Bow-Wen Chen, MD

• Senior Attending Physician
• Division of Pediatric Hematology and Oncology
• Koo Foundation Sun Yat-Sen Cancer Center
• Taipei, Taiwan

It has a posterior part that is photosensitive; its anterior part quiz menstrual cycle 0.625 mg premarin with amex, which is not photosensitive women's health issues pregnancy week by week 0.625 mg premarin buy visa, constitutes the inner lining of the ciliary body and the posterior part of the iris women's health center jensen beach buy premarin 0.625 mg amex. Rods are approximately 120 million in number and are most numerous approximately 0 menopause 2014 speaker slides order generic premarin on line. They contain rhodopsin menopause rating scale buy discount premarin 0.625 mg line, a visual purple pigment and are specialized for vision in dim light. Optic Disk, also called as the blind Spot, consists of optic nerve fibers formed by axons of the ganglion cells. It is located nasal (or medial) to the fovea centralis and the posterior pole of the eye, has no receptors, and is insensitive to light. The wall of the eyeball is organized in three separate cocentric layers: an outer supporting fibrous layer, the corneoscleral coat; a middle vascular coat of uvea; and an inner layer consisting of the retina. The photosensitive and nonphotosensitive parts of the neural retina occupy different regions of the eye. The photosensitive part of the retina is found in the posterior part of the eye and terminates anteriorly along the ora serrata. The nonphotosensitive region of the retina is located anterior to the ora serrata and lines the inner aspect of the ciliary body and the posterior surface of the iris. The vitreous body (partially removed) occupies considerable space within the eyeball. Macula lutea, also called as the yellow spot, is the area near the center of the retina on the temporal side of the optic disk for the most distinct vision. It contains the fovea centralis, which is a central depression (foveola) in the macula. The iris is attached at its periphery to the middle of the anterior surface of the ciliary body. Peripheral to this attachment the ciliary body and narrow rim of sclera form the iridocorneal angle. Sinus venosus sclerae (canal of Schlemm) is a circularly running canal within the sclera, lying just behind the junction. Refractive media of the eyeball is constituted by the cornea, aqueous humor, lens, and vitreous body. Cornea has five layers: Corneal epithelium is non-keratinized stratified squamous epithelium. Corneal stroma (substantia propria) makes 90% of the corneal thickness and has regularly arranged collagen (type I) fibers along with sparsely distributed interconnected keratocytes (for repair and maintenance). Corneal endothelium is a simple squamous or low cuboidal epithelium, responsible for regulating fluid and solute transport between the aqueous and corneal stromal compartments. The cells of the endothelium do not regenerate, instead, they stretch to compensate for dead cells which reduces the overall cell density of the endothelium, which may affect fluid regulation. Cornea is supplied by the ophthalmic division of the trigeminal nerve by long & short ciliary nerves. Aqueous humor is formed by the ciliary processes and provides nutrients for the avascular cornea and lens. It passes through the pupil from the posterior chamber (between the iris and the lens) into the anterior chamber (between the cornea and the iris) and is drained into the scleral venous plexus through the canal of Schlemm at the iridocorneal angle. Impaired drainage causes an increased intraocular pressure, leading to atrophy of the retina and blindness. Lens is the transparent avascular biconvex body, 1 cm in diameter and 4 mm thick, placed between the anterior and posterior compartments of the eyeball. It is enclosed in an elastic capsule, held in position by radially arranged zonular fibers (suspensory ligament of the lens), which are attached medially to the lens capsule and laterally to the ciliary processes. It flattens to focus on distant objects by pulling the zonular fibers and gains more convex shape to accommodate the eye for near objects by contracting the ciliary muscle and thus relaxing zonular fibers. These cells are in direct contact with the aqueous humor of the anterior chamber of the eye. Head and Neck Vitreous body is the transparent gel called vitreous humor, which fills the eyeball posterior to the lens (vitreous chamber between the lens and the retina). It is perforated by the tendons of the ocular muscles, and is reflected backward on each as a tubular sheath. The expansions from the sheaths of the lateral rectus and medial rectus are strong, especially that from the latter muscle, and are attached to the zygomatic bone and lacrimal bone respectively. They check the actions of these two Recti, hence called medial and lateral check ligaments. Suspensory ligament of Lockwood is the thickening of the lower part of the fascia bulbi. It is slung like a hammock below the eyeball, being expanded in the centre, and narrow at its extremities which are attached to the zygomatic and lacrimal bones respectively. Eyelid has five layers: Skin, superficial fascia, orbicularis oculi muscle, tarsal plate & palpebral fascia and conjunctiva. The tarsal plates are made up of condensed fibrous tissue, and form the skeleton of the eyelids. The inferior tarsal plate is a narrow strip attached to the inferior orbital margin by palpebral fascia. Meibomian tarsal glands are modified sebaceous glands, partly embedded on the deeper aspects of the tarsal plates. Levator palpebrae superioris is a skeletal muscle inserting on the skin of the upper eyelid, as well as the superior tarsal plate. Superior tarsal muscle is a smooth muscle, attached to the levator palpebrae superioris, also insert on the superior tarsal plate itself. There are two types of ciliary glands opening into the follicles of eyelashes: Glands of Zeis, the modified sebaceous glands. Behind rectus insertion · · · · Sclera is the thinnest (weakest) behind the attachment of recti muscle into the sclera. The thickness gradually decrease towards the attachment of recti and the again increases - the sclera at the limbus is quite thick (800 µm) again. The thinnest part of the sclera is just posterior to (and under) the attachment of the four recti muscles. Inner surface of choroid is smooth, brown and lies in contact with pigmented epithelium of the retina. Pigmented layer of retina · · Lacrimatory Apparatus Lacrimal gland lies in the upper lateral region of the orbit on the lateral rectus and the levator palpebrae superioris It is drained by 12 lacrimal ducts, which open into the superior conjunctival fornix. Lacrimal canaliculi are two curved canals that begin as a lacrimal punctum (or pore) in the margin of the eyelid and open Lacrimal sac is the upper dilated end of the nasolacrimal duct, which opens into the inferior meatus of the nasal cavity. Tears enter the lacrimal canaliculi through their lacrimal puncta (which is on the summit of the lacrimal papilla) before the nasolacrimal duct opens into the inferior meatus is partially covered by a mucosal fold (valve of Hasner). Excess tears flow through nasolacrimal duct which drains into the inferior nasal meatus. Junction of lacrimal sac and canaliculus · Valve of Rosenmuller is a fold of mucous membrane at the junction between canaliculus and lacrimal sac. Arterial Supply (Eyeball) Ophthalmic artery is a branch of the internal carotid artery (cerebral part), enters the orbit through the optic canal beneath the optic nerve. It gives numerous