By R. Hector. Westwood College Illinois. 2018.

The falciform ligament ascends to the liver from the umbilicus purchase kamagra chewable 100 mg overnight delivery erectile dysfunction information, somewhat to the right of the midline buy discount kamagra chewable 100mg line whey protein causes erectile dysfunction, and bears the ligamentum teres in its free border. The ligamentum teres passes into its fissure in the inferior surface of the liver while the falciform ligament passes over the dome of the liver and then divaricates. Its right limb joins the upper layer of the coronary liga- ment and its left limb stretches out as the long narrow left triangular ligament which, when traced posteriorly and to the right, joins the lesser omentum in the upper end of the fissure for the ligamentum venosum. The lesser omentum arises from the fissures of the porta hepatis and the ligamentum venosum and passes as a sheet to be attached along the lesser curvature of the stomach. Structure The liver is made up of lobules, each with a solitary central vein which is a tributary of the hepatic vein which, in turn, drains into the inferior vena cava. In spaces between the lobules, termed portal canals, lie branches of the hepatic artery (bringing systemic blood) and the portal vein, both of which drain into the central vein by means of sinusoids traversing the lobule. Branches of the hepatic duct also lie in the portal canals and receive fine bile capillaries from the liver lobules. Segmental anatomy The gross anatomical division of the liver into a right and left lobe, demar- cated by a line passing from the attachment of the falciform ligament on the anterior surface to the fissures for the ligamentum teres and ligamentum venosum on its posterior surface, is simply a gross anatomical descriptive term with no morphological significance. Studies of the distribution of the hepatic blood vessels and ducts have indicated that the true morphological and physiological division of the liver is into right and left lobes demar- cated by a plane which passes through the fossa of the gall-bladder and the fossa of the inferior vena cava. Although these two lobes are not differenti- ated by any visible line on the dome of the liver, each has its own arterial and portal venous blood supply and separate biliary drainage. This mor- phological division lies to the right of the gross anatomical plane and in this the quadrate lobe comes to be part of the left morphological lobe of the liver while the caudate lobe divides partly to the left and partly to the right lobe (Fig. Note that the quadrate lobe is morphologically a part of the left lobe while the caudate lobe belongs to both right and left lobes. The right and left morphological lobes of the liver can be further subdi- vided into a number of segments, four for each lobe (Fig. The student need not learn the details of these, but of course to the hepatic surgeon, car- rying out a partial resection of the liver, knowledge of these segments, with their individual blood supply and biliary drainage, is of great importance. At the hilum of the liver, the hepatic artery, portal vein and bile duct each divide into right and left branches and there is little or no anastomosis between the divisions on the two sides (Fig. From the region of the porta hepatis, the branches pass laterally and spread upwards and down- The gastrointestinal adnexae 97 Fig. Note that the quadrate lobe is supplied exclusively by the left hepatic artery and drained by the left hepatic duct. The hepatic veins (Figs 72c, 74) These veins are massive and their distribution is somewhat different from that of the portal, hepatic arterial and bile duct systems already described. These pass upwards and backwards to drain into the inferior vena cava at the superior margin of the liver. Their terminations are somewhat variable but usually the central hepatic vein enters the left hepatic vein near its termination. In addition, small hepatic venous tributaries run directly backwards from the substance of the liver to enter the vena cava more dis- tally to the main hepatic veins. Although these are not of great functional importance they obtrude upon the surgeon during the course of a right hepatic lobectomy. The three principal hepatic veins have three zones of drainage corre- sponding roughly to the right, the middle and left thirds of the liver. The plane defined by the falciform ligament corresponds to the boundary of the zones drained by the left and middle hepatic veins. Unfortunately for the surgeon, the middle hepatic vein lies just at the line of the principal plane of the liver between its right and left morphological lobes and it is this fact which complicates the operation of right hepatic resection (Fig. The common bile duct commences about 1in (4cm) above the duodenum, then passes behind it to open at a papilla on the medial aspect of the second part of the duodenum. In this course the common duct lies either in a groove in the posterior aspect of the head of the pancreas or is actually buried in its sub- stance. As a rule, the common duct termination joins that of the main pancre- atic duct (of Wirsung) in a dilated common vestibule, the ampulla of Vater, whose opening in the duodenum is guarded by the sphincter of Oddi. The common hepatic duct and the supraduodenal part of the common bile duct lie in the free edge of the lesser omentum where they are related as follows (Fig. It lies in a fossa separating the right and quadrate lobes of the liver and is related inferiorly to the duodenum and transverse colon. Other vessels derived from the hepatic artery pass to the gall-bladder from its bed in the liver. Structure The gall-bladder wall and the sphincter of Oddi contain muscle, but there are only scattered muscle fibres throughout the remaining biliary duct system. The mucosa is lined throughout by columnar cells and bears mucus-secreting glands. Development The gall-bladder and ducts are subject to numerous anatomical variations which are best understood by considering their embryological develop- ment. A diverticulum grows out from the ventral wall of the duodenum which differentiates into the hepatic ducts and the liver (see Fig. Another diverticulum from the side of the hepatic duct bud forms the gall- bladder and cystic duct.

