORIES

Divizia MERCK & CO., INC.
Whittehouse Sttattion, N.J. 2006

MANUALUL MERCK. EDITIA A XVIII-A

THE MERCK MANUAL OF DIAGNOSIS AND THERAPY

Mark H. Beers, Robert S. Porter
Copyright 2006 Merck & Co., Inc., Whitehouse Station, N.J., USA, All Rights Reserved.
Publicat n original n limba englez cu titlul The Merck Manual of Diagnosis & Therapy,
18th Edition. Copyright 2006 by Merck&Co., Inc.
MANUALUL MERCK DE DIAGNOSTIC I TRATAMENT
Mark H. Beers, Robert S. Porter
Toate drepturile rezervate Editurii ALL. Nicio parte din acest volum nu poate fi
copiat fr permisiunea scris a Editurii ALL.
Drepturile de distribuie n strintate aparin n exclusivitate editurii.
All rights reserved. The distribution of this book outside Romania,
without the written permission of ALL, is strictly prohibited.
Copyright 2009, 2012, 2014 by ALL.

61

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Comenzi la:

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Redactor:
Coperta:

Dr. Bianca Vasilescu

Alexandru Novac

MANUALUL MERCK. EDITIA A XVIII-A

Traductori:

Adriana Muat
Graiela Niu
Ioana Popescu
Oana Trifnescu
Andrei-Vlad Vasilescu
Tiparul executat la G. Canale & C. S. A. Romnia

MANUALUL MERCK. EDITIA A XVIII-A

CUVNT NAINTE

Ediia precedent a Manualului Merck a celebrat cea de a 100-a aniversare i o

istorie strlucit n oferirea informaiilor pentru cei implicai n sistemul de sntate
din toat lumea. Cu aceast nou ediie, implementm schimbrile necesare pentru
a fi siguri c Manualul Merck satisface nevoile dumneavoastr de informare n noul
secol. Nevoile dumneavoastr s-au schimbat, aa c Manualul Merck trebuie s se
schimbe la rndul su.
n ziua de azi, cititorii doresc s gseasc rapid ceea ce caut pentru a se putea
concentra asupra subiectelor specifice. Cu toate acestea, cititorii doresc o resurs
bogat n toate informaiile de care au nevoie, acum sau mai trziu. Pentru c n
medicin informaiile noi apar foarte rapid, o carte de medicin devine la rndul ei
foarte rapid depit. Manualul Merck nu mai poate atepta nc cinci ani pn s
apar cu noi informaii. Revoluia a venit i, odat cu ea, Manualul Merck ncepe un
nou capitol n istoria sa.
n anul 1899, Merck a publicat o lucrare de 192 de pagini intitulat Mercks Manual
of the Materia Medica, care mai trziu a devenit cunoscut ca The Merck Manual of
Diagnosis and Therapy (Manualul Merck de Diagnostic i Tratament). Acea carte a fost
printat i legat, ditribuit i, n final, rescris i publicat ca a doua ediie civa ani
mai trziu. Dup aceea, au urmat mai multe ediii, la intervale cuprinse ntre 2 i 12
ani. Dac ar fi fost ca durata dintre ediii s fie proporional cu viteza cu care se
moderniza ngrijirea medical, atunci ediiile ar fi aprut din ce n ce mai rapid, cu
apariii intermitente de ediii atunci cnd s-au descoperit antibioticele, atunci cnd a
fost perfecionat chirurgia pe cord deschis, sau cnd studiile de imagistic asistat
de computer s-au dezvoltat. n zilele noastre, progresele importante n ngrijirea
medical sunt continue, informaiile nvechite sunt potenial periculoase, iar
ntrzierea n oferirea informaiilor corecte este inacceptabil. Aceast carte trebuie
s se schimbe sau s dispar.
Aceast ediie a Manualului Merck a fost astfel organizat i structurat pentru a
v ajuta s gsii ceea ce dorii mult mai uor. Indexul este complet i detaliat.
Informaiile au fost separate chiar mai clar acum n entiti care descriu fiziopatologia,
etiologia, simtomele i semnele, diagnosticul, prognosticul, tratamentul i profilaxia.
Un sumar al punctelor cheie se gsete n introducerea fiecre pri importante. Cu
toate c putei n aceast ediie nou s rsfoii i s citii subiecte aa cum dorii,
acum este mult mai uor i rapid s cutai ceva precis de care avei nevoie.
Manualul pe care l avei acum n fa este att de nou n prospeimea informaiei

MANUALUL MERCK. EDITIA A XVIII-A

pe ct poate fi o carte tiprit. Este ediia a XVIII-a i, chiar mai important, este
ediia anului 2006. A fost revizuit i finalizat chiar nainte s fie dat la tiprit. Cu
toate acestea, n doar cteva luni dup apariia pe pia, ea va deveni depit.
Bineneles, marea majoritate a informaiei pe care o conine va fi corect i relevant
pentru cei din sistemul de sntate, timp de ani buni de acum ncolo. ns, n unele
domenii ale medicinei, noi informaii vor deveni disponibile dup aceasta. Pe ct de
repede posibil, noi vom remprospta aceste informaii pe site-ul nostru de internet
www.merckmanuals.com, care poate fi accesat gratuit.
v