ocular and orbital vessels Central artery of the retina travels in the optic nerve, divides into superior and inferior branches to the optic disk, and each of those further divides into temporal and nasal branches. It is an end artery that does not anastomose with other arteries, and thus, its occlusion results in blindness. Long posterior ciliary arteries (branches of ophthalmic artery) pierce the posterior part of the sclera at some distance from the optic nerve, and run forward, between the sclera and choroid, to the ciliary muscle, where they divide into two branches. They form an arterial circle, the circulus arteriosus major (around the circumference of the iris), from which numerous converging branches run, in the substance of the iris, to its pupillary margin, where they form a second (incomplete) arterial circle, the circulus arteriosus minor. It is associated with the fibrous extension of the ocular tendons (annulus of Zinn). Arteries of orbit Artery Ophthalmic Central artery of retina Course and distribution Traverses optic foramen to reach orbital cavity Pierces dural sheath of optic nerve and runs to eyeball; branches from center of optic disc; supplies optic retina (except cones and rods) Supraorbital Passes superiorly and posteriorly from supraorbital foramen to supply forehead and scalp Supratrochlear Passes from supraorbital margin to forehead and scalp. Lacrimal Passes along superior border of lateral rectus muscle to supply lacrimal gland, conjunctiva, and eyelids Dorsal nasal Ophthalmic artery Courses along dorsal aspect of nose and supplies its surface Short posterior ciliaries Pierce sclera at periphery of optic nerve to supply choroid, which in turn supplies cones and rods of optic retina Long posterior ciliaries Pierce sclera to supply ciliary body and iris Posterior ethmoidal Passes through posterior ethmoidal foramen to posterior ethmoidal cells Anterior ethmoidal Passes through anterior ethmoidal foramen to anterior cranial fossa; supplies anterior and middle ethmoidal cells, frontal sinus, nasal cavity, and skin on dorsum of nose. Superficial temporal artery · · · · · Ophthalmic artery gives central artery of retina. It also gives the supraorbital & supratrochlear arteries, along with dorsal nasal artery. Ophthalmic artery arises from internal carotid artery as it emerges from the roof of the cavernous sinus, enters the orbit through optic canal inferolateral to the optic nerve, both lying in a common dural sheath. Gives central artery to retina (an end artery), and also supplies ethmoidal sinuses by giving ethmoidal arteries. Leaves orbit through inferior orbital fissure Venous Drainage (Eyeball) Ophthalmic Veins (dig): Superior ophthalmic vein is formed by the union of the supraorbital, supratrochlear, and angular veins. It receives branches corresponding to most of those of the ophthalmic artery and, in addition, receives the inferior ophthalmic vein before draining into the cavernous sinus. Inferior ophthalmic vein begins by the union of small veins in the floor of the orbit. It communicates with the pterygoid venous plexus and often with the infraorbital vein and terminates directly or indirectly into the cavernous sinus. Optic Nerve and Visual Pathway Optic nerve is formed by the axons of ganglion cells of the retina, which converge at the optic disk. Optic nerve axons are covered by a membrane continuous with the dura and leave the orbit by passing through the optic canal. It joins the optic nerve from the corresponding eye to form the optic chiasma, which contains fibers from the nasal retina that cross over to the opposite side of the brain. Rods and cones are the first-order receptor cells that respond directly to light stimulation. Rods contain rhodopsin (visual purple) are sensitive to low-intensity light and work for night vision. Cones contain the iodopsin, operate at high illumination levels, are concentrated in the fovea centralis and responsible for high visual acuity, day vision and color vision. They project directly to the hypothalamus, superior colliculus, pretectal nucleus, and lateral geniculate body. Three other type of cells are present in retina: Horizontal, Amacrine and Muller cells. Horizontal cells are the laterally interconnecting neurons in the inner nuclear layer of the retina. They interconnect photoreceptors and bipolar cells, inhibit neighboring photoreceptors (lateral inhibition) and play a role in the differentiation of colors. Muller cells are the retinal glial cells, that serve as support cells for the neurons of the retina, they extend from the inner limiting layer to the outer limiting layer. The arrow (on the left side) indicates the direction of light falling on the retina. It is important to note that several rods and cones converge on a single bipolar neuron and several bipolar neurons activate one ganglion cells. The one-to-one relationship between rods and cones, bipolar neurons and ganglion cells shown in this figure is only for the sake of simplicity. On the basis of histologic features that are evident in the photomicrograph on right, the retina can be divided into ten layers. The layers correspond to the diagram on left, which shows the distribution of major cells of the retina. Note that light enters the retina and passes through its inner layers before reaching the photoreceptors of the rods and cones that are closely associated with retinal pigment epithelium. Also, the interrelationship between the bipolar neurons and ganglion cells that carry electrical impulses from the retina to the brain is clearly visible. Optic chiasma contains decussating fibers from the two nasal hemiretinas and non-crossing fibers from the two temporal hemiretinas and projects fibers to the suprachiasmatic nucleus of the hypothalamus. Optic tract contains fibers from the ipsilateral temporal hemiretina and the contralateral nasal hemiretina. It projects to the ipsilateral lateral geniculate body, pretectal nuclei, and superior colliculus. Layers 1, 4, and 6 receive crossed fibers; layers 2, 3, and 5 receive uncrossed fibers. It contains input from the superior retinal quadrants, which represent the inferior visual-field quadrants. It contains input from the inferior retinal quadrants, which represent the superior visual field quadrants. It has a retinotopic organization: the posterior area receives macular input (central vision); intermediate area receives paramacular input (peripheral input) and the anterior area receives monocular input. Optic nerve injury ­ leads to ipsilateral blindness, with no direct pupillary light reflex. Midline lesions (like pituitary tumor) results in bitemporal hemianopia (tunnel vision) 3. Bilateral lateral compression causes binasal hemianopia (nasal visual field is lost). A lesion in the optic radiation (geniculo-calcarine tract) again results in contralateral homonymous hemianopia. Transection of upper division of geniculo-calcarine tract causes a contralateral lower quadrantanopia. Transection of lower division of geniculo-calcarine tract causes a contralateral upper quadrantanopia (pie in the sky). One case is cortical blindness due to a block in posterior cerebral artery resulting in contralateral homonymous hemianopia with macular sparing (macular area on brain has additional supply from middle cerebral artery).

Syndromes

• Runny nose
• Several skin punctures may be needed to treat large areas. The surgeon may approach the areas to be treated from different directions to get the best contour.
• Clicking, popping, or grating sound when opening or closing the mouth
• Spinal cord injury is suspected.
