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Rigidity of voluntary muscles may not be evident at Sedation in critical care units is used to reduce patient the outset or in mild cases purchase generic tadalis sx on-line erectile dysfunction bangalore doctor. Whenever possible purchase tadalis sx 20mg erectile dysfunction vascular disease, patients are doses are given at 10-min intervals until the patient sedated only to a level that enables them to open their eyes responds cheap 20 mg tadalis sx overnight delivery erectile dysfunction at age of 30, to a cumulative maximum dose of 10 mg/kg buy tadalis sx cheap online erectile dysfunction cause of divorce. Commonly Dantrolene (t½ 9h)probablyactsbypreventingthe used drugs include propofol and midazolam, and opioids 309 Section | 4 | Nervous system such as fentanyl, alfentanil, morphine or remifentanil, Reassurance from sympathetic nursing staff is extremely and the centrally-acting alpha-2 agonists clonidine and important and far more effective than drugs. Anaesthesia andIntensiveCare Oxford University Press, Oxford molecular mechanisms of general Medicine 9, 240–243. This ality disorders, disorders of childhood and adolescence chapter considers the following drug groups: (e. No account of drug treatment strategies for psychiatric • Drugs for attention deficit/hyperactivity disorder. Psychotherapies range widely, from simple counsel- ling (supportive psychotherapy) through psychoanalysis to newer techniques such as cognitive behavioural therapy. The term ‘psychosis’ treatment, with psychotherapy being adjunctive, for in- is still widely used to describe a severe mental illness with stance in promoting drug compliance, improving family re- hallucinations, delusions, extreme abnormalities of behav- lationships and helping individuals cope with distressing iour including marked overactivity, retardation and catato- symptoms. Psychotic disorders such as panic disorder and obsessive–compulsive disorder, include schizophrenia, severe depression and mania. Psy- forms of psychotherapy are available that provide alterna- chosis may also be due to illicit substances or organic con- tive first-line treatment to medication. Clinical features of schizophrenia are subdivided drugs and psychotherapy depends on treatment availabil- into ‘positive symptoms’, which include hallucinations, de- ity, previous history of response, patient preference and lusions and thought disorder, and ‘negative symptoms’ the ability of the patient to work appropriately with the such as apathy, flattening of affect and poverty of speech. In many cases there is scope and some- Disorders formerly grouped under ‘neuroses’ include times advantage to the use of drugs and psychotherapy in anxiety disorders (e. As antide- bTrazodone, nefazodone and mirtazapine have been classed as pressants are largely similar in their therapeutic efficacy, ‘receptor blocking’ antidepressants based on their antagonism of awareness of profiles of unwanted effects is of particular postsynaptic serotonin receptors (trazodone, nefazodone, importance. Next came fluvoxamine, fol- chlorpromazine derivative that showed antidepressant lowed by fluoxetine (ProzacW). The monoamine hypothesis proposes that, in depression, there Mirtazapine also achieves an increase in noradrenergic and is deficiency of the neurotransmitters noradrenaline/norepi- serotonergic neurotransmission, but through antagonism nephrine and serotonin in the brain which can be restored of presynaptic a2-autoreceptors (receptors that mediate neg- by antidepressants. Itisrelevantthat trazodone, which blocks several types of serotonin receptor (older) antihypertensive agents, e. However, for ibly to monamine oxidase by forming strong (covalent) 313 Section | 4 | Nervous system Synaptic cleft Postsynaptic receptors Presynaptic A neuron 3 D 4 B Induction of post- synaptic effects 1 2 Postsynaptic neuron Physiological processes at the synapse: 1. When an electrical signal reaches the presynaptic terminal, presynaptic amine vesicles fuse with the neuronal membrane and release their contents into the synaptic cleft. The finding tive such that amine metabolising activity can be restored that 50% of depressed patients have raised plasma corti- only by production of fresh enzyme, which takes weeks. Drugs with similar modes of action to antidepressants But how do changes in monoamine transmitter levels find other uses in medicine. Raised neuro- inhibits reuptake of both dopamine and noradrenaline/ transmitter concentrations produce immediate alterations norepinephrine. It was originally developed and used as in postsynaptic receptor activation, leading to changes in an antidepressant but is now more frequently used to assist second-messenger (intracellular) systems and to gradual smoking cessation (see p. Where there is a failure (and which provide potential targets for drug therapy) in- of response, measurement of plasma concentration can be clude the hypothalamic–pituitary–thyroid axis and the useful as the failure may be attributable to low plasma 314 Psychotropic drugs Chapter | 20 | levels due to ultra-rapid