MANUALUL MERCK. EDITIA A XVIII-A

vi

CUVNT NAINTE
Varianta electronic a Manualul Merck de Diagnostic i Tratament va fi mult mai la
curent cu ultimele informaii medicale dect aceast form tiprit. Publicaiile
electronice fac acest lucru s fie posibil, chiar dac rpesc o parte din farmecul
acestei cri. Site-ul este, ns, o surs electronic, el neavnd niciun pic din farmecul
i confortul unui volum tiprit. Mai mult ca sigur, astfel de acuzaii au fost ndreptate
i ctre Guttenberg din partea scribilor care afirmau c toate crile ar fi trebuit s
fie obiecte de art i nu obiecte utilitare, produse n mas. Cartea s-a schimbat i noi
suntem recunosctori c aceast modificare a avut loc.
La un moment dat n viitorul apropiat, vom tipri o nou ediie a Manualul Merck
de Diagnostic i Tratament. Va fi versiunea printat a coninutului adus la zi de pe siteul Web. Vom face acest lucru pentru aceia care se bucur de senzaia de a ine
o
carte n mn, rsfoindu-i paginile, ndoindu-i colurile i fcnd notaii pe marginea
paginilor. Sperm c aceia care se ncadreaz n aceast categorie s rmn ct mai
numeroi pentru muli ani de acum ncolo.
De asemenea, sperm ca aceast ediie a Manualul Merck s v fie de ajutor
dumneavoastr, cititorilor notri, s fie compatibil cu nevoile dumneavoastr i
demn de a fi consultat frecvent. Mulumim celor cteva sute de persoane care au
contribuit la realizarea ei. Sugestii pentru mbuntirea crii vor fi primite cu
bucurie i analizate atent.
MARK H. B EERS, MD, i ROBERT S. PORTER, MD

MANUALUL MERCK. EDITIA A XVIII-A

Dedicat oferirii informaiilor medicale:

Merck i Manualele Merck

n anul 1899, productorul american de medicamente

Merck & Co. a publicat
pentru prima oar o carte intitulat Merck s Manual of the Materia Medica. Aceast
carte avea ca scop s fie un ajutor pentru medici i farmaciti, amintind doctorilor c
memoria poate s joace feste. Compact ca dimensiuni, uor de folosit i cuprinztor,
Manualul Merck (cum a ajuns s fie cunoscut cartea mai trziu) a devenit o favorit
printre cei implicai n industria medical, dar i printre cei care cutau informaii
medicale. Chiar i Albert Schweitzer a avut aceast carte n Africa n anul 1913, iar
amiralul Byrd a luat cu el Manualul n cltoria sa ctre Polul Sud n anul 1929.
n anii 1980, cartea devenise deja cel mai vndut text medical i era tradus n
peste 12 limbi. Cu toate c numele companiei mam s-a schimbat ntr-o anumit
msur peste ani, numele crii a rmas neschimbat, cunoscut oficial ca Manualul
Merck de Diagnostic i Tratament dar pomenit ca Manualul Merck, sau mai
simplu, Merck-ul.
n anul 1990, editorii au introdus pe pia The Merck Manual of Geriatrics, care a
devenit rapid cea mai bine vndut carte cu aceast tem, oferind informaii specifice
i cuprinztoare n legtur cu ngrijirea persoanelor n vrst. Cea de a treia ediie
a fost publicat n cinci limbi. Crearea acestei cri reflect dedicarea Merck-ului
fa de populaia acestei lumi i dorina companiei de a mbunti ngrijirea geriatric
n toat lumea.
n anul 1997, a fost publicat The Merck Manual of Medical Information Home Edition.
n aceast carte revoluionar, editorii au tradus limbajul medical complex din
Manualul Merck ntr-un limbaj accesibil, crend astfel o carte care putea fi citit i
de cei care nu aveau o pregtire medical. Cartea a primit aprecieri excepionale i
a fost vndut n peste dou milioane de exemplare. Cea de a doua ediie a fost
publicat n anul 2003 i a continuat angajamentul companiei de a oferi informaii
medicale cuprinztoare, uor de neles, pentru publicul larg.
The Merck Manual of Health and Aging, publicat n anul 2004, a continuat

MANUALUL MERCK. EDITIA A XVIII-A

angajamentul societii Merck pentru educaie i mbtrnire sntoas, oferind

informaii n legtur cu mbtrnirea i ngrijirea persoanelor n vrst, ntr-un
limbaj pe nelesul tuturor.
Ca parte a dorinei ca orice persoan care are nevoie i dorete informaii medicale
s le poat obine, Merck ofer coninutul acestor cri pe site-ul su, fr a percepe
nicio tax (vizitai www.merckmanuals.com). Nu este necesar nregistrarea pe
site i accesul este nelimitat. Publicaiile on-line sunt n permanen actualizate,
astfel nct informaiile s fie ct mai recente.
Merck susine, de asemenea, i comunitatea chimitilor i a altor persoane care
au nevoie s cunoasc informaii n legtur cu compuii chimici, oferindu-le acestora
vii

MANUALUL MERCK. EDITIA A XVIII-A

viii /

DEDICAT OFERIRII INFORMAIILOR MEDICALE

Merck Index. Publicat pentru prima oar n anul 1889, este de fapt mai vechi dect
Manualul Merck, fiind n acelai timp i cel mai larg folosit text din categoria sa. The
Merck Veterinary Manual a fost publicat pentru prima oar n anul 1955, oferind
informaii n legtur cu ngrijirea animalelor; este cea mai important lucrare n
acest domeniu.
Merck & Co, Inc. este una dintre cele mai mari companii farmaceutice din lume.
Compania este dedicat oferirii de informaii medicale de excepie i, ca parte a
acestui efort, continu s ofere toate manualele sale ca un serviciu pentru
comunitate.