• Imipramine (Tofranil)
• Hemorrhage

In which of the following vessels transverse mesocolon seen: (All India Dec 13 Pattern) a women's health center parkland purchase 0.625 mg premarin with amex. Left subhepatic · Left subhepatic space is the other name for the lesser sac (omental bursa) womens health 28 day challenge purchase premarin 0.625 mg with mastercard. Hepatic vein · Right tree margin of lesser omentum contains:- (i) Hepatic artery proper pregnancy 9 weeks cramping cheap premarin 0.625 mg with mastercard, (ii) Portal vein menstruation jelly like blood cheap premarin 0.625 mg amex, (iii) Bile duct menstruation 3 days early buy premarin 0.625 mg visa,(iv) Lymph nodes and lymphatics,and (v) Hepatic plexus of nerves. Anterior wall:- Caudate lobe of liver,stomach,lesser omentum,and 2nd layer of greater omentum. Posterior wall:- 3rd layer of greater omentum, and structures forming stomach bed (transverse colon, transverse mesocolon, diaphragm,left kidney,left suprarenal gland, pancreas and splenic vessels). Right border:- Right free margin of greater omentum and floor of epiploic foramen 4. Left border:- Left free margin of greater omentum;gastrosplenic, linorenal and gastrophrenic ligaments. Omental bursa · A posterior gastric ulcer may perforate into the lesser sac (omental bursa). Inferior liver · Epiploic foramen (foramen of winslow or aditus to lesser sac) is a slit like opening through which lesser sac communicates with greater sac. Its boundaries are:· Anterior:- Right free margin of lesser omentum (contains portal vein,hepatic artery proper and bile duct). Left subhepatic space · Lesser sac (Omental bursa) is left posterior intraperitoneal space, also called left subhepatic space. Uterus and rectum · In females rectouterine pouch (pouch of Douglas) lies between rectum (posteriorly) and uterus and posterior fornix of vagina (anteriorly). Inferior mesenteric vein · Inferior mesenteric vein lies in the free edge of the peritoneal fold of paraduodenal recess. Intersigmoid recess · Intersigmoid recess is constantly present in the foetus and in early infancy, but may disappear with age. Left ureter · Left ureter crossing the bifurcation of left common iliac artery lies behind intersigned recess, which is a surgical guide for locating left ureter. Middle colic artery Mesentery of gut Mesentery proper (Mesentery of small intestine) Transverse mesocolon Mesoappendix Sigmoid mesocolon Vessels contained by mesentery Jejunal and ileal branches of superior mesenteric vessels Middle colic vessel Appendicular vessels Sigmoid vessels 15. Inferior rectal vein · Mesorectum does not contain inferior rectal vein · Mesorectum contains superior rectal artery,branches from the inferior mesenteric plexus which descend to innervate the rectum and loose adipose connective tissue. Fascia between the rectal ampulla and the prostate and the seminal vesicles · Posterior surface of prostate is separated from rectum by the fascia of Denonvilliers which is the obliterated rectovesical pouch of peritoneum. Right and left gastric arteries which supply the lesser curvature (abdominal aorta celiac trunk common hepatic Right and left gastroepiploic arteries which supply the greater curvature (abdominal aorta celiac trunk common artery right gastric artery; abdominal aorta celiac trunk left gastric artery). Short gastric arteries which supply the fundus (abdominal aorta celiac trunk splenic artery short gastric arteries). Right and left gastric veins (right and left gastric veins portal vein hepatic sinusoids central veins hepatic veins Left gastroepiploic vein and short gastric veins (left gastroepiploic vein and short gastric veins splenic vein portal Right gastroepiploic vein (right gastroepiploic vein superior mesenteric vein portal vein hepatic sinusoids central veins hepatic veins inferior vena cava). Innervation the innervation of the stomach is by the enteric nervous system which in the stomach consists of the myenteric plexus of Parasympathetic Preganglionic neuronal cell bodies are located in the dorsal nucleus of the vagus. The enteric nervous system is modulated by the parasympathetic and sympathetic nervous systems. Sympathetic Preganglionic neuronal cell bodies are located in the intermediolateral cell column of the spinal cord (T5 to T9). Postganglionic axons synapse in the complex circuitry of the enteric nervous system. Gastric ulcers most often occur within the body of the stomach along the lesser curvature above the incisura angularis. Carcinomas of the stomach are most commonly found in the pylorus of the stomach and may metastasize to supraclavicular lymph nodes (Virchow nodes) on the left side which can be palpated within the posterior triangle of the neck. Carcinomas of the stomach may also metastasize to the ovaries where it is called a Krukenberg tumor. The short gastric arteries, left gastroepiploic artery and, when present, the posterior gastric artery are branches of the splenic artery. The right gastric artery and right gastroepiploic artery arise from the hepatic artery and its gastroduodenal branch, respectively. Stomach · Main gastric nerve of Latarjet is branch of vagus and supplies the stomach. All of the above · Arterial supply of stomach is as follows · Along lesser curvature: Left gastric artery (branch of coeliac trunk) and right gastric artery (branch of proper hepatic artery). Left gastric artery · he consistently largest artery to the stomach is left gastric artery. These structures forming stomach bed are (i) Diaphragm,(ii) left kidney, (iii) left suprarenal (adrenal) gland, (iv) pancreas (body), (v) transverse colon, (vi) splenic flexure of colon and (vii) splenic artery. Sometimes spleen is also included in stomach bed, but it is separated from stomach by greater sac(not lesser sac). Pre aortic nodes Lymphatic drainage of stomach · the stomach can be divided into four lymphatic territories. Lymph vessels from these nodes travel along the splenic artery to reach the coeliac nodes. Lymph vessels arising in these nodes drain into the first and second parts of the duodenum. From here the lymph is drained further into the hepatic nodes that lie along the hepatic artery; and finally into the coeliac nodes. From here it passes through the intestinal lymph trunk to reach the cisterna chyli. Superior Part (First Part) the first 2 cm of the superior part is intraperitoneal and therefore has a mesentery and is mobile; the remaining distal 3 cm of the superior part is retroperitoneal. Radiologists refer to the first 2 cm of the superior part of the duodenum as the duodenal cap or bulb. The superior part begins at the pylorus of the stomach (gastroduodenal junction) which is marked by the prepyloric vein. The hepatoduodenal ligament attaches superiorly and the greater omentum attaches inferiorly. Descending Part (Second Part) the descending part is retroperitoneal and receives the common bile duct and main pancreatic duct on its posterior/ medial wall at the hepatopancreatic ampulla (ampulla of Vater). In severe abdominal injuries, this part of the duodenum may be crushed against the L3 vertebra. Ascending Part (Fourth Part) the ascending part is intraperitoneal and ascends to meet the jejunum at the duodenojejunal junction which occurs approximately at the L2 vertebral level about 2 to 3 cm to the left of the midline. This junction usually forms an acute angle which is called the duodenojejunal flexure which is supported by the ligament of Treitz (represents the cranial end of the dorsal mesentery). The arterial supply of the duodenum is from the following: Supraduodenal artery which supplies the upper portion of the duodenum (abdominal aorta celiac trunk common hepatic