purchase kamagra chewable 100mg with visa

purchase 100mg kamagra chewable with mastercard

Acute condi- A polycystic (pol-e-SIS-tik) kidney is one in which tions usually arise suddenly generic 100 mg kamagra chewable with mastercard erectile dysfunction doctor austin, most frequently as the result many fluid-containing sacs develop in the active tissue of infection with inflammation of the nephrons order kamagra chewable 100mg fast delivery erectile dysfunction 27. Blood also known as acute poststreptococcal glomerulonephritis, is in the urine and dull pain in the kidney region are warn- the most common disease of the kidneys. Surgical removal of usually occurs in children about 1 to 4 weeks after a strep- the kidney offers the best chance of cure because most tococcal throat infection. These damaged glomeruli allow protein, es- pecially albumin, to filter into the glomerular capsule and Kidney Stones Kidney stones, or calculi (KAL-ku-li), ultimately to appear in the urine (albuminuria). Accumulation of fluid in the tis- resembling bits of gravel up to large masses that fill the sue spaces may occur late in chronic renal disease, renal pelvis and extend into the calyces. There is no way of dissolving these stones because sub- ◗ Electrolyte imbalance, including retention of sodium stances that could do so would also destroy kidney tissue. A lithotriptor (LITH-o- ◗ Anemia occurs when the kidneys cannot produce the trip-tor), literally a “stone-cracker,” is a device that employs hormone erythropoietin to activate red blood cell pro- external shock waves to shatter kidney stones. When these levels are very high, Renal Failure Acute renal failure may result from a urea can be changed into ammonia in the stomach and medical or surgical emergency or from toxins that dam- intestine and cause ulcerations and bleeding. This condition is characterized by a sud- Checkpoint 22-13: What is the difference between acute and den, serious decrease in kidney function accompanied by chronic kidney disorders? Renal Dialysis and Kidney Transplantation Chronic renal failure results from a gradual loss of Dialysis (di-AL-ih-sis) means “the separation of dissolved nephrons. As more and more nephrons are destroyed, the molecules based on their ability to pass through a semi- kidneys gradually lose the ability to perform their normal permeable membrane” (Fig. As the disease progresses, nitrogenous waste pass through the membrane move from an area of greater products accumulate to high levels in the blood, causing concentration to one of lesser concentration. In many who have defective kidney function, the accumulation of cases, there is a lesser decrease in renal function, known urea and other nitrogenous waste products can be re- as renal insufficiency, that produces fewer symptoms. The principle of “molecules leaving the area of Two of the characteristic signs and symptoms of greater concentration” thus operates to remove wastes chronic renal failure are the following: from the blood. In fact, angiotensin II is estimated which is manufactured by capillary endothelium, especially in to be four to eight times more powerful than norepinephrine, the lungs. THE URINARY SYSTEM ✦ 445 From dialysis fluid supply Dialysis fluid Peritoneal New cavity solution PRO Blood From To vein artery Catheter Old solution Bicarbonate To waste A Potassium B Figure 22-11 A hemodialysis system and a peritoneal dialysis system. This membrane is porous enough to allow all of the constituents except the plasma proteins (PRO) and blood cells (WBC, RBC) to diffuse between the two compartments. This procedure Abnormalities in structure of the ureter include subdivi- 22 may be done at intervals through the day or during the sion at the renal pelvis and constricted or abnormally nar- night. Abnormal A 1973 amendment to the Social Security Act pro- pressure from tumors or other outside masses may cause vides federal financial assistance for people who have ureteral narrowing.. Records show that fit of anesthesia, were permitted by their patients to cut transplantation success is greatest when surgeons use a through the skin and the muscles of the back to remove kidney from a living donor who is closely related to the stones from the ureters. To perform Aa nephrology technician, specializes in the safe and effec- these duties, hemodialysis technicians need a thorough un- tive delivery of renal dialysis therapy to patients suffering derstanding of anatomy and physiology. Before treatment begins, the technician the United States receive their training from