MANUALUL MERCK. EDITIA A XVIII-A

CUPRINS
NR.

SECIUNE

PAG.

GHID PENTRU CITITORI ......................................... x

ABREVIERI ............................................................. xi
COMITET EDITORIAL ......................................... xiii
CONSULTANI ...................................................... xv
COLABORATORI.................................................... xvii

NUT
DIG
HEP

1
2

BOLILE DE NUTRIIE ............................................. 1

BOLILE APARATULUI DIGESTIV .......................... 62

MUS

BOLILE FICATULUI I CILOR

BILIARE ............................................................... 184

RES
URG
CVS
ORL

5
6
7

BOLILE OSTEOMUSCULARE I ALE

ESUTULUI CONJUNCTIV ................................. 249
BOLILE APARATULUI RESPIRATOR .................. 351
MEDICINA DE URGEN .................................... 512
BOLILE CARDIOVASCULARE ............................. 570

OFT
DER
HEM
END
IMU
INF
PSI
NEU
GU
GIN
PED
FAR
TRA

9
10
11
12
13
14
15
16
17
18
19
20
21

AFECIUNI OTORINOLARINGOLOGICE
I DENTARE ........................................................ 773
BOLILE OFTALMOLOGICE ................................. 867
AFECIUNI DERMATOLOGICE .......................... 929
HEMATOLOGIE I ONCOLOGIE ..................... 1028
BOLILE ENDOCRINE I METABOLICE .............. 1172
IMUNOLOGIA; BOLILE ALERGICE ................... 1319
BOLILE INFECIOASE ...................................... 1381
AFECIUNI PSIHIATRICE .................................. 1665
AFECIUNI NEUROLOGICE ............................. 1745
BOLILE GENITO-URINARE ............................... 1926
GINECOLOGIE I OBSTETRIC ....................... 2059
PEDIATRIE ......................................................... 2213
FARMACOLOGIE CLINIC ............................... 2513
TRAUMATISME; INTOXICAII ......................... 2545

MANUALUL MERCK. EDITIA A XVIII-A

SSP
APE

IND

22

SUBIECTE SPECIALE .......................................... 2696

APENDICE
Ghid de referin ............................................ 2773
Denumirile comerciale ale unor
medicamente frecvent utilizate ................... 2776
INDEX ................................................................. 2787
ix

MANUALUL MERCK. EDITIA A XVIII-A

GHID PENTRU CITITORI

Cuprinsul (pag. IX) conine paginile la care cititorii vor gsi lista membrilor comitetului
editorial, consilierilor, consultanilor suplimentari i autorilor, precum i abrevierile i
simbolurile, titlurile seciunilor, apendicele i indicele.
Fiecare seciune ncepe cu propria tabl de materii, enumernd capitolele i
subcapitolele din acea seciune. Capitolele sunt numerotate progresiv, de la nceputul
pn la sfritul crii.
Indicele conine intrri multiple, ncruciate; numrul paginilor cu caractere bold
semnific prezentarea principal a temei. n plus, cititorii vor gsi multe referine
ncruciate la alte seciuni i capitole din text.
Colontitlurile indic pe pagina din stnga numrul i titlul seciunii, iar pe pagina din
dreapta numrul i titlul capitolului.
Abrevierile i simbolurile utilizate n text pentru economia de spaiu sunt enumerate n paginile XI i XII. Alte abrevieri din text sunt exprimate la prima menionare n
capitolul sau subcapitolul respectiv.
Tabelele i figurile sunt trecute la indice, dar nu sunt enumerate ntr-o tabl de
materii.
Seciunea 22, Subiecte speciale, trateaz, printre altele, medicina complementar i
alternativ, suplimente dietetice, elemente de genetic, oprirea fumatului, recuperarea,
medicina geriatric, ngrijirea pacientului chirurgical, ngrijirea pacientului muribund i
luarea de decizii clinice.
Valorile de laborator din carte sunt date n uniti convenionale. ns, n majoritatea
cazurilor, sunt trecute n parantez i unitile din sistemul internaional.
Medicamentele sunt desemnate n text prin denumirile generice (comerciale). n
Apendicele II, multe dintre medicamentele menionate n lucrare sunt listate alfabetic, cu
denumirea generic urmat de una sau mai multe denumiri comerciale.
Important: autorii, consultanii i editorii acestei lucrri au depus mari eforturi pentru
a se asigura c tratamentele, medicamentele i schemele de dozaj sunt corecte i conforme
cu standardele acceptate n momentul publicrii. Cu toate acestea, schimbrile constante
informaionale care rezult din continua cercetare i experien clinic, diferenele
acceptate de opinie dintre specialitii de marc, aspectele unice ale cazurilor clinice
individuale i posibilitatea de eroare uman n pregtirea unui text de asemenea amploare
impun ca fiecare cititor s-i exercite propriul raionament atunci cnd ia o decizie clinic
i, dac este necesar, s consulte i s compare informaii provenite din alte surse.
ndeosebi, cititorul este sftuit s verifice informaiile legate de produs, oferite de
productor, nainte de a prescrie sau a administra medicamentul, n special dac acesta
nu i este familiar sau este utilizat rar.

MANUALUL MERCK. EDITIA A XVIII-A

Not: cititorii pot gsi informaii actualizate, tabele i figuri suplimentare, precum i
date multimedia la adresa de web www.merckmanuals.com. Vizitai frecvent site-ul
pentru a vedea ultimele date i informaii medicale.