artery gastroduodenal artery supraduodenal artery). Anterior and posterior superior pancreaticoduodenal arteries (abdominal aorta celiac trunk common hepatic artery gastroduodenal artery anterior and posterior superior pancreaticoduodenal arteries). Anterior and posterior inferior pancreaticoduodenal arteries (abdominal aorta superior mesenteric artery anterior and posterior inferior pancreaticoduodenal arteries). The venous drainage of the duodenum is to the following: Anterior and posterior superior pancreaticoduodenal veins (anterior and posterior superior pancreaticoduodenal veins portal vein hepatic sinusoids central veins hepatic veins inferior vena cava). Anterior and posterior inferior pancreaticoduodenal veins (anterior and posterior inferior pancreaticoduodenal veins superior mesenteric vein portal vein hepatic sinusoids central veins hepatic veins inferior vena cava). Clinical Considerations Duodenal ulcers most often occur on the anterior wall of the first part of the duodenum. Perforations of the duodenum occur most often with ulcers on the anterior wall of the duodenum. However, posterior wall perforations may erode the gastroduodenal artery causing severe hemorrhage and extend into the pancreas. Different arteries of the duodenum derived directly or indirectly from the above two arteries are: 1. Superior pancreaticoduodenal artery, a branch of gastroduodenal artery (a branch of hepatic artery from the coeliac trunk). Respective branches of superior and inferior pancreaticoduodenal arteries anastomose to form anterior and posterior pancreaticoduodenal arterial arcades. The vasa recta of the anterior arcade supply the anterior surface and those of the posterior arcade supply the posterior surface of the duodenum. Supraduodenal artery of "Wilkie": Usually it is a branch of the gastroduodenal artery from the coeliac trunk and supplies the anterosuperior and posterosuperior surfaces of the first part. Artery from the first jejunal branch of the superior mesenteric artery: It supplies branches to the fourth part of the duodenum. Note: Valvulae conniventes (also known as plicae circulares, valves of Kerckring) are the permanent transverse folds of the luminal surface of the small intestine (less marked in ileum), involving both the mucosa and submucosa. Duodenum Part of gut Stomach Duodenum Jejunum Ileum Large intestine Histological features Gastric pits and glands. Gastric glands contain (from above downwards): Mucus neck cells,parietal cells, chief cells. Accessory pancreatic duct · Major duodenal papilla -> Hepatopancreatic ampulla (opening of biliary pancreatic duct). Supplied by superior mesenteric artery · First part of duodenum also called superior part, is 5 cm (2 inches) long. Supraduodenal artery · the part of duodenum before the opening of bile duct (major duodenal papilla) develops from foregut and therefore is supplied by coeliac trunk through superior pancreaticoduodenal artery, a branch of gastroduodenal artery, which in turn is a branch of common hepatic artery. First part of duodenum receives additional supply from right gastric artery, supraduodenal artery (a branch of common hepatic artery),retroduodenal branch of gastrodudenal artery and right gastroepiploic artery. However among these, supraduodenal artery is inconstant and therefore can be chosen as the answer. Large circular mucosal folds · Circular folds are smaller and fewer · There are 3 or 6 arterial arcades with no windows. Jejunum · the nervous and villous coal of the jejunum are extensive and are thrown into folds,called Valvulae conniventes which give feathery appearance in the jejunum. Distal part of duodenum has a cap · the first part of the duodenum has the duodenal cap or bulb and not the distal part. Epicolic nodes are minute whitish nodules on the serosal surface of the colon, sometimes within the appendices epiploicae. Paracolic nodes lie along the medial borders of the ascending and descending colon and along the mesenteric borders of the transverse and sigmoid colon. Intermediate colic nodes lie along the named colic vessels (the ileocolic, right colic, middle colic, left colic, sigmoid and superior rectal arteries). Preterminal colic nodes lie along the main trunks of the superior and inferior mesenteric arteries and drain into pre-aortic nodes at the origin of these vessels. Watershed area between superior mesenteric artery and inferior mesenteric artery prone to early ischemia is splenic Colonic ischaemia is usually maximal in the region of the splenic flexure and proximal descending colon because this segment is furthest from the collateral arterial supplies. They are absent from other parts of intestine like caecum, appendix, rectum, anal canal. General Features the appendix is an intraperitoneal (mesoappendix), narrow, muscular tube attached to the posteromedial surface of the cecum. The appendix may lie in the following positions: Retrocecal (65%), pelvis (32%), subcecal (2%), anterior juxta-ileal (1%), and posterior juxta-ileal (0. Arterial Supply the arterial supply of the appendix is from the appendicular artery (abdominal aorta superior mesenteric artery ileocolic artery posterior cecal artery appendicular artery). Venous Drainage the venous drainage of the appendix is to the posterior cecal vein (posterior cecal vein superior mesenteric vein portal vein hepatic sinusoids central veins hepatic veins inferior vena cava). Clinical Consideration Appendicitis begins with the obstruction of the appendix lumen with a fecal concretion (fecalith) and lymphoid hyperplasia followed by distention of the appendix. Clinical findings include initial pain in the umbilical or epigastric region (later pain localizes to the right lumbar region), nausea, vomiting, anorexia, tenderness to palpation, and percussion in the right lumbar region. McBurney point is located by drawing a line from the right anterior superior iliac spine to the umbilicus. Preaortic · Terminal nodes for colon are superior mesenteric and inferior mesentric nodes (both are preaortic nodes). Internal iliac artery · the blood supply of colon is derived from the marginal artery of Drummond. It is a paracolic anastomotic artery formed by anastomosis between colic branches of superior mesenteric artery (ileocolic, right colic, middle colic) and colic branches of inferior mesenteric artery (left colic and sigmoidal arteries). Terminal branches from marginal artery are distributed as long and short vessels vasa longa and vasa bravia. Splenic flexure · There are areas of colon with poor blood supply resulting from incomplete anastomosis of marginal arteries. Splenic flexure (Griffith point): Water shed area between superior mesenteric artery and inferior mesenteric artery. Duodenum · Watershed area is a region of the body which is supplied by terminal part of two or more arteries. Sigmoid colon · Small bags of peritoneum filled with fat, called appendices epiploicae are present over the surface of large intestine, except for appendix, coecum and rectum. A patient has a penetrating ulcer of the posterior wall of the first part of the duodenum. Which of the following is present in the peritoneal reflection which forms one of the borders of the paraduodenal fossa: a. Tail of pancreas · Splenic artery (and not vein) is in the posterior relation of stomach. Inferior mesenteric vein · Inferior mesenteric vein is present in the paraduodenal fossa (a peritoneal recess in the vicinity of duodenum). The surgeon should be careful while operating in this region for cases like internal herniation. Left gastric artery · According to the surgery books by Sabiston and Schwartz, the largest artery to the stomach is left gastric artery.

