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Thirst is rarely an tion buy avanafil 100mg visa erectile dysfunction psychological treatment techniques, which reduces the urine fow rate in paediatric practice generic avanafil 100 mg amex crestor causes erectile dysfunction, as infantile diar- overriding factor in determining intake to as little as 0 purchase avanafil overnight delivery lipo 6 impotence. Urinary sodium output is regulated compartment if it is held there by the any salt ingested is maximally retained quality avanafil 100mg erectile dysfunction drugs compared. Aldosterone also stimulates has been vomiting and has diarrhoea Assessment of the sodium conservation by the sweat from a gastrointestinal infection. With volumes of body fuid glands and the mucosal cells of the no intake the patient becomes fuid compartments is not carried out in colon, but in normal circumstances depleted. Specialized cells in the juxta- the patient begins to take fuids orally, glomerular apparatus of the nephron sense decreases in blood pressure and secrete renin, the frst step in a sequence of events that leads to the secretion of aldosterone by the glomerular zone of Case history 3 the adrenal cortex (Fig 7. Atrial natriuretic peptide What will have happened to his body fuid compartments? To date, no disease state can be attributed to a primary disorder n Sodium may be lost from the body in urine or from the gut, e. Powerful non- Gastric juice 70 10 110 extracellular cation and plays a Small intestinal fuid 120 10 100 osmotic stimuli include hypovolaemia critical role in the maintenance of Diarrhoea 50 30 50 and/or hypotension, nausea and vomit- blood volume and pressure, by Rectal mucus 100 40 100 ing, hypoglycaemia, and pain. Thus when peritoneal fuids clinical practice mirrors the widespread signifcant sodium depletion occurs, prevalence of these stimuli. Primary sodium depletion from mineralocorticoid defciency (espe- to restore blood volume to normal. Another reason why only when there is pathological sodium sodium-losing patients may become loss, either from the gastrointestinal hyponatraemic is because a defcit of Water retention tract or in urine. Gastrointestrinal losses isotonic sodium-containing fuid is The causes of hyponatraemia due to (Table 8. In some sodium depletion can also be present make any contribution to the osmolal- situations, the factors that cause the with a normal serum sodium concentra- ity. In short, the serum sodium con- patient with severe hyponatraemia is, (such as infammation or restricted centration does not of itself provide any thus, strongly suggestive of pseudohy- venous return) are localized. Pseudohyponatraemia Case history 4 A 64-year-old woman was admitted with anorexia, weight loss and anaemia. The following in patients with severe hyperproteinae- biochemical results were obtained shortly after admission. Sodium and the other electro- How may this patient’s hyponatraemia be explained? However, many of the methods used in analytical instruments measure the sodium concentration in the total plasma volume, and take no account of Hyponatraemia: pathophysiology a water fraction that occupies less of the n Hyponatraemia because of water retention is the commonest biochemical disturbance total plasma volume than usual. In the early phases Clinical assessment depletion (see below), there is a high of sodium depletion postural hypoten- Clinicians assessing a patient with risk of mortality if treatment is not insti- sion may be the only sign. Each sodium depletion, such as dizziness, Biochemistry of these may provide valuable clues. Sodium depletion is diagnosed largely If there is no history of fuid loss, on clinical grounds, whereas in patients water retention is likely. Many patients with suspected water retention, history Severity will not give a history of water retention and examination may be unremarkable. It may be low or high in The serum sodium concentration If they are present in the recumbent sodium depletion depending on whether itself gives some indication of dangerous state, severe life-threatening sodium the pathological loss is from gut or or life-threatening hyponatraemia. However, this arbitrary cut-off should be applied with caution, particularly if