MANUALUL MERCK. EDITIA A XVIII-A

ABREVIERI
Urmtoarele abrevieri sunt utilizate n text; alte abrevieri sunt explicate la prima
menionare n capitolul sau subcapitolul respectiv.

ACTH
ADH
ADN
AINS
ALT
AMPc
ARN
AST
ATP
BCG
BPOC
C
Ca
CHEM
cGy
Ci
CIM
CK
Cl
cm
CO2
CPER
CPK
CT
cu
D/A
sau D
dL

hormon adrenocorticotrop
hormon antidiuretic
acid dezoxiribonucleic
medicamente anti-inflamatorii
nesteroidiene
alanin aminotransferaz
(fost GPT)
adenozin monofosfat ciclic
acid ribonucleic
aspartat aminotransferaz
(fost GOT)
adenozin trifosfat
bacilul Calmette-Gurin
boal pulmonar obstructiv
cronic
Celsius; centigrad;
complement
calciu
concentraia eritrocitar
medie de hemoglobin
centigray
curie
concentraie inhibitorie
minim
creatinkinaz
clor
centimetru
dioxid de carbon
colangiopancreatografie
endoscopic retrograd
creatinfosfokinaz
tomografie computerizat
cubic

DTP
EBS
ECA
ECG

diftero-tetano-pertussis
(anatoxin/vaccin)
endocardit bacterian
subacut
enzima de conversie a
angiotensinei
electrocardiogram

dextroz n ap
decilitru (=100 mL)

MANUALUL MERCK. EDITIA A XVIII-A

EEG
electroencefalogram
F
Fahrenheit (grad)
FDA U.S. Food and Drug Administration
(S.U.A.)
FEN
febr de etiologie necunoscut
g
gram
G6PD
glucozo-6-fosfat
dehidrogenaz
GI
gastro-intestinal
GU
genito-urinar
Gy
gray
h
or
Hb
hemoglobin
HCl
acid clorhidric
HCO3
bicarbonat
Hg
mercur
HIV
virusul
imunodeficienei
umane
HLA
antigen leucocitar uman
HMGCoA
hidroximetil glutaril
coenzima A
Ht
hematocrit
Hz
hertz (cicli/secund)
i.m.
intramuscular
i.v.
intravenos
ICRS
infecie de ci
respiratorii
superioare
IgA etc. imunoglobulina A etc.
IL
interleukin
IM
infarct miocardic
INR
raport
normalizat
internaiona
l
IQ
coeficient de
inteligen ITU infecie de
tract urinar K
potasiu
kcal
kilocalorie (calorie
alimentar)

kg
L
lb
LCR
LDH
LEC

kilogram
litru
livr (pound)
lichid cefalorahidian
lactic dehidrogenaz
lichid extracelular

MANUALUL MERCK. EDITIA A XVIII-A

xi

xii

/ ABREVIERI

LES
LIC
m
M
m2
mCi
mEq
Mg
mg
min
mL
mm
mmol
mOsm
mUI
N
Na
NaCl
ng
nm
nmol
NPT
O2
OMS
ORL
OTC
P
p.o.
PACO2
PaCO2
PAO2
PaO2
PCO2

lupus eritematos sistemic

lichid intracelular
metru
molar
metru ptrat
milicurie
milliechivalent
magneziu
miligram
minut
mililitru
milimetru
milimol
miliosmol
mili-unitate internaional
azot; normal (puterea unei
soluii)
sodiu
clorur de sodiu
nanogram (=milimicrogram)
nanometru (=milimicron)
nanomol
nutriie parenteral total

PO2

oxigen
Organizaia Mondial a
Sntii
otorinolaringologie
fr prescripie medical
(medicament)
fosfor; presiune
per os (oral)

SNC
sol
sp
spp
TA
TB
TP
TPT

presiune parial a dioxidului

de carbon alveolar
presiune parial a dioxidului
de carbon arterial
presiune parial a oxigenului
alveolar
presiune parial a oxigenului
arterial
presiune parial a dioxidului
de carbon (sau tensiune)

UI
UI
UTI
(ATI)
VEM
VD
VS
VSH

PPD
ppm
PR
PTI
RCR
RFG
RMB
RMN
s.c.
SaO2
SCT
SHU
SI
SIDA
SIDS

presiune parial a oxigenului

(sau tensiune)
derivat proteic purificat
(tuberculin)
pri per milion
poliartrita reumatoid
purpur trombocitopenic
idiopatic
resuscitare cardiorespiratorie
rat de filtrare glomerular
rat metabolic bazal
rezonan magnetic
nuclear
subcutanat
saturaie arterial n oxigen
suprafa corporal total
sindrom hemolitic uremic
Sistem Internaional de
Uniti
sindrom de imunodeficien
dobndit
sindromul morii subite la
sugar
sistem nervos central
soluie
specie (singular)
specii (plural)
tensiune arterial
tuberculoz
timpul de protrombin
timp parial de
tromboplastin
uniti internaionale
urografie intravenoas
unitate de terapie intensiv
volum eritrocitar mediu
ventricul drept
ventricul stng
viteza de sedimentare a
hematiilor

MANUALUL MERCK. EDITIA A XVIII-A

PCR
PET
pg
pH

PMN

reacie de polimerizare n lan

tomografie cu emisie de
pozitron
picogram (=micromicrogram)
logaritmul cu semn schimbat
al concentraiei ionilor de
hidrogen
polimorfonucleare (leucocite)

Ci
g
L
m
mol
Osm
m

micro-; micron
microcurie
microgram
microlitru
micrometru (=micron)
micromol
micro-osmol
milimicron (=nanometru)