a college or tech- prepares the dialysis solutions and ensures that the dialysis nical school, and many states require that the technician be machine is clean, sterile, and in proper working order. During dialysis, the the incidence of kidney disease is expected to rise, as will the technician monitors the patient for adverse reactions and need for hemodialysis. The Cystitis Inflammation of the bladder, called cystitis transurethral route through the urethra and urinary blad- (sis-TI-tis), is 10 times as common in women as in men. Pain, A full (distended) bladder lies in an unprotected position urgency to urinate, and urinary frequency are common in the lower abdomen, and a blow may rupture it, neces- symptoms of cystitis. The con- Scrotum dition may originate with a neurologic disorder, trauma to the spinal cord, weakness of the pelvic muscles, im- paired bladder function or medica- tions. If it is not removed surgi- may cause damage to the musculature of the pelvic floor, cally, it can cause back pressure of the urine, with serious resulting in urinary tract problems in later years. There is also a condition in the male in Enlargement of the prostate, common in older men, which the urethra opens on the undersurface of the penis may cause obstruction and back pressure in the ureters instead of at the end. Changes with age, in- Urethritis, which is characterized by inflammation of cluding decreased bladder capacity and decreased muscle the mucous membrane and the glands of the urethra, is tone in the bladder and urinary sphincters, may predis- much more common in men than in women. However, most elderly people (60% caused by infection with gonococci or chlamydias, al- in nursing homes, and up to 85% living independently) though many other bacteria may be involved. Peritoneal cavity Ductus (vas) deferens Urinary bladder Pubic symphysis Rectum Prostate Ampulla Urethra of ductus deferens Corpus cavernosum of penis Seminal Corpus spongiosum vesicle of penis Glans penis Ejaculatory duct Prepuce (foreskin) (Cowper) Epididymis gland Testis Path of spermatozoa Figure 23-1 Male reproductive system. THE MALE AND FEMALE REPRODUCTIVE SYSTEM ✦ 457 Meiosis Spermatic cord Gametes are characterized by having half as many chro- mosomes as are found in any other body cell. During their formation, they go through a special process of cell Vein division, called meiosis (mi-O-sis), which halves the Head of Artery number of chromosomes. Lobule ◗ The Male Reproductive System Septum Body of Capsule The male reproductive system, like that of the female, epididymis may be divided into two groups of organs: primary and Seminiferous accessory (see Fig. Specialized interstitial (in-ter-STISH-al) cells that se- crete the male sex hormone testosterone (tes-TOS-teh- The Testes rone) are located between the seminiferous tubules.

Antiparkinsonian drugs Lüllmann cheap 100 mg kamagra chewable with visa erectile dysfunction at age 26, Color Atlas of Pharmacology © 2000 Thieme All rights reserved buy 100mg kamagra chewable with amex erectile dysfunction books. In principle, responsivity can be synchronized rhythmic activity and decreased by inhibiting excitatory or ac- manifests itself in motor, sensory, psy- tivating inhibitory neurons. Most excit- chic, and vegetative (visceral) phenom- atory nerve cells utilize glutamate and ena. From a pharmaco- seizure threshold, notably certain neu- therapeutic viewpoint, these may be roleptics, the tuberculostatic isoniazid, classified as: and "-lactam antibiotics in high doses; – general vs. Instead, antiepileptics are tor is a ligand-gated ion channel that, used to prevent seizures and therefore upon stimulation with glutamate, per- need to be given chronically. Only in the mits entry of both Na+ and Ca2+ ions into case of status epilepticus (a succession of the cell. The antiepileptics lamotrigine, several tonic-clonic seizures) is acute phenytoin, and phenobarbital inhibit, anticonvulsant therapy indicated — among other things, the release of glu- usually with benzodiazepines given i. The initiation of an epileptic attack Benzodiazepines and phenobarbital involves “pacemaker” cells; these differ augment activation of the GABAA recep- from other nerve cells in their unstable tor by physiologically released amounts resting membrane potential, i. Chloride influx polarizing membrane current persists is increased, counteracting depolariza- after the action potential terminates. Tiagabin blocks removal of GABA stabilize neuronal resting potential and, from the synaptic cleft by decreasing