metabolism (though it is often not available). A substrate is a substance that is acted upon and changed by an A substrate is a substance that is acted upon and changed by an enzyme. Where two substrates of the same enzyme are prescribed together, they will compete and, if present in sufficient quantities, together, they will compete and, if present in sufficient quantities, themetabolismofoneorother,orboth,drugsmayalsobeinhibited, themetabolismofoneorother,orboth,drugsmayalsobeinhibited, resulting in increased plasma concentration and possibly in resulting in increased plasma concentration and possibly in enhanced therapeutic or adverse effects. An enzyme inducer accelerates the metabolism of co-prescribed drugs that are accelerates the metabolism of co-prescribed drugs that are substrates of the same enzyme, reducing their effects. An enzyme inhibitor retards metabolism of co-prescribed drugs, increasing their inhibitor retards metabolism of co-prescribed drugs, increasing their effects. Several of these drugs produce active metabolites that Antidepressants usually require 3–4 weeks for the full ther- prolong their action (e. By contrast, pa- line (from amitriptyline), desipramine (from lofepramine tients may experience unwanted effects, especially ‘jitteri- and imipramine) and imipramine (from clomipramine). If the drug is pressants, need to be started at a low and generally tolerable then tolerated, plasma concentration assay may confirm starting dose to the therapeutic dose. Only when the drug has reached the minimum ther- apeutic dose and been taken for at least 4 weeks can Therapeutic efficacy response or non-response be adequately established. How- ever, some patients do achieve response or remission at Provided antidepressant drugs are prescribed at an adequate subtherapeutic doses, for reasons of drug kinetics and lim- dose and taken regularly, 60–70% of patients with depression ited capacity to metabolise, the self-limiting nature of de- should respond within 3–4 weeks. Conventional meta- pression, or by a placebo effect (reinforced by the analyses have shown little evidence that any particular drug experience of side-effects suggesting that the drug must or class of antidepressant is more efficacious than others, but be having some action). Of the novel compounds, trazodone usually re- and lack of safety in overdose relative to more modern quires titration to a minimum therapeutic dose of at least agents. Venlafaxine is licensed for a form of depressive illness where mood reactivity is treatment-resistant depression by gradual titration from preserved, lack of energy may be extreme and biological 75 to 375 mg/day. Selection An antidepressant should be selected to match individual Changing and stopping patients’ requirements, such as the need or otherwise for antidepressants a sedative effect, or the avoidance of antimuscarinic effects (especially in the elderly). In the absence of special factors, When an antidepressant fails through lack of efficacy de- the choice rests on the weight of evidence of efficacy, the spite an adequate trial or due to unacceptable adverse ef- tolerability, the safety in overdose and the likelihood of fects, a change to a drug of a different class is generally an effective dose being reached. Some of the augmen- ences between drugs within a class may also be helpful tations discussed may even be used earlier than this if there when patients cannot tolerate other drug classes. The initial justifica- When changing between antidepressant doses, a conser- tion for this combination stems from mirtazapine’s unor- vative approach would be to reduce the first antidepressant thodox mechanism of action – the idea being that the progressively over 2 or more weeks before starting the new presynaptic adjustments effected by mirtazapine could drug. A second justifi- continuation syndromes’ if stopped abruptly, and less im- cation is more practical – mirtazapine is known to portant with fluoxetine due to its long half-life active improve the quality of sleep and serotonin reuptake in- metabolite which offers ‘built-in’ protection against with- hibitors may initially disrupt this, thus mirtazapine can drawal problems. A more proactive approach would in- be added both to boost the antidepressant effect and to volve ‘cross-tapering’ the second antidepressant – i. An evidence starting it while the first antidepressant is being reduced base does exist both for mirtazapine–venlafaxine and and gradually titrating the dose up. Trial evi- cases where three or more depressive episodes have oc- dence is strongest using olanzapine, and also exists for curred, evidence suggests that long-term continuation of quetiapine, risperidone and aripiprazole. Antipsychotics an antidepressant offers protection, as further relapse is al- also have important potential for side-effects which must most inevitable in the next 3 years. Sustained post-traumatic stress disorder, obsessive–compulsive disor- hypertension (due to blockade of noradrenaline/norepi- der and social phobia (see p. Venlafaxine order bulimia nervosa, in higher doses (60 mg/day) than appears to have some association with cardiac arrhythmias are required for depression. This effect is independent of but whether this is to a degree that is clinically significant is that on depression (which may coexist), and may there- unclear. Antidepressants Duloxetine may cause early nausea, which tends to sub- appear to be ineffective in anorexia nervosa. It also has the advantages of Adverse effects lacking antimuscarinic effects and of being relatively safe As most antidepressants have similar therapeutic efficacy, in overdose.