Uterine tube · Once ejaculated into the female pregnancy symptoms at 5 weeks buy cheap premarin 0.625 mg online, the spermatozoa reach the uterus and in the isthmus of the uterine tubes pregnancy after tubal ligation premarin 0.625 mg with mastercard, they undergo capacitation women's health magazine weight loss tips generic premarin 0.625 mg otc. Pampiniform plexus · Pampiniform plexus of spermatic veins is present on the surface of the epididymis and run parallel to the spermatic arteries 8 menopause myths effective 0.625 mg premarin. Right side · Left testis descent begins early and it lies slightly at the lower level than the right breast cancer boots buy premarin 0.625 mg fast delivery. Straight tubules rete testis efferent ductules · the sperms form in the seminiferous tubules and pass on to the straight tubules (tubuli recti). Left renal vein · Left testicular vein empties into the left renal vein and right testicular vein empties into the inferior vena cava. Para-aortic lymph nodes · Testis drains into the pre-aortic and paraa-ortic lymph nodes. Skin of penis is supplied by superficial external pudendal artery · Penis consists of 2 corpora cavernosa and 1 corpus spongiosum. Ilioinguinal · During herniorrhaphy ilio-inguinal nerve is damaged, while working in the inguinal canal, whereas, ilio-hypogastric nerve may be damaged while putting the incision for herniorrhaphy at the inguinal region · Ilioinguinal nerve pierces the obliquus internus, distributing filaments to it, and, accompanying the spermatic cord through the superficial inguinal ring, is distributed to the skin of the upper and medial part of the thigh, and to the following locations in the male and female: - In the male (anterior scrotal nerve) to the skin over the root of the penis and anterior part of the scrotum - In the female (anterior labial nerve) to the skin covering the mons pubis and labium majus · the nerve does not pass through the deep inguinal ring, and therefore it only travels through part of the inguinal canal. Prostate Gland Prostate gland is located between the base of the urinary bladder and the urogenital diaphragm. It has three surfaces: Muscular anterior surface related to the retropubic space Inferior lateral surfaces related to the levator ani Posterior surface related to the seminal vesicles and the ampulla of the rectum. It has five lobes developmentally and are well observed in fetal prostate: Anterior lobe (or isthmus) lies in front of the urethra and is devoid of glandular substance. Lateral lobes (a pair), which are situated on either side of the urethra and form the main mass of the gland. Cut surface of an adult prostate do not resemble to lobes and is described in four zones: Name Fraction of gland Description Peripheral zone Central zone Transition zone ~70% ~25% ~5% the sub-capsular portion of the posterior aspect of the prostate gland that surrounds the distal urethra and is prone to cancer. It lies posterior to urethra and surrounds the ejaculatory ducts, accounts for ~2. It surrounds the proximal urethra (periurethral zone) and grows throughout life and is responsible for the benign prostatic hypertrophy. It has fibromuscular components only (glandular components absent) 776 Anterior fibromuscular zone ~5% Abdomen Anterior lobe roughly corresponds to part of transitional zone; posterior lobe to peripheral zone; lateral lobes span all zones and median lobe roughly corresponds to part of central zone. There are numerous openings for the prostatic ducts on either side in prostatic sinus - a groove between the urethral crest and the wall of the prostatic urethra. The crest has a rounded elevation called the seminal colliculus (verumontanum), on which the two ejaculatory ducts and the prostatic utricle open. Prostatic utricle is a blind pouch (5 mm deep); it is considered as an analogue to the uterus and vagina in the female. Arterial Supply Prostate gland is supplied by the branches of inferior vesical, middle rectal, and internal pudendal arteries (branches of internal iliac artery). Prostatic cancer may metastasize to the vertebral column and brain, through this channel. They are derived from degenerate cells or thickened secretions and occur more frequently with advancing age. A 50-year-old man suffering from carcinoma of prostate showed areas of sclerosis and collapse of T10 and T11 vertebrae in X-ray. Median lobe · the trigone of the urinary bladder is bounded by the two orifices of the ureters (base) and the internal urethral orifice (apex). Median lobe · Benign prostatic hypertrophy involves mainly the transitional zone of the prostate, and is mainly due to the glandular hyperplasia of the median lobe. Inferior vesical artery · the prostate gland is supplied by the branches of inferior vesical, middle rectal, and internal pudendal arteries. This fluid makes up a major portion of the preseminal fluid (or pre-ejaculate fluid) and probably serves to lubricate the penile urethra. Seminal Vesicle Seminal Vesicles Are enclosed by dense endopelvic fascia and are lobulated glandular structures that are diverticula of the ductus deferens. Seminal vesicles produce the alkaline constituent of the seminal fluid, which contains fructose and choline 779 Self Assessment and Review of Anatomy Seminal Vesicles A. The seminal vesicles are highly coiled tubular diverticula that originate as evaginations of the ductus deferens distal to the ampulla. Contraction of the smooth muscle of the seminal vesicle during emission will discharge seminal fluid into the ejaculatory duct. The seminal fluid is a whitish yellow viscous material that contains fructose (the principal metabolic substrate for sperm) and other sugars, choline, proteins, amino acids, ascorbic acid, citric acid, and prostaglandins. In forensic medicine, the presence of fructose (which is not produced elsewhere in the body) and choline crystals are used to determine the presence of semen. Ductus Deferens and Ejaculatory Ducts the vas deferens is supplied by the artery to vas deferens. It may be a branch of superior vesical artery, inferior vesical artery or middle rectal artery. Ductus Deferens Is a thick-walled tube that enters the pelvis at the deep inguinal ring at the lateral side of the inferior epigastric artery. Crosses the medial side of the umbilical artery and obturator nerve and vessels, passes superior to the ureter near the wall Contains fructose, which is nutritive to spermatozoa, and receives innervation primarily from sympathetic nerves of the hypogastric plexus and parasympathetic nerves of the pelvic plexus. Ejaculatory Ducts Are formed by the union of the ductus deferens with the ducts of the seminal vesicles. Peristaltic contractions of the muscular layer of the ductus deferens and the ejaculatory ducts propel spermatozoa with seminal fluid into the Open into the prostatic urethra on the seminal colliculus just lateral to the blind prostatic utricle (see the section on urethral crest). Ductus Deferens General Features the ductus deferens begins at the inferior pole of the testes, ascends to enter the spermatic cord, transits the inguinal canal, enters the abdominal cavity by passing through the deep inguinal ring, crosses the external iliac artery and vein, and enters the pelvis. The distal end of the ductus deferens enlarges to form the ampulla, where it is joined by a short duct from the seminal vesicle to form the ejaculatory duct. The smooth muscular coat of the ductus deferens is similar to the tail region of the epididymis. The arterial supply of the ductus deferens is from the artery of the ductus deferens, which arises from the internal iliac artery and anastomoses with the testicular artery. The venous drainage of the ductus deferens is to the testicular vein and the distal pampiniform plexus. Ejaculatory Duct the distal end of the ductus deferens enlarges to form the ampulla, where it is joined by a short duct from the seminal vesicle to form the ejaculatory