its hence, to lower excitability. Gabapentin may augment the is tried to achieve control of seizures, availability of glutamate as a precursor valproate usually being the drug of first in GABA synthesis(B) and can also act as choice in generalized seizures, and car- a K+-channel opener. Dosage is increased until seizures are no longer present or adverse effects become unacceptable. Only when monotherapy with different agents proves inadequate can changeover to a Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Drugs Acting on Motor Systems 191 Drugs used in the treatment of status epilepticus: Benzodiazepines, e. Choice seizures Simple seizures Carbam- Valproic acid, Primidone, azepine Phenytoin, Phenobar- Clobazam bital Complex + Lamotrigine or Vigabatrin or Gabapentin or secondarily generalized Generalized Tonic-clonic Valproic acid Carbam- Lamotrigine, attacks attack (grand mal) azepine, Primidone, Tonic attack Phenytoin Phenobarbital Clonic attack + Lamotrigine or Vigabatrin or Gabapentin Myoclonic attack Ethosuximide alternative Absence addition seizure + Lamotrigine or Clonazepam B. Indications for antiepileptics Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Combinations between anticon- type Ca2+ channel (A) and represents a vulsants or with other drugs may result special class because it is effective only in clinically important interactions in absence seizures. All antiepileptics are likely, albeit to For the often intractable childhood different degrees, to produce adverse epilepsies, various other agents are effects. Sedation, difficulty in concentrat- used, including ACTH and the glucocor- ing, and slowing of psychomotor drive ticoid, dexamethasone. Multiple encumber practically all antiepileptic (mixed) seizures associated with the therapy. Moreover, cutaneous, hemato- slow spike-wave (Lennox–Gastaut) syn- logical, and hepatic changes may neces- drome may respond to valproate, la- sitate a change in medication. Pheno- motrigine, and felbamate, the latter be- barbital, primidone, and phenytoin may ing restricted to drug-resistant seizures lead to osteomalacia (vitamin D prophy- owing to its potentially fatal liver and laxis) or megaloblastic anemia (folate bone marrow toxicity. During treatment with Benzodiazepines are the drugs of phenytoin, gingival hyperplasia may de- choice for status epilepticus (see velop in ca. Clonazepam is used it is less sedating than other anticonvul- for myoclonic and atonic seizures. Tremor, gastrointestinal upset, Clobazam, a 1,5-benzodiazepine exhib- and weight gain are frequently ob- iting an increased anticonvulsant/seda- served; reversible hair loss is a rarer oc- tive activity ratio, has a similar range of currence. Gastrointestinal problems and used mainly to treat agitated states, es- skin rashes are frequent. It exerts an pecially alcoholic delirium tremens and antidiuretic effect (sensitization of col- associated seizures. Despite this, treatment should continue during pregnancy, as the po- tential threat to the fetus by a seizure is greater. However, it is mandatory to ad- minister the lowest dose affording safe and effective prophylaxis. Concurrent high-dose administration of folate may Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Drugs Acting on Motor Systems 193 Na+Ca++ Excitatory neuron NMDA- receptor Inhibition of Glutamate glutamate NMDA-receptor- release: antagonist phenytoin, felbamate, lamotrigine valproic acid phenobarbital Ca2+-channel T-Type- calcium channel blocker Voltage ethosuximide, dependent (valproic acid) Na+-channel Enhanced inactivation: GABAA- carbamazepine receptor valproic acid GABA phenytoin CI– Gabamimetics: benzodiazepine barbiturates vigabatrin Inhibitory tiagabine neuron gabapentin A. Neuronal sites of action of antiepileptics Benzodiazepine GABA - A Tiagabine Allosteric receptor # " # Inhibition of enhance- GABA ment of! Sites of action of antiepileptics in GABAergic synapse Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Pain is a designation for a spectrum of Impulse traffic in the neo- and pa- sensations of highly divergent character leospinothalamic pathways is subject to and intensity ranging from unpleasant modulation by descending projections to intolerable. Pain stimuli are detected that originate from the reticular forma- by physiological receptors (sensors, tion and terminate at second-order neu- nociceptors) least differentiated mor- rons, at their synapses with first-order phologically, viz.

Kamagra Chewable
9 of 10 - Review by R. Hector
Votes: 138 votes
Total customer reviews: 138