it is not known how quickly the sodium concen- tration has fallen from normal to its Increased pulse current level. A patient whose serum sodium falls from 145 to 125 mmol/L in Apostural decrease Dry mucous in blood membranes 24 hours may be at great risk. Symptoms due to hyponatrae- mia refect neurological dysfunction resulting from cerebral overhydration Decreased Soft/sunken induced by hypo-osmolality. They are urine output eyeballs non-specifc and include nausea, malaise, headache, lethargy and a reduced level of consciousness. Seizures, coma and focal neurological signs are not usually Decreased Decreased seen until the sodium concentration is consciousness skin turgor less than about 115 mmol/L. Oedema Oedema is an accumulation of fuid in Clinical note the interstitial compartment. It is readily The use of oral glucose elicited by looking for pitting in the and salt solutions to lower extremities of ambulant patients correct sodium depletion in (Fig 9. It arises from a reduced major therapeutic advances of the effective circulating blood volume, last century and is life-saving, due either to heart failure or particularly in developing countries. Family practitioners, nurses and The response to this is secondary even parents are able to treat hyperaldosteronism. Case history 5 Treatment A 42-year-old man was admitted with a 2-day history of severe diarrhoea with some Hypovolaemic patients are sodium- nausea and vomiting. Oedematous patients have an 3 mmol/L µmol/L excess of both total body sodium and 131 3. Thirdly, concentration rarely rises above serum sodium concentration above the infants are susceptible to hypernatrae- 150 mmol/L. The clinical context is Pure water loss may arise from decreased teronism (Conn’s syndrome), where all-important. Severe hyper- there is excessive aldosterone secretion mia (sodium <150 mmol/L), if the natraemia due to poor intake is most and consequent sodium retention by the patient has obvious clinical features of often seen in elderly patients, either renal tubules. However, in mia (sodium 150 to 170 mmol/L), pure The failure of intake to match the both these conditions the serum sodium water loss is likely if the clinical signs of ongoing insensible water loss is the cause of the hypernatraemia. Water and sodium loss can result in hypernatraemia if the water loss exceeds Excessive Na+ the sodium loss. However, Urine is loss of body fuids because of vomiting maximally or diarrhoea usually results in hyponat- concentrated. Normal or It is easily missed precisely because it increased volume may not be suspected. Firstly, sodium bicarbonate is sometimes given to correct life- threatening acidosis. Secondly, near-drowning in salt- (a) (b) water may result in the ingestion of Fig 10. Other osmolality Note that of the three examples above, disorders only glucose causes signifcant fuid A high plasma osmolality may some- movement. Causes include: tion causes water to move out of cells and leads to intracellular dehydration. Any difference between measured osmolality and calculated osmolality is called the osmolal gap (see p. If the gap is large, this suggests the presence of a signifcant contributor to the meas- ured osmolality, unaccounted for in the calculated osmolality. He or she will be clinically very useful in the assess- be unable to communicate his/her dehydration are mild in relation to the ment of comatose patients. This is The consequences of disordered will continue from lungs/skin and because pure water loss is distributed osmolality are due to the changes in need to be replaced.
The pancreas may initially be difcult to visualize cheap avanafil 100 mg visa what is an erectile dysfunction pump, but can be identifed as it lies immediately anterior to the splenic vein purchase avanafil overnight delivery erectile dysfunction caused by herniated disc. The pancreas is at least as echogenic as the liver order avanafil with paypal erectile dysfunction 16, and is more echogenic with increasing age and body fat buy avanafil 50 mg with mastercard erectile dysfunction help. Only afer a minute or • Va r i a n t s more does the splenic parenchyma achieve uniform · the shape and position of the normal spleen can vary homogeneous enhancement (Fig. Tis is considerably