duct. The ejaculatory duct passes through the prostate gland and opens into the prostatic urethra at the seminal colliculus of the urethral crest. The ejaculatory duct has no smooth muscular coat, so it does not contribute to the force for emission. It is separated from the base of bladder by the peritoneum · Vas deferens lies on the posterior wall (base) of the bladder and there is no peritoneum between them. So, there is no separation of vas deferens from the base of bladder by the peritoneum. It shows a terminal dilatation called as ampulla, before it joins the duct of seminal vesicle to form common ejaculatory duct. Penis has a root, which includes two crura and the bulb of the penis, and the body, which contains the three erectile corpora. Glans penis is the terminal part of the corpus spongiosum, covered by a fold of skin (prepuce). The prominent margin of the glans penis is the corona, the median slit near the tip of the glans is the external urethral orifice, and the terminal dilated part of the urethra in the glans is the fossa navicularis. Smegma is secreted by the preputial sebaceous glands of the corona, at the inner surface of the prepuce and neck of the glans penis. Deep fascia of the penis (Buck Fascia) is a continuation of the deep perineal fascia. It is continuous with the fascia covering the external oblique muscle and the rectus sheath. Tunica Albuginea is a dense fibrous layer that envelops both the corpora cavernosa and the corpus spongiosum. It is more dense around the corpora cavernosa and more elastic around the corpus spongiosum. Artery Supply Three arteries arise from internal pudendal arteries, branches of anterior divisions of internal iliac arteries. Artery to the bulb of penis (supplies proximal half of corpus spongiosum Dorsal artery of penis which supplies distal part of corpus spongiosum and the glans penis Superficial dorsal arteries of penis. In the flaccid state of the penis, these vessels appear spiral hence termed helicine arteries. Venous Drainage Deep dorsal vein of the penis is a midline vein lying deep to the deep (Buck) fascia and superficial to the tunica albuginea. It leaves the perineum through the gap between the arcuate pubic ligament and the transverse perineal ligament and drains into the prostatic and pelvic venous plexuses. Superficial dorsal vein of the penis runs toward the pubic symphysis between the superficial and deep fasciae and terminates in the external (superficial) pudendal veins, which drain into the greater saphenous vein. Lymphatic Drainage the lymphatics from the glans penis drain into the deep inguinal lymph nodes (of Cloquet & Rosenmuller). Deep artery of penis · Deep arteries are the principal vessels for filling the lacunae of erectile tissue during erection of the penis. Deep inguinal lymph nodes · Glans penis lymphatics drain into the deep inguinal lymph nodes (of Cloquet & Rosenmuller) 3. Deep artery of penis · Deep arteries fill the lacunae of erectile tissue in corpus cavernosum. Cremaster Reflex Cremasteric Reflex Stroking of the skin on the front and inner side of the thigh evokes a reflex contraction of cremaster, which retracts the the afferent limb for cremaster reflex is femoral branch of genitofemoral nerve (and by ilio-inguinal nerve additionally) the reflex is usually absent if there is torsion of the testicle. Abdomen Erection and Ejaculation Erection is under parasympathetic system - carried out by pelvic splanchnic nerves. There occurs dilatation of the arteries supplying the erectile tissue, and thus causes engorgement of the corpora cavernosa and corpus spongiosum, compressing the veins and thus impeding venous return and causing erection. Erection is maintained by contraction of the bulbospongiosus and ischiocavernosus muscles, which compresses the erectile tissues of the bulb and the crus. Ejaculation is under sympathetic system Friction to the glans penis and other sexual stimuli result in excitation of sympathetic fibers. There occurs contraction of the smooth muscle of the epididymal ducts, the ductus deferens, the seminal vesicles, and the prostate. The contraction of the smooth muscles push spermatozoa and the secretions of both the seminal vesicles and prostate into the prostatic urethra, where they join secretions from the bulbourethral and penile urethral glands. Rhythmic contractions of the bulbospongiosus compresses the urethra and pushes and ejects the secretions from the penile urethra. Ejaculation is accompanied by contraction of the internal urethral sphincter (of the bladder), which prevents retrograde ejaculation of the semen into the bladder. Ilio-inguinal nerve · the afferent limb for cremaster reflex is femoral branch of genitofemoral nerve (and also by ilio-inguinal nerve additionally) and efferent limb is carried by genital branch of genitofemoral nerve. Abdominal Cavity and Peritoneum Phrenocolic ligament Lienorenal ligament Gastrosplenic ligament Support anterior end of spleen and prevents its downwards displacement. Lesser Omentum A fold of peritoneum that extends from the porta hepatis of the liver to the lesser curvature of the stomach. Contents: Along the lesser curvature of the stomach the lesser omentum contains: Right and left gastric vessels and associated gastric lymph nodes and branches of the left gastric nerve. The portal triad lies in the free margin of the hepatoduodenal ligament and consists of the following: Common bile duct (anterior and to the right) Hepatic artery (anterior and to the left) Portal vein (lies posterior) B. Greater Omentum A fold of peritoneum that hangs down from the greater curvature of the stomach. It is known as the abdominal policeman because it adheres to areas of inflammation. Greater/Lesser Sac; Morison Pouch Peritoneal cavity is a potential space between the visceral and parietal peritoneum. Lesser sac forms due to the clockwise rotation of the stomach by 90-degree during embryologic development. Boundaries Anterior wall (from above downwards) Caudate lobe of liver Lesser omentum Stomach (postero-inferior surface) Greater omentum (anterior two layers) Posterior wall (from below upward) Greater omentum (posterior two layers) Structures forming the stomach bed (except spleen) Transverse colon. Right border: Liver Left border: Gastrosplenic and splenorenal ligaments Applied anatomy: Acute pancreatitis is probably the most common cause of a fluid collection within the lesser sac. Bleeding from trauma or a ruptured splenic artery aneurysm and perforation of a posterior gastric ulcer are other causes of lesser sac collections. Epiploic foramen boundaries are also evident Greater Peritoneal Sac the remainder of the peritoneal cavity and extends from the diaphragm to the pelvis. It contains a number of pouches, recesses, and Paracolic gutters through which peritoneal fluid circulates. Normally, peritoneal fluid flows upward In supine position excess Peritoneal Fluid due to peritonitis or ascites flows upward through the paracolic gutter to the In upright (sitting/standing) position excess Peritoneal Fluid due to peritonitis or ascites flows downward through the paracolic gutters to the rectovesical pouch (in males) or the rectouterine pouch (in females). Note: Rectouterine pouch of Douglas is the peritoneal space between the rectum and uterus. Hepatorenal pouch (of Morison) It is the right subhepatic space, lies between the inferior surface of the right lobe of the liver and the upper pole of the right kidney. Greater omentum · Greater omentum is present as the anterior as well as posterior boundary of lesser sac. Quadrate lobe of liver · Caudate (and not quadrate) lobe lies as the superior border of the epiploic foramen. Greater sac · Spleen develops in the dorsal mesentery and projects into the greater sac of peritoneal cavity. Omental bursa · A posterior perforation of ulcer in the pyloric antrum of the stomach will discharge the contents behind the stomach in the omental bursa.