MANUALUL MERCK. EDITIA A XVIII-A

EDITORI I
COMITETUL EDITORIAL
EDITORI
Editor ef
MARK H. BEERS, MD
Executive Director of Geriatrics and Clinical Literature, Merck & Co., Inc. and Clinical
Professor of Medicine, Drexel University College of Medicine

Editor
ROBERT S. PORTER, MD
Merck & Co., Inc. and Clinical Assistant Professor, Department of Emergency Medicine,
Jefferson Medical College

Editor asociat
THOMAS V. JONES, MD, MPH
Merck & Co., Inc. and Adjunct Clinical Associate Professor of Medicine, Temple Univer sity School of Medicine

Editor asistent
JUSTIN L. KAPLAN, MD
Merck & Co., Inc. and Clinical Associate Professor, Department of Emergency Medicine,
Jefferson Medical College

Editor asistent
MICHAEL BERKWITS, MD, MSCE
Merck & Co., Inc. and Adjunct Assistant Professor of Medicine, University of Pennsylvania
School of Medicine

COMITETUL EDITORIAL
RICHARD K. ALBERT, MD
Professor, Department of Medicine, University of Colorado Health Sciences Center;
Chief of Medicine, Denver Health Medical

Center
MARJORIE A. BOWMAN, MD, MPA
Professor and Chair of Family Practice and
Community Medicine, University of Penn-

MANUALUL MERCK. EDITIA A XVIII-A

sylvania School of Medicine

SIDNEY COHEN, MD
Professor of Medicine and
Research Programs, Thomas
University

Director,
Jefferson

JAN FAWCETT, MD
Professor of Psychiatry, University of New
Mexico School of Medicine
EUGENE P. FRENKEL, MD
Professor of Internal Medicine and Radiology, Patsy R. and Raymond D. Nasher Distinguished Chair in Cancer Research; Elaine
Dewey Sammons Distinguished Chair in
Cancer Research in honor of Eugene P. Frenkel,
MD; and A. Kenneth Pye Professorship in
Cancer Research, Harold C. Simmons
Comprehensive Cancer Center, The University of Texas Southwestern Medical Center
at Dallas
xiii

MANUALUL MERCK. EDITIA A XVIII-A

xiv

EDITORI I COMITETUL EDITORIAL

SUSAN L. HENDRIX, DO
Professor, Department of Obstetrics and
Gynecology, Wayne State University School
of Medicine, Hutzel Womens Hospital

H. RALPH SCHUMACHER, JR., MD

Professor of Medicine, University of Pennsylvania School of Medicine; Chief of Rheumatology, Department of Veterans Affairs
Medical Center, Philadelphia

MICHAEL JACEWICZ, MD
Professor of Neurology, University of
Tennessee Health Science Center and Veterans Administration Medical Center, Memphis

DAVID A. SPAIN, MD
Professor of Surgery and Chief of Trauma/
Surgical Critical Care, Stanford University

GERALD L. MANDELL, MD, MACP

Professor of Medicine, Owen R. Cheatham
Professor of the Sciences, University of
Virginia Health Center

PETER G. SZILAGYI, MD, MPH

Professor of Pediatrics and Chief, Division
of General Pediatrics, University of Rochester School of Medicine and Dentistry

JOHN E. MORLEY, MB, BCh

Dammert Professor of Gerontology, Saint
Louis University Health Sciences Center;
Director, Geriatric Research, Education
and Clinical Center, St. Louis VA Medical
Center

PAUL H. TANSER, MD, FRCP(C),

FRCP
(Glasgow)
Professor of Medicine (Emeritus), McMaster
University; Medical Head of Cardiology,
Palmerston North Hospital, New Zealand

MANUALUL MERCK. EDITIA A XVIII-A

CONSULTANI

INA CALLIGARO, PharmD

Assistant Dean for Education and Associate Professor of Clinical Pharmacy, Temple
University School of Pharmacy
Formule farmaceutice pediatrice i dozri
ROBERT B. COHEN, DMD
Associate Professor of Dentistry and Practice Coordinator, Tufts University School
of Dental Medicine
Afeciuni dentare
RALPH E. CUTLER, MD
Professor of Medicine (Emeritus), Loma
Linda University School of Medicine; Consultant in Nephrology, Loma Linda VAMC
Afeciuni genitourinare
DAVID P. HUSTON, MD
Cullen Professor of Immunology, Departments of Medicine and Immunology, Baylor
College of Medicine
Imunologie
SIDNEY N. KLAUS, MD
Professor of Medicine, Section of Dermatology, Dartmouth Medical School
Afeciuni dermatologice

JOANNE LYNN, MD, MA, MS

Senior Researcher, RAND Health, Arlington
Subiecte speciale
NAYAHMKA MCGRIFF-LEE, PharmD
Senior Regional Medical Scientist, GlaxoSmithKline
Formule farmaceutice i dozri
MELVIN I. ROAT, MD
Assistant Surgeon, Wills Eye Hospital,
Philadelphia
Afeciuni oftalmologice
JAMES R. ROBERTS, MD, FACEP,
FAAEM, FACMT
Professor and Vice Chair, Department of
Emergency Medicine and Director, Division
of Medical Toxicology, The Drexel University College of Medicine; Chair, Department
of Emergency Medicine and Director, Division of Medical Toxicology, Mercy Catholic
Medical Center
Intoxicaii i traumatisme
ROBERT J. RUBEN, MD, FACS, FAAP
Distinguished University Professor, Albert
Einstein College of Medicine, Department of
Otolaryngology, Montefiore Medical Center
Afeciuni otorinolaringologice