thought to refect the variable blood fow within diferent compartments of the spleen · embryologically formed from fusion of multiple small splenunculi •The adult spleen measures approximately 12–15 cm length, · accessory or unfused splenunculi seen in 10%. Retroperitoneum • Positioned in the lef upper quadrant adjacent to 9th–11th ribs and has a diaphragmatic and visceral surface. Left para-aortic Coeliac axis node node Aortocaval Aorta node Retrocrural node Diaphragmatic crus B Inferior vena cava Fig. Normal uptake is in thyroid, liver, spleen, kidneys and Gallium is taken up at infammatory sites and non- reticulo-endothelial system with excretion via the gut specifcally by some tumours. It is used 270° anticlockwise rotation, resulting in the fourth part of transabdominally at high frequencies (10 and 13. Failure of this ileum for Crohn’s disease and the small/large bowel for intus- rotation results in the D-J fexure and jejunum remaining susception in children. Endoscopic and endocavity ultrasound on the right and colon on the lef, known as malrotation. Terefore, knowledge of luminal anatomy and its variants is known as exompholos, whereby the child is born remains crucial. Foregut •The forgut consists of the pharynx, oesophagus, stomach and the frst and second parts of the duodenum. The blood supply of these structures is predominantly derived from the coeliac artery, apart from the mid oesophagus, which derives its arterial supply from the thoracic aorta directly and the proximal third of the oesophagus from the inferior thyroid vessels. The vascular supply Nasopharynx is predominantly from the inferior mesenteric artery, except the rectum, which also derives supply from the internal iliac arteries. Oropharynx Pharynx Epiglottis Larynx • Muscular tube extending from the base of the skull to the level of C6, where it connects to the cervical oesophagus. Thyroid • Food passes over the erect epiglottis, through the piriform cartilage Oesophagus fossae and into the cervical oesophagus. The laryngopharynx is draped over the posterior aspect of the larynx, creating two posterolateral recesses; the piriform fossae (Fig. Valleculae A B Epiglottis Piriform fossa Piriform fossa Cervical oesophagus Cervical oesophagus Fig. On the lateral view, and then enters the thorax, where it will return to the the narrow posterior indentation of the cricopharyngeal midline at T5. Anteriorly, a wider but shallow indentation is caused by a submucosal venous plexus ( Fig. Its the lef subclavian artery, arch of the aorta, lef lung and short course within the abdomen is retroperitoneal and descending aorta. On the right, the azygos vein lies behind forms the gastro-oesophageal junction as it ends at the and to the right, crossing iThat T4 where it terminates. Oesophageal Mucosal layers of lumen the oesophagus Sternocleidomastoid Muscularis layers m. The oesophagus has fve layers, as demonstrated on Neurovascular and lymphatic anatomy endoscopic ultrasound (Fig. Drainage into the oesophageal branch of the lef gastric vein which drains into the anatomy portal vein. Plain chest radiograph •The oesophagus is difcult to see unless it is dilated and Lymphatic drainage fuid flled. Paraoesophageal lymphatic plexus draining: • Below the level of T4/right hilum, the azygo-oesophageal • superiorly to the posterior mediastinal lymph nodes and line may be seen, where the azygos vein and oesophagus then into the supraclavicular node abut the right lung. Barium studies • Show three impressions on the oesophagus – the Nervous system aortic arch, lef main bronchus and the lef atrium • Upper oesophagus – branches of the recurrent laryngeal ( Fig. Tese sympathetic fbres from the upper 4–6 thoracic spinal are minor transient muscular contractions, which segments. Superficial A Aortic arch mucosal layer impressions of the oesophagus Aortic arch Aortic arch impressions Left main bronchus of the oesophagus impressions of the oesophagus Left main bronchus impressions of the oesophagus Oesophagus Pulmonary trunk Left atrium Left atrial Left atrial Impressions impressions of the of the oesophagus oesophagus Descending aorta Right hemidiaphragm Oesophagus Left lobe of the liver Stomach Oesophagus B A ring – upper limit of the vestibule Right hemidiaphragm