By contrast best 20mg tadalis sx erectile dysfunction treatment bangkok, a number of organ-specific and the response of the innate immune system to a challenge buy cheap tadalis sx 20mg on line coke causes erectile dysfunction, multi-system rheumatic diseases are characterised by a pri- are useful in many settings to damp down an over- mary abnormality within the immune response tadalis sx 20 mg without a prescription best erectile dysfunction pills for diabetes, requiring exuberant or pathologically prolonged inflammatory treatments that modify or suppress it purchase 20 mg tadalis sx with visa erectile dysfunction after zoloft. Immunomodulatory agents, which act on com- the process of inflammation, drugs in current use and those ponents of the adaptive immune response, are important in development that act to modify it, and the management for the treatment of complex autoimmune diseases and of certain common inflammatory diseases. Many drugs used in the covers the following areas: treatment of these diseases have complex mechanisms of • Acute inflammation. The cen- the manufacture of a rapidly expanding group of new tral process by which these are achieved is inflammation: the agents (‘biologicals’) that target specific components of sequence of events by which a pathogen is detected, cells of the immune response thought to be driving particular the immune system are recruited, the pathogen is eliminated diseases. Neutrophils and macro- phages may also cause damage to the surrounding host tissue through the release of digesting enzymes such as matrix metalloproteinases and collagenases. The inflam- matory process therefore needs to be halted rapidly once Prostaglandins Thromboxanes Leukotrienes the invading organism has been cleared. The adaptive immune response, although integrated into These are 20-carbon unsaturated fatty acids derived from the process of inflammation, becomes active at later stages. The prostaglandins, (2) memory: when an invading pathogen has been recog- thromboxanes and leukotrienes have diverse pro- nised once, a small number of specific cells remain dormant inflammatory roles. Platelet-activating factor and thromboxane T cell recognises a peptide antigen presented on the surface A2 affect the coagulation and fibrinolytic cascades. Glucocorticoids act by inducing the synthesis of liferation of adaptive cellular effectors, the generation and lipocortin-1, a polypeptide that inhibits phospholipase A2, release of antibodies by plasma cells and the production of and thereby exert a broad anti-inflammatory effect. On oc- kotriene receptor antagonists montelukast and zafirlukast casion, amplification loops may become self-perpetuating, cause bronchodilatation and are used to treat asthma. Black arrows denote activation, the red line inhibition, the red dashed arrow repression, and the red X lack of product. Other newer approaches target specific to prevention of allograft rejection, to rheumatoid arthritis components of the immune system. It is used to treat dis- ferred acute treatment for severe inflammatory disease in eases in which pathogenic autoantibody production is a wide variety of settings despite their adverse effects. Besides their response element within target gene promoters, anti-inflammatory actions they exert effects on carbohy- increasing transcription of various anti-inflammatory drate, protein and lipid metabolism, some of which con- genes. These include I-kB, which inhibits the activation tribute to their substantial adverse effect profile. They increase transcription of a number of genes encoding anti-inflammatory proteins and decrease transcription of pro- inflammatory genes. While they retain an important role in the treatment ociated with a neutrophilia caused by release of neutro- of acute gout, inflammatory arthritis, ankylosing spondy- phils from the bone marrow and reduced adherence to litis and dysmenorrhea, long-term prescription should vascular walls. Differences reduces the incidence of colonic cancer by approximately in t½ are not necessarily reflected proportionately in dura- 50%. The medication should fen and naproxen) studies all indicate that coxib use leads be prescribed for the shortest possible time and regularly to an approximately 50% reduction of upper gastrointesti- reviewed. Papillary protective agent and should be considered in all patients necrosis and interstitial nephritis arerare complications, often with at least one of the above risk factors. Journal of the American • Antihypertensives: their effect is lessened due to Medical Association 