MANUALUL MERCK. EDITIA A XVIII-A

xv

MANUALUL MERCK. EDITIA A XVIII-A

xvi

Revizia capitolelor
Steven Berney, MD
William C. Black, MD
Jerrold T. Bushberg, PhD, DABMP
John J. Caronna, MD
Patricia Coyle, MD
Dwight L. Evans, MD
Margery Gass, MD
Laura C. Hanson, MD, MPH
Mary L. Hardy, MD
Jerome M. Hershman, MD
Helen Hoenig, MD
Randall Hughes, MD

Gail P. Jarvik, MD, PhD

Peter Laibson, MD
Allen S. Levine, PhD
Colonel David F. Murchison, DDS, MMS
John S. Oghalai, MD
Ann Ouyang, MB, BS
Stewart Shankel, MD
David R. Thomas, MD
Elise W. van der Jagt, MD, MPH
James Wayne Warnica, MD, FRCP(C)
Eric C. Westman, MD, MHS

Mulumiri
Mulumim pentru asistena editorial acordat lui: Rosalyn Carson-Dewitt, MD, J. Ricker
Polsdorfer, MD, Susan Spitz, MD, MSJ, i Oren Traub, MD, PhD. De asemenea, adresm
mulumiri lui Andrew J. Fletcher, MB, BChir, Sandra J. Masse, Debra G. Share, i
Jonathan S. Simmons, care ne-au ajutat la prima editare a acestei cri, i lui Maureen
Howard, Mary Evangelisto Miller, J. Donna LeBlanc, Beth A. Mescolotto, Nicole L. Paul,
i Regina A. Stamatis, care ne-au ajutat la corectur.

MANUALUL MERCK. EDITIA A XVIII-A

COLABORATORI

MOIRA L. AITKEN, MD
Professor of Medicine,
Washington
Broniectaziile

University

of

ROY D. ALTMAN, MD
Professor of Medicine, Division of Rheumatology and Immunology, David Geffen
School of Medicine at University of California, Los Angeles
Afeciuni articulare; Boala Paget a osului

Cornell University
Boli demielinizante
NOEL A. ARMENAKAS, MD
Clinical Associate Professor of Urology, Cornell
Weill Medical School; Attending Surgeon, Lenox
Hill Hospital and New York Presbyterian
Hospital
Traumatismele tractului genitourinar

BRADLEY D. ANAWALT, MD
Associate Professor of Medicine, University of Washington; Assistant Chief of Medicine, VA Puget Sound
Endocrinologia sistemului reproductor masculin
KENNETH C. ANDERSON, MD
Kraft Family Professor of Medicine, Harvard
Medical School; Chief, Division of
Hematologic Neoplasia, Dana-Farber Cancer
Institute
Afeciunile celulelor plasmatice
GERALD L. ANDRIOLE, MD
Professor and Chief of Urologic Surgery,
Washington University School of Medicine;
Urologist-in-Chief, Barnes-Jewish Hospital, St. Louis
Afeciunile prostatei
BRIAN R. APATOFF, MD, PhD
Director, Multiple Sclerosis Clinical Care
and Research Center, Department of Neurology and Neuroscience, New York Presbyterian Hospital; Weill Medical College of

MANUALUL MERCK. EDITIA A XVIII-A

J. MALCOLM O. ARNOLD, BSc,

MD, FRCP, FACC
Professor of Medicine, Physiology and
Phar- macology, University of Western
Ontario; Program Leader, Circulation
Group, Lawson Health Research
Institute; Re- search Director, Division
of Cardiology, London Health
Sciences Center Insuficiena cardiac i
cardiomiopatiile
JOHN A. ASTIN, PhD
California Pacific Medical Center, San
Francisco
Medicin complementar i alternativ
GEORGE L. BAKRIS, MD
Professor of Preventive Medicine and
Internal
Medicine
and
Director,
Hypertension/Clinical
Research
Center, Rush Medi- cal Center
Hipertensiunea arterial
DAVID H. BARAD, MD, MS

Associate Clinical Professor, Albert Einstein

College of Medicine, Bronx
Abordarea pacientei cu afeciuni ginecologice
JOHN G. BARTLETT, MD
Professor of Medicine and Chief, Division
of Infectious Diseases, Johns Hopkins University School of Medicine
Bronitia acut; Pneumonia; Abcesul pulmonar
ROSEMARY BASSON, MD, FRCP (UK)
Clinical Professor, Department of Psychiatry, University of British Columbia
Disfunciile sexuale la femei
BYRON E. BATTEIGER, MD
Professor of Medicine and Microbiology and
Immunology, Division of Infectious Diseases,
Indiana University School of Medicine
Infeciile cu Chlamydia i Mycoplasma
J. BRAD BELLOTTE, MD
Department of Neurosurgery, Allegheny
General Hospital, Pittsburgh
Traumatismele coloanei vertebrale

xvii

MANUALUL MERCK. EDITIA A XVIII-A

xviii

COLABORATORI

CHESTON M. BERLIN, JR., MD

University Professor of Pediatrics, Penn
State Childrens Hospital, M. S. Hershey
Medical Center, Hershey
Principiile tratamentului medicamentos la copii

KAREN BOWEN, MD
Assistant Clinical Professor of Medicine,
The George Washington University; Associate Medical Director, Community Hospices of The Washington Home
ngrijirea pacientului muribund