Right hemidiaphragm B ring (Schatzki’s Gas within the ring) – lower limit stomach fundus of the vestibule Gastro-oesophageal Oesophageal junction vestibule Body of the stomach Fig. Circular muscle surrounds the stomach flls, expands inferiorly and anteriorly as the body but is especially prominenThat the pylorus and the oblique majority of the stomach is mobile muscle forms a sling around the cardiac orifce to prevent · covered by peritoneum and are divided by the refux. The longitudinal layer is mostly centred on the lesser peritoneal attachments of the lesser and greater and greater curves. Tese run mostly along Plain flm and contrast study anatomy the longitudinal axis of the stomach. Within the pylorus these On the plain flm, the stomach may not be seen if fuid-flled or have the appearance of fne lines. In the antrum, small nodular empty, otherwise the gastric bubble is seen on the erect X-ray. The gastric rugae are seen on the double-contrast • Posteriorly – peritoneum of the lesser sac superiorly and barium meal, and are thick linear elevations or folds of the stomach bed inferiorly. A Distal oesophagus Stomach fundus Lesser curve Gastric antrum Body of the stomach Pylorus Greater curve Duodenal cap 2nd part of the duodenum Jejunal loops 4th part of the duodenum 3rd part of the duodenum B Body of the stomach Transverse colon Left lobe of the liver Gastric rugae Lesser curve Greater curve Left gastric a. Tail of the pancreas Right lobe of the liver Spleen Aorta Inferior vena cava Kidney Lesser curve D Left lobe of the liver Right lobe of Stomach fundus the liver Gallbladder Body of the stomach Incisura Greater curve Gastric antrum Transverse colon Transverse colon Greater curve Jejunal loops Fig. Transverse colon C Left hemidiaphragm Left lobe of the liver Gastric body Body of the pancreas Left kidney Gastric antrum D-J flexure Fourth part of the duodenum Transverse colon Fig. Ultrasound is not routinely used because of gas within the stomach; however, the pylorus can be seen and examined in • Fundus – short gastric arteries arising from the splenic the infant to look for pyloric stenosis (Fig. Normal limits Venous drainage are a length of < 15 mm and overall wall thickness < 8 mm. It is used to stage gastric • short gastric veins and lef gastroepiploic drain to splenic tumours or investigate outlet obstruction/extrinsic compres- vein sion seen on endoscopy. Nervous system Right kidney Transverse colon Parasympathetic supply from lef and right vagus nerves. Ascending colon Descending • Anterior vagal trunk – supplies the lesser curve, cardia and colon pylorus. Inferior vena cava Aorta • Posterior vagal trunk – supplies the majority of the Fig. Fibres from the 190 Chapter 11: The gastrointestinal tract Serosal layer – low echogenicity rim Liver Mucosa Antrum Circular muscle Gallbladder layer Mucosa Liver Fig. Relations Duodenum • Anteriorly – gallbladder and liverThe duodenum is a 25cm C-shaped muscular tube, which • Posteriorly - common bile duct, portal vein, gastroduodenal curves over and around the head and uncinate process of the artery, which separate it from the inferior vena cava pancreas; it then lies inferior to the pancreatic body, up to the duodeno-jejunal ( D – J ) fexure. Tere may be an accessory opening • Posteriorly – right kidney, ureter and adrenal for pancreatic drainage 2 cm proximally. A B Gastric antrum Right lobe of the liver Hepatic flexure Duodenal cap (1st part) Head of the pancreas Right kidney Second part of the Duodenal cap (1st part) duodenum (origin) Right lobe of the liver Second part of the duodenum (origin) Common bile duct Superior mesenteric v. Gastric antrum Jejunum Jejunum Descending colon Second part of the Jejunum Ascending colon Hepatic flexure duodenum (origin) C D Superior mesenteric v. Transverse colon Head of the pancreas Splenic flexure Common bile duct Main portal v. Hepatic flexure D-J flexure Right lobe of the liver Common bile duct Second part of the Head of the pancreas duodenum (origin) Pancreatic duct Right kidney Jejunum Fourth part of the duodenum Descending colon Ampulla Duodenal genu Third part of Fourth part of of Vater (D2/D3 junction) the duodenum the duodenum E Superior mesenteric v.
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