284:1247–1255. Paracetamol (acetaminophen) The plasma concentration of paracetamol is of predictive Mode of action and uses. Paracetamol is an effective value; if it lies above a semi-logarithmic graph joining treatment for mild-moderate pain and for relieving fever. Paracetamol has analgesic efficacy equivalent to patic damage is likely (plasma concentrations measured aspirin, but in therapeutic doses it has only weak anti- earlier than 4 h are unreliable because of incomplete ab- inflammatory effects, a functional separation that reflects sorption). Patients who are malnourished are regarded as its differential inhibition of enzymes responsible for pros- being at risk at 50% of these plasma concentrations. It is inactivated in the liver, principally by the smaller, is thought to have been ingested within the conjugation as glucuronide and sulphate. This substance is normally Specific therapy involves replenishing stores of liver glu- rendered harmless by conjugation with glutathione. Maximal, long- most effective if administered within 8 h of the overdose, term, daily dosing may predispose to chronic renal disease. Her husband said that his wife ‘knew that too much paracetamol was In the 18th century, the Reverend Edmund Stone wrote dangerous but she did not realise there was paracetamol in [the about the value of an extract of bark from the willow tree proprietary preparation]’ which she bought at a supermarket that did not have a dispensary counter where she could have received advice. Aspirin is a common cause of allergic or proved highly successful in the treatment of rheumatic fe- pseudoallergic symptoms and signs. The new preparation proved acceptable aspirin use to the development of the rare Reye’s tohisfatherandpavedthewayfortheproductionofaspirin. Platelets cannotregeneratethe enzyme comfort, tinnitus, deafness, sweating, pyrexia, restlessness, and the resumption of thromboxane A2 production is tachypnoea and hypokalaemia. A large overdose (plasma dependent on the entry of new platelets into the salicylate concentration above 750 mg/L) may result in circulation (platelet lifespan is 7 days). Thus a pulmonary oedema, convulsions and coma, with severe de- continuousantiplateleteffectisachieved withlow doses. Bleeding is unusual, despite the anti- • Respiratory stimulation is a characteristic of aspirin platelet effect of aspirin. In • Although aspirin in high dose reduces renal tubular children under 4 years, severe metabolic acidosis is more reabsorption of uric acid so increasing its elimination, likely than respiratory alkalosis, especially if the drug has other treatments for hyperuricaemia are preferred. Indeed aspirin should be avoided in gout as low doses Serial measurements of plasma salicylate are necessary to inhibit uric acid secretion and on balance its effects on monitor the course of the overdose, for the concentration uric acid elimination are adverse. The main use of aspirin is as an antiplatelet agent to agement of overdose applies, but the following are relevant prevent arterial thrombotic events due to atherosclerosis. Gastric lavage or the use in Kawasaki disease, in combination with intravenous im- of an emetic is no longer recommended. Hydrolysis removes is treated with sodium bicarbonate, which alkalinises the acetyl group, and the resulting salicylate ion is inacti- the urine and accelerates the removal of salicylate in the vated largely by conjugation with glycine. Doses of 75–150 mg/day are used to prevent throm- Colchicine is derived from the autumn crocus (Colchicum botic vascular occlusion; 300 mg as immediate treatment for autumnale). Its anti-inflammatory properties have long myocardial infarction; 300–900 mg every 4–6 h for analgesia. Effects particularly associated with aspi- tion to relieving inflammation in acute gout attacks, it is rin are: used to treat other inflammatory disorders including Beh- • Salicylism (the symptoms of an excessive dose): tinnitus c¸et’s syndrome and the hereditary fever syndrome familial and hearing difficulty, dizziness, headache and Mediterranean fever. The most common adverse effect of colchicine is diar- Most conventional immunomodulatory agents act by rhoea, due to its effects on rapidly proliferating gastrointes- inhibiting activation or reducing proliferation of lympho- tinal epithelial cells. Many have more than one mechanism of action may follow and it is therefore a sign to stop the drug and often the precise way in which they exert their effects and restart at a lower dose. Methotrexate, azathioprine, mycophenolate mofetil and Immunomodulatory drugs are used both to control symp- leflunomide are antimetabolites, interfering with the de toms and to retard or arrest the progression of chronic in- novo synthesis of purines and pyrimidines, on which pro- flammatory diseases. Metho- variety of ways, and reduce the proliferation and activation trexate is thought to have additional anti-inflammatory of lymphocytes. The calcineurin antagonists (ciclosporin and tacro- The terminology surrounding immunomodulatory drugs limus) and sirolimus selectively inhibit T-cell activation has evolved separately in different specialties, although the and proliferation, by inhibiting cytokine expression and underlying management principles are similar. Intravenous immuno- disease progression in illnesses such as rheumatoid or psori- globulin has immunomodulatory effects through interfer- aticarthritis. Treatmentregimensforsystemicvasculitisorse- ence with Fcg receptor signalling, among other vere organ involvement in the connective tissue diseases mechanisms.