The presence of diffuse tenderness or rebound tenderness on physical exam ination may indicate perforation and requires urgent surgical intervention women's health nutrition tips premarin 0.625 mg buy line. Treatment Antibiotic therapy with coverage for Gramnegative rods and anaerobes; no advantage to intravenous route over oral administration women's health issues in thrombosis and haemostasis 2015 buy discount premarin 0.625 mg online. Complicated diverticulitis may also require surgical resection pregnancy 0-0-1-0 0.625 mg premarin free shipping, if the patient fails to improve with conservative measures menstruation signs quality 0.625 mg premarin. Repeated bouts of uncomplicated diverticulitis do not mandate surgical intervention; however women's health clinic miami premarin 0.625 mg order, in immunocompromised patients, a lower threshold for surgical intervention applies. A preoperative colonoscopy is not mandatory but should be considered to rule out malignancy. Elective colonic resection is generally scheduled 6 weeks after the acute attack of diverticulitis. Abdominal Emergencies 391 Laboratory tests are usually nonspecific; leukocytosis and electrolyte abnormalities may be present. Delayed diagnosis increases mortality, especially in the elderly and in patients with comorbidities. Diagnosis Plain abdominal Xray in the supine and upright position (see Chapter 27). Peritoneal signs (guarding and rebound tenderness) are typically present on physical examination but may be absent in the elderly, ill, or immunocompromised patient. Marked leukocytosis, thrombocytosis, elevated serum lactate levels; serum amylase may be elevated, and serum electrolytes may be abnormal. Treatment Broadspectrum antibiotics and fluid resuscitation should begin immediately. Acute mesenteric ischemia occurs in the distribution of the celiac axis and superior mesenteric artery, whereas ischemic colitis occurs in the distribution of the inferior mesenteric artery. Clinical Features Persistent, poorly localized pain out of proportion to findings on physical examination. Treatment Most patients should be volume resuscitated and anticoagulated with hepa rin. Once peritoneal signs appear, surgical intervention with embolectomy or thrombectomy and resection of infarcted bowel is mandatory. The prevalence increases with age, and men are more 394 Common Problems in Gastroenterology frequently affected than women (5:1). Clinical Features Abrupt onset of acute abdominal (midabdominal, paravertebral, or flank) pain. A palpable pulsatile mass may be present, but the sensitivity of this finding ranges from 44% to 97%. Pearls Evaluation of acute abdominal pain at the extremes of age (infants and the elderly) may present a challenge due to difficulty in obtaining the history and potentially misleading laboratory data. Therefore, a carefully obtained history, thorough physical examination, and high index of suspicion are needed to make a diagnosis and institute appropriate treatment. During evaluation of acute abdominal pain, conditions of the abdominal wall, such as muscle strain or herpes zoster infection, should be considered. Serum amylase and lipase levels should be obtained in patients with acute abdominal pain. These tests are not included in a comprehensive metabolic panel in most laboratories. Surgical consultation should be obtained early, especially in patients who have peritoneal signs and those who are hemodynamically unstable (with tachycardia and hypotension). Abdominal Emergencies 395 Questions Questions 1 and 2 relate to Clinical Vignette 1. B Doppler ultrasonography of the celiac, superior mesenteric, and inferior mesenteric arteries. A 47yearold man presents to the emergency department with a 2day history of progressive left lower quadrant abdominal pain. The pain is con stant and associated with lowgrade fever, nausea, and constipation. The abdominal examination reveals guarding in the left lower quadrant and tenderness to palpation. There is no rebound 4 5 396 Common Problems in Gastroenterology tenderness, and bowel sounds are present. Laboratory test results are remarkable for a white blood cell count of 15 000 mm­3. Doppler ultrasonography of the splanchnic vessels (arteries or veins) is generally unreliable due to overlying bowel gas. Mesenteric arteriography may be diagnostic (and potentially therapeutic) in mesenteric ischemia, but not in any of the other causes of acute abdominal pain. The patient does not have peritoneal signs, and exploratory laparotomy is not immediately indicated. All other diagnoses listed are possible, but mesenteric ischemia must be ruled out because it is a lifethreatening emergency. B Physical examination in this patient (peritoneal signs, absent bowel sounds) is most concerning for a perforated viscous. Given the use of nonsteroidal antiinflammatory drugs, a perforated peptic ulcer is a likely possibility. Bowel obstruction causes colicky pain and bowel sounds are generally present, although they may be high pitched or absent in pro longed obstruction. Abdominal pain associated with choledocholithiasis, acute myocardial infarction, and renal colic do not cause peritonitis. C A plain Xray of the abdomen with an upright chest Xray would be the appropriate next examination to evaluate for free air. Because he is febrile and has an elevated white blood cell count, it is reasonable to administer antibiotics immediately. Colonoscopy and barium enema are contraindi cated when acute diverticulitis is suspected because of the increased risk of perforation. Rice Clinical Vignette 1 A 20yearold man presents with a 3month history of intermittent bright red blood per rectum. Family history is notable for colonic polyps in his father, paternal uncle, and several cousins. Physical examination shows faded hyperpigmented macules concentrated around the lips and buccal mucosa. Abdominal examination reveals a soft, nontender, nondistended abdomen with no palpable masses and no hepatosplenomegaly. Laboratory testing shows a hemoglobin level of 8 g dl­1, iron 20 g dl­1, ferritin 10 ng ml­1, total iron binding capacity 394 g dl­1, and iron saturation 4. Colonoscopy reveals numerous polyps ranging in size from 2 mm to 2 cm throughout the colon. Histologic examination of polyps from the colon, stomach, and duodenum reveal disorganization and proliferation of the muscularis mucosa with normal overlying epithelium, suggestive of hamartomas. Clinical Vignette 2 A 35yearold woman presents with a 6week history of bloody diarrhea and fatigue. Abdominal examination is significant for mild left lower quadrant tenderness without rebound tenderness or guarding. Routine