BRIAN M. BERMAN, MD
Professor of Family Medicine; Director,
Center for Integrative Medicine, Univer- sity
of Maryland School of Medicine Medicin
complementar i alternativ
RICHARD W. BESDINE, MD
Professor of Medicine, Greer Professor of
Geriatric Medicine, and Director, Division
of Geratrics (Medicine) and Director of
Center for Gerontology and Healthcare
Research, Brown Medical School
Medicin geriatric
ALBERT BIGLAN, MD
Adjunct Associate Professor of Ophthalmology, University of Pittsburgh School of
Medicine; Staff Physician, Childrens Hospital of Pittsburgh
Afeciuni i malformaii oculare
JOSEPH J. BIUNDO, MD
Medical Director of Rehabilitation, Kenner
Regional Medical Center
Bursitele, Tendinitele, i Fibromialgia
SEAN BLACKWELL, MD
Assistant Professor, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Hutzel Womens
Hospital
Sarcina i patologia asociat
ANN S. BOTASH, MD
Professor of Pediatrics, State University of
New York, Upstate Medical University
Abuzarea copilului
ALFRED A. BOVE, MD, PhD
Chief of Cardiology, Cardiology Section,
Temple University School of Medicine
Boli provocate de scufundare sau de lucrul n
condiii de presiune ridicat

MANUALUL MERCK. EDITIA A XVIII-A

THOMAS G. BOYCE, MD, MPH

Assistant Professor of Pediatrics, Mayo
Clinic College of Medicine; Consultant in
Pediatric Infectious Diseases, Mayo Clinic
Gastroenteritele
PETER C. BRAZY, MD
Professor of Medicine, University
Wisconsin-Madison
Anomalii n transportul renal

CHARLES LEE CAPERTON II, MD

Assistant Professor of Obstetrics and Gynecology, The University of Texas Health
Science Center at San Antonio
Endocrinologia sistemului reproductor feminin

of

CHRISTIAN M. BRIERY, MD
Fellow, Maternal-Fetal Medicine, University of Mississippi Medical Center
Sarcina cu risc crescut
GEORGE R. BROWN, MD
Professor and Associate Chairman,
Depart- ment of Psychiatry, East
Tennessee State University; Chief of
Psychiatry, Mountain Home VAMC
Sexualitatea i tulburrile sexuale
HAYWOOD L. BROWN, MD
Professor and Chair, Department of Obstetrics and Gynecology, Duke University
Medical Center
Sarcina normal, Traaliul; Naterea
ROBERT G. BRZYSKI, MD, PhD
Associate Professor of Obstetrics and
Gynecology, The University of Texas
Health Science Center at San Antonio
Endocrinologia
sistemului
reproductor
feminin
REBECCA H. BUCKLEY, MD
J. Buren Sidbury Professor of Pediatrics
and Professor of Immunology, Duke University Medical Center
Afeciuni imunodeficitare
ANGELA CAFIERO, PharmD, CGP
Assistant Professor of Clinical Pharmacy,
University
of
the
Sciences
in
Philadelphia, Philadelphia College of
Pharmacy; Clinical Pharmacy SpecialistGeriatrics, Philadel- phia VA Medical
Center
Farmacodinamica

MANUALUL MERCK. EDITIA A XVIII-A

Dentistry
Afeciuni hematologice perinatale
JOHN J. CARONNA, MD
Professor of Clinical Neurology and Vice
Chairman, Department of Neurology and
Neuroscience, Weill Medical College of
Cornell University
Starea de incontien i coma

WILLIAM J. COCHRAN, MD
Vice Chairman, Department of Pediatrics,
Geisinger Clinic, Danville, PA
Malformaii
congenitale
gastrointestinale;
Afeciuni gastrointestinale la nou-nscut i sugar

MARY T. CASERTA, MD
Associate Professor of Pediatrics, University of Rochester School of Medicine and
Dentistry; Attending Physician, Golisano
Childrens Hospital at Strong
Enteroviroze; Alte viroze; Infeciile nou-nscutului
BRUCE A. CHABNER, MD
Professor of Medicine and Clinical Director, Massachusetts General Hospital Cancer Center and Harvard Medical School
Principiile tratamentului n cancer
IAN M. CHAPMAN, MBBS, PhD
Associate Professor of Endocrinology, University of Adelaide; Department of Medicine, Royal Adelaide Hospital
Afeciunile glandei hipofize
RACHEL L. CHAPMAN, MD
Assistant Professor, Department of Pediatrics, Yale University School of Medicine
Fiziologia perinatal; Abordarea ngrijirii
sugarului i copilului; ngrijirea copilului bolna
i a familiei
LAN X. CHEN, MD, PhD
Clinical Assistant Professor and Attending
Rheumatologist, University of Pennsylvania Medical Center-Presbyterian and
VAMC
Infeciile articulaiilor i ale oaselor
WILLIAM D. CHEY, MD, FACG, FACP
Associate Professor, Director of Gastrointestinal Physiology Laboratory, University of Michigan
Bezoarele i corpurile strine
JILL M. CHOLETTE, MD
Critical Care Pediatrics Fellow, University
of Rochester School of Medicine and

MANUALUL MERCK. EDITIA A XVIII-A

COLABORATORI / xix
ALAN S. COHEN, MD
Distinguished Professor of Medicine
(Emeritus), Boston University School of
Medicine; Editor-in-Chief, Amyloid: The
Journal of Protein Folding Disorders
Amiloidoza

Hospital
Fiziologie perinatal; Abordarea ngrijirii nounscutului i sugarului; ngrijirea copilului
bolnav i a familiei sale
MARY ANN COOPER, MD
Professor, Department of Emergency Medicine, University of Illinois at Chicago
Leziuni produse de curentul electric