Less commonly purchase tadalis sx line erectile dysfunction books, it passes in front of or behind the terminal ileum purchase tadalis sx 20mg fast delivery erectile dysfunction pills for high blood pressure, or lies in front of the caecum or in the right paracolic gutter buy cheap tadalis sx online erectile dysfunction drugs walgreens. Along appendix has been known to ulcerate into the duodenum or per- forate into the left paracolic gutter buy generic tadalis sx 20 mg line erectile dysfunction uptodate. The mesentery of the appendix, containing the appendicular branch of the ileocolic artery, descends behind the ileum as a triangular fold (Fig. Another peritoneal sheet, the ileocaecal fold, passes to the appendix or to the base of the caecum from the front of the ileum. The ileocaecal fold is termed the bloodless fold of Treves although, in fact, it often contains a vessel and, if cut, proves far from bloodless. Clinical features 1The lumen of the appendix is relatively wide in the infant and is fre- The gastrointestinal tract 81 quently completely obliterated in the elderly. Since obstruction of the lumen is the usual precipitating cause of acute appendicitis it is not unnat- ural, therefore, that appendicitis should be uncommon at the two extremes of life. It runs ﬁrst in the edge of the appendicular mesentery and then, distally, along the wall of the appendix. Acute infection of the appendix may result in thrombosis of this artery with rapid development of gangrene and subsequent perforation. This is in contrast to acute cholecystitis, where the rich collateral vascular supply from the liver bed ensures the rarity of gangrene of the gall-bladder even if the cystic artery becomes thrombosed. The caecum is delivered into the wound and, if the appendix is not immediately visible, it is located by tracing the taeniae coli along the caecum— they fuse at the base of the appendix. When the caecum is extraperitoneal it may be difﬁcult to bring the appendix up into the incision; this is facilitated by ﬁrst mobiliz- ing the caecum by incising the almost avascular peritoneum along its lateral and inferior borders. The appendix mesentery, containing the appendicular vessels, is ﬁrmly tied and divided, the appendix base tied, the appendix removed and its stump invaginated into the caecum. It commences anterior to the third segment of the sacrum and ends at the level of the apex of the prostate or at the lower quarter of the vagina, where it leads into the anal canal. The rectum is straight in lower mammals (hence its name) but is curved in man to ﬁt into the sacral hollow. Moreover, it presents a series of three lateral inﬂexions, capped by the valves of Houston, projecting left, right and left from above downwards. They must be visualized in carrying out a rectal examination, they provide the key to the local spread of rectal growths and they are important in operative removal of the rectum. Posteriorly lie sacrum and coccyx and the middle sacral artery, which are separated from it by extraperitoneal connective tissue containing the rectal vessels and lymphatics. The lower sacral nerves, emerging from the anterior sacral foramina, may be involved by growth spreading posteriorly from the rectum, resulting in severe sciatic pain. Anteriorly, the upper two-thirds of the rectum are covered by peri- toneum and relate to coils of small intestine which lie in the cul-de-sac of the pouch of Douglas between the rectum and the bladder or the uterus. In front of the lower one-third lie the prostate, bladder base and seminal 82 The abdomen and pelvis Sacral promontory Symphysis Seminal vesicle pubis Rectum Fascia of Prostate Denonvilliers Anal sphincter Fig. A layer of fascia (Denonvil- liers) separates the rectum from the anterior structures and forms the plane of dissection which must be sought after in excision of the rectum. The mid-anal canal repre- sents the junction between endoderm of the hind-gut and ectoderm of the The gastrointestinal tract 83 Fig. Acarcinoma of the upper anal canal is thus an adenocarci- noma, whereas that arising from the lower part is a squamous tumour. The two venous systems communicate and therefore form one of the anastomoses between the portal and systemic circulations. This comprises: the internal anal sphincter, of involuntary muscle, which continues above with the circular muscle coat of the rectum; the external anal sphincter, of voluntary muscle, which surrounds the internal sphincter and which extends further downwards and curves medi- ally to occupy a position below and slightly lateral to the lower rounded edge of the internal sphincter, close to the skin of the anal oriﬁce. The