laboratory tests including a complete blood count and comprehensive metabolic panel are normal with the exception of a hemoglobin level of 10 g dl­1. Stool examination is positive for fecal leukocytes, but bacterial cultures, examination for ova and parasites, and a test for Clostridium difficile toxin are negative. Colonoscopy reveals friable mucosa with exudates involving the rectum and sigmoid colon. Colonic mucosal biopsies of the affected areas reveal crypt abscesses and crypt architectural distortion as well as inflammatory infiltrates in the lamina propria. Histologic examination reveals panniculitis with acute and chronic inflammation localized to the fibrous septae between the fat lobules of the dermis. Tumor necrosis factoralpha inhibitors have been shown to benefit some patients, with infliximab being the most studied. Debridement or surgery should be avoided because of pathergy, a condition in which minor trauma leads to worsening of lesions, which may be resistant to healing. Gastrointestinal symptoms include abdominal pain, gastrointestinal hemorrhage, intussusception, and perforation. Biopsy of a lesion shows a leukocytoclastic vasculitis with immunoglobulin A (IgA) deposits in the superficial capillaries. Hereditary Hemorrhagic Telangiectasia (Osler­Weber­Rendu Disease) Hereditary hemorrhagic telangiectasia is an autosomal dominant vascular disorder characterized by telangiectasias, arteriovenous malformations, and aneurysms of the skin, lung, brain, and gastrointestinal tract (see Chapter 22). Epistaxis, gastrointestinal hemorrhage, and irondeficiency anemia are common complications of the disease. The diagnosis is based on four criteria: (1) spontaneous recurrent epistaxis; (2) mucocutaneous telangiectasias; (3) visceral involvement; and (4) a first degree family member with the disease. Treatment is supportive with iron supplements and/or periodic blood transfusions for anemia, as well as ablation of telangiectasias using laser for the skin lesions and argon plasma coagulation for lesions in the gastrointestinal tract. The diagnosis is made by the classic appearance of the lesion; a skin biopsy is rarely needed unless the diagnosis is uncertain. Therefore, dapsone is commonly used as a bridge therapy, as lesions typically resolve within days on this medication. Oral lesions may present as asymptomatic lacelike lesions on the buccal mucosa or painful erosive lesions on the tongue, buccal mucosa, or gingiva. Systemic glucocorticoids, phototherapy, or acitretin are alternatives in patients with widespread disease. Other findings include arthralgias, peripheral neuropathy, lymphadenopathy, hepatosplenomegaly, renal disease, and hypocomplementemia. It is less commonly associated with other chronic infections and connective tissue diseases. Deposits of IgM, IgG, and complement C3 may be seen with direct immunofluorescence. Treatment includes therapy of the underlying disorder, including antiviral therapy for chronic hepatitis C (or B). Immunosuppressive therapy may be used in patients with a more severe course of cryoglobulinemia. Treatment includes avoidance of exacerbating factors and treatment of underlying hepatitis C or hemochromatosis. Treatment is with glucocorticoids, with the addition of cyclophosphamide in moderate to severe disease. Small, and Saurabh Chawla Achalasia Achalasia is an esophageal motor disorder characterized by the absence of esophageal peristalsis and failure of the lower esophageal sphincter to relax with swallowing (see Chapter 2). The radiologic study of choice in the diagnosis of achalasia is a barium swallow (barium esophagogram) performed under fluoroscopic guidance. Multiple uncoordinated tertiary contractions in early stages and absence of peristalsis in late stages. Endoscopy is generally performed to exclude secondary causes of achalasia such as an infiltrating carcinoma at the gastroesophageal junction. Esophageal Ulcer Esophagitis and esophageal ulcers may be caused by gastroesophageal reflux disease, viral infections (human immunodeficiency virus, cytomegalovirus, herpes simplex virus), and medications (see Chapter 2). Barium studies are often used as an initial step in the diagnostic workup of dysphagia and serve as a complementary test to endoscopy. Gastric Ulcer (Benign versus Malignant) Gastric ulcers can be benign (peptic ulcer disease) or malignant (gastric adenocarcinoma, lymphoma, metastasis). Endoscopy is the diagnostic procedure of choice in patients suspected of gastric ulcer. Nevertheless, a doublecontrast barium study has a sensitivity of 95% for detecting malignant gastric ulcer, and may be used as an alternative to endoscopy in selected patients for either detection or followup of a gastric ulcer. Hampton line (a thin, sharp, lucent line that traverses the orifice of the ulcer). This ulcer is surrounded by a prominent ring of edema represented by the lucent area around the crater (black arrows). Radiographic finding Benign Malignant Hampton line* Extension beyond gastric wall Folds Ulcer shape Associated mass Carmen meniscus sign Healing Present Yes Smooth, even Round, oval, or linear Absent Absent Complete Absent No Irregular, nodular Irregular Present Present Usually incomplete *A Hampton line is a thin, sharp lucent line that traverses the orifice of the ulcer. A Carmen meniscus sign indicates a large, flatbased, inwardly folded ulcer with heapedup edges. Carmen meniscus sign (a large, flatbased, inwardly folded ulcer with heapedup edges). Relatively large amounts of gas are normally present in the stomach and colon, but only a small amount of air is seen in the small intestine. The presence of bowel gas is helpful in assessing the position and diameter of the bowel. Air and fluid represent normal bowel contents, and the presence of three to five air­fluid levels <2. The amount of air present in a normal colon is quite variable, but sufficient gas is usually present for the colonic haustra to be identified readily. The colonic diameter is also variable, with the transverse colon measuring up to 5. A colonic diameter >9 cm is considered abnormal, and indicates obstruction or ileus. The borders of the kidneys and the posterior borders of the liver and spleen can often be identified by the fat that surrounds them. The fat lines may be displaced due to enlargement of these organs or effaced by inflammation or fluid. Small Intestinal Obstruction On a plain abdominal film, the normal smallintestinal lumen diameter is 2. Functional bowel obstruction (called pseudoobstruction or ileus) causes diffuse bowel dilatation with no transition point.

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