ROBERT B. COHEN, DMD

Associate Professor of Dentistry and
Prac- tice Coordinator, Tufts University
School of Dental Medicine
Abordarea pacientului stomatologic; Urgene
dentare; Afeciuni dentare comune; Abordarea
pacientului cu simptome nazale, bucale i
faringiene; Traumatismele faciale
SIDNEY COHEN, MD
Professor of Medicine and Director,
Research Programs, Thomas Jefferson
University
Gastrite i Ulcerul peptic; Afeciuni esofagiene
i Tulburri de nghiire
NANANDA F. COL, MD, MPP, MPH,
FACP
Associate Professor of Medicine, Brown
University Medical School
Luarea deciziilor medicale
KATHRYN COLBY, MD, PhD
Assistant Professor of Ophthalmology,
Harvard Medical School; Attending Surgeon, Cornea Service and Director of the
Joint Clinical Research Center, Massachusetts Eye and Ear Infirmary
Abordarea pacientului oftalmologic
DANIEL W. COLLISON, MD
Associate Professor of Medicine and Surgery, Section of Dermatology, Dartmouth
Medical School
Psoriazisul i alte boli nrudite; Tulburri de
pigmentare; Tulburri ale transpiraiei; Tumori
benigne; Ulcere de presiune
EVE R. COLSON, MD
Associate Professor of Pediatrics, Yale
Uni- versity School of Medicine; Director,
Well Newborn Nursery, Yale-New Haven

MANUALUL MERCK. EDITIA A XVIII-A

xx /

COLABORATORI

BRYAN D. COWAN, MD
Professor and Chairman, Department of
Obstetrics and Gynecology; University of
Mississippi Medical Center
Fibroamele uterine

PATRICIA A. DALY, MD
Assistant Professor of Clinical Medicine,
University of Virginia; Clinical Endocrinologist, Front Royal, VA
Sindromul de neoplazie endocrin multipl

JILL P. CRANDALL, MD
Assistant Professor, Division of Endocrinology, Diabetes Research and Training Center, Albert Einstein College of Medicine
Diabetul zaharat i Afeciunile metabolismului
carbohidrailor

JOHANNA P. DAILY, MD
Associate Physician, Brigham and Womens
Hospital; Instructor, Harvard Medical School
Virozele

RICARDO CRUCIANI, MD, PhD

Clinical Assistant and Professor, Department of Neurology and Anesthesiology,
Albert Einstein College of Medicine; Director, Research Division, Department of Pain
Medicine and Palliative Care, Beth Israel
Medical Center
Neurotransmisia
BURKE A. CUNHA, MD
Professor of Medicine, State University of
New York School of Medicine; Chief, Infectious Disease Division, Winthrop-University Hospital, Mineola
Spirochetele; Bacilii Gram-Negativi
EMMETT T. CUNNINGHAM, JR., MD,
PhD, MPH
Professor of Ophthalmology and Director,
The Uveitis Service, New York University
School of Medicine; Senior Vice President,
Medical Strategy, Eyetech Pharmaceuticals
Uveitele
DREW C. CUTLER, MD
Associate Professor of Pediatrics, Loma
Linda University School of Medicine
Boala chistic renal
RALPH E. CUTLER, MD
Professor of Medicine (Emeritus),
Loma
Linda University School of Medicine; Consultant in Nephrology, Loma Linda VAMC
Abordarea pacientului genitourinar; Terapia de
nlocuire renal; Afeciunile tubulointerstiiale;
Infeciile de tract urinar

MANUALUL MERCK. EDITIA A XVIII-A

DANIEL F. DANZL, MD
Professor and Chair of
Medicine, University
of
School of Medicine
Leziuni produse de frig

Emergency
Louisville

NORMAN L. DEAN, MD, FCCP

Pulmonologist,
Internal
Medicine,
Geriatrics, North Carolina Department of
Corrections; Director of Airway Clinics,
North Carolina Correctional Institution for
Women
necul

DEEPINDER KAUR K. DHALIWAL, MD

Associate Professor, University of Pittsburgh School of Medicine; Director of
Cornea/ External Disease and Director of
Refractive Surgery, University of Pittsburgh
Medical Center Eye Center; Medical Director, University of Pittsburgh Medical Center
Laser Center
Erori de refracie

ALAN H. DeCHERNEY, MD
Professor of Obstetrics and Gynecology,
Division of Reproductive Endocrinology,
David Geffen School of Medicine at University of California, Los Angeles
Endometriozele
RONALD DEE, MD
Associate Clinical Professor of Surgery,
Albert Einstein College of Medicine, Bronx
Afeciunile sistemului venos periferic i a
sistemului limfatic
PETER J. DELVES, PhD
Reader in Immunology, Department of
Immunology and Molecular Pathology,
Division of Infection and Immunity, University College London
Biologia sistemului imun
CRAIG S. DERKAY, MD
Professor, Otolaryngology and Pediatrics,
Eastern Virginia Medical School; Director,
Pediatric Otolaryngology, Childrens Hospital of the Kings Daughters, Norfolk
Afeciuni orofaringiene
ARA DerMARDEROSIAN, PhD
Professor of Pharmacognosy and Medicinal Chemistry, Roth Chair of Natural
Products,
Scientific
Director,
Complementary
and
Alternative
Medicine Institute, Univer- sity of the
Sciences in Philadelphia, Phila- delphia
College of Pharmacy
Suplimente dietetice

MANUALUL MERCK. EDITIA A XVIII-A