lower- 84 The abdomen and pelvis most, or subcutaneous, portion of the external sphincter is traversed by a fan-shaped expansion of the longitudinal muscle ﬁbres of the anal canal which continue above with the longitudinal muscle of the rectal wall. In carrying out a digital rectal examination, the ring of muscle on which the ﬂexed ﬁnger rests just over an inch from the anal margin is the anorectal ring. This represents the deep part of the external sphincter where this blends with the internal sphincter and levator ani, and demarcates the junc- tion between anal canal and rectum. The anal canal is related posteriorly to the ﬁbrous tissue between it and the coccyx (anococcygeal body), laterally to the ischiorectal fossae con- taining fat, and anteriorly to the perineal body separating it from the bulb of the urethra in the male or the lower vagina in the female. Note that the ischiorectal fossa is now often referred to, more accurately, as the ischio- anal fossa—it relates to the anal canal rather than the rectum. Rectal examination The following structures can be palpated by the ﬁnger passed per rectum in the normal patient: 1both sexes — the anorectal ring (see above), coccyx and sacrum, ischiorectal fossae, ischial spines; 2male—prostate, rarely the healthy seminal vesicles; 3female—perineal body, cervix, occasionally the ovaries. Abnormalities which can be detected include: 1within the lumen—faecal impaction, foreign bodies; 2in the wall—rectal growths, strictures, granulomata, etc. During parturition, dilatation of the cervical os can be assessed by rectal examination since it can be felt quite easily through the rectal wall. Initially contained within the anal canal (1st degree), they gradually enlarge until they prolapse on defaecation (2nd degree) and ﬁnally remain prolapsed through the anal oriﬁce (3rd degree). Anatomically, each pile comprises: a venous plexus draining into one of the superior rectal veins; terminal branches of the corresponding superior rectal artery; and a covering of anal canal mucosa and submucosa. The so-called ‘thrombosed external pile’ is a small tense haematoma at the anal margin caused by rupture of a subcutaneous vein and is much better termed a perianal haematoma. Occasionally, abscesses lie in the pelvirectal space above levator ani, alongside the rectum and deep to the pelvic peritoneum. They are classiﬁed anatomically and may be: submucous—conﬁned to the tissues immediately below the anal mucosa; subcutaneous—conﬁned to the perianal skin; low-level— passing through the lower part of the superﬁcial sphincter (most common); high-level—passing through the deeper part of the superﬁcial sphincter; anorectal—which has its track passing above the anorectal ring and which may or may not open into the rectum. In laying open ﬁstulae in ano, it is essential to preserve the anorectal ring if faecal incontinence is to be avoided. The anatomical basis for this probably lies in the insertion of the superﬁcial 86 The abdomen and pelvis component of the external anal sphincter posteriorly into the coccyx; between the two limbs of the V thus formed, the mucosa is relatively unsupported and may therefore be torn by a hard faecal mass at this site. Arterial supply of the intestine The alimentary tract develops from the fore-, mid- and hind-gut; the arterial supply to each is discrete, although anastomosing with its neigh- bour. The fore-gut comprises stomach and duodenum as far as the entry of the bile duct and is supplied by branches of the coeliac axis which arises from the aorta at T12 vertebral level (see Fig. The mid-gut extends from mid-duodenum to the distal transverse colon and is supplied by the superior mesenteric artery (Fig. Its branches are: 1the inferior pancreaticoduodenal artery; 2jejunal and ileal branches—supplying the bulk of the small intestine; 3the ileocolic artery, supplying terminal ileum, caecum and commence- ment of ascending colon and giving off an appendicular branch to the appen- dix—the most commonly ligated intra-abdominal artery; 4the right colic artery—supplying the ascending colon; 5the middle colic artery—supplying the transverse colon. The portal system of veins The portal venous system drains blood to the liver from the abdominal part of the alimentary canal (excluding the anal canal), the spleen, the pancreas and the gall-bladder and its ducts. The distal tributaries of this system correspond to, and accompany, the branches of the coeliac and the superior and inferior mesenteric arteries enumerated above; only proximally (Fig. The inferior mesenteric vein ascends above the point of origin of its artery to enter the splenic vein behind the pancreas. The superior mesenteric vein joins the splenic vein behind the neck of the pancreas in the transpyloric plane to form the portal vein, which ascends behind the ﬁrst part of the duodenum into the anterior wall of the foramen of Winslow and thence to the porta hepatis. Here the portal vein divides into right and left branches and breaks up into capillaries running between the lobules of the liver.
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