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The appendix the appendix arises from the posteromedial aspect of the caecum approximately 1 in (2 weight loss 1200 calories per day alli 60mg without prescription. In the fetus it is a direct outpouching of the caecum tomato plant weight loss purchase alli 60 mg on-line, but differential overgrowth of the lateral caecal wall results in its medial displacement weight loss pills kohls buy alli discount. The appendix is usually quite free in this position top 5 weight loss pills 2012 cheap alli 60 mg online, although occasionally it lies beneath the peritoneal covering of the caecum. If the appendix is very long, it may actually extend behind the ascending colon and abut against the right kidney or the duodenum; in these cases, its distal portion lies extraperitoneally. In approximately 20% of cases, the appendix lies just below the caecum or else hangs down into the pelvis. Less commonly, it passes in front of or behind the terminal ileum, or lies in front of the caecum or in the right paracolic gutter. A long appendix has been known to ulcerate into the duodenum or perforate into the left paracolic gutter. The mesentery of the appendix, containing the appendicular branch of the ileocolic artery, descends behind the ileum as a triangular fold. 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. Since obstruction of the lumen is the usual precipitating cause of acute appendicitis it is not unnatural, 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. When the caecum is extraperitoneal it may be difficult to bring the appendix up into the incision; this is facilitated by first mobilizing 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, in the female, at the level of the lower end of the intrapelvic vagina, where it pierces levator ani and 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, externally, a series of three lateral inflexions, marked on the inside 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 the 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 peritoneum 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 Sacral promontory Bladder Symphysis pubis Prostate Seminal vesicle Rectum Fascia of Denonvilliers Anal sphincter. A layer of fascia (Denonvilliers) separates the rectum from the anterior structures and forms the plane of dissection which must be sought when performing excision of the rectum. The mid-anal canal represents the junction between the endoderm of the hindgut and the ectoderm of the cutaneous invagination termed the proctodaeum. A carcinoma of the upper anal canal is thus an adenocarcinoma, whereas that arising from the lower part is a squamous tumour. In contrast, the blood supply of the lower anal canal and the surrounding perianal skin is from the inferior rectal vessels, derived from the internal pudendal and, ultimately, the the gastrointestinal tract 91 Levator ani Anorectal ring Valves of Ball Ischiorectal fossa. Internal sphincter External sphincter Pectinate line internal iliac artery and vein. The two venous systems communicate and therefore form one of the anastomoses between the portal and systemic venous systems. A carcinoma of the rectum that invades the lower anal canal may thus metastasize to the groin nodes. The lowermost, or subcutaneous, portion of the external sphincter is traversed by a fan-shaped expansion of the longitudinal muscle fibres of the anal canal that 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 1 in (2. This represents the deep part of the external sphincter where 92 the abdomen and pelvis this blends with the internal sphincter and levator ani, and demarcates the junction between the anal canal and the rectum. The anal canal is related posteriorly to the fibrous tissue between it and the coccyx (the anococcygeal body), laterally to the ischio-anal fossa on either side, containing fat, and anteriorly to the perineal body, which separates it from the bulb of the urethra in the male and the lower vagina in the female.

Indeed weight loss 80 20 purchase on line alli, diaphragmatic movement accounts for approximately 65% of air exchange whereas chest movement accounts for the remaining 35% weight loss aids trusted 60 mg alli. These are the muscles attached to the thorax that are normally used in movements of the arms and the head weight loss vegetable soup purchase alli 60mg on line. Each pleura consists of two layers: a visceral layer intimately related to the surface of the lung weight loss pills 2015 uk cheap alli, and a parietal layer lining the inner aspect of the chest wall, the 20 the thorax upper surface of the diaphragm and the sides of the pericardium and mediastinum. In contrast, the parietal pleura is separated from its overlying structures by a loose, thin layer of connective tissue, the extrapleural fascia, which enables the surgeon to strip the parietal pleura easily from the chest wall. The surface markings of the pleura and lungs have already been described in the section on surface anatomy. Notice that the lungs do not occupy all the available space in the pleural cavity, even in forced inspiration. It may, however, fill with air (pneumothorax), blood (haemothorax) or pus (empyema). The lower respiratory tract the trachea (Figs 14, 15) the trachea is approximately 4. It commences at the lower border of the cricoid cartilage (C6) and terminates by bifurcating at the level of the sternal angle of Louis (T4/5) to form the right and left main bronchi. The lower respiratory tract 21 Left common carotid Left subclavian Thyroid isthmus Brachiocephalic artery Right brachiocephalic vein Left brachiocephalic vein Aortic arch Right pulmonary artery Superior vena cava Pulmonary trunk. Posteriorly, where the cartilage is deficient, the trachea is flattened and its wall completed by fibrous tissue and a sheet of smooth muscle (the trachealis). The lower respiratory tract 23 2nd costal cartilage Internal thoracic artery and veins Thymus Superior vena cava Right phrenic nerve Azygos vein Right vagus nerve Trachea Oesophagus T4 (a) Left phrenic nerve Left vagus nerve Left recurrent laryngeal nerve Aortic arch Thoracic duct Internal thoracic artery Superior vena cava Azygos vein Trachea Oesophagus T4 Aortic arch (b). In the elderly, calcification of the tracheal rings may be a source of radiological confusion. Displacement the trachea may be compressed or displaced by pathological enlargement of the neighbouring structures, particularly the thyroid gland and the arch of the aorta. Tracheostomy Tracheostomy may be required for laryngeal obstruction (diphtheria, tumours, inhaled foreign bodies), for the evacuation of excessive secretions (severe postoperative chest infection in a patient who is too weak to cough adequately) and for long-continued artificial respiration (poliomyelitis, severe chest injuries). It is important to note that respiration is further assisted by considerable reduction of the dead-space air. A vertical incision is made downwards from the cricoid cartilage, passing between the anterior jugular veins. Alternatively, a more cosmetic transverse skin crease incision, placed halfway between the cricoid and suprasternal notch, is employed. A hook is thrust under the lower border of the cricoid to steady the trachea and pull it forwards. The pretracheal fascia is split longitudinally, the isthmus of the thyroid either pushed upwards or divided between clamps and the cartilage of the trachea clearly exposed. In children the neck is relatively short and the left brachiocephalic vein may come up above the suprasternal notch so that dissection is rather more difficult and dangerous. In contrast, the trachea may be ossified in the elderly and small bone shears may be required to open into it. If this is not done, major vessels are in jeopardy and it is possible, although the student may not credit it, to miss the trachea entirely. Cricothyroid puncture is now frequently used in the treatment of emergency upper respiratory obstruction (see page 313 and. Before joining the lung it gives off its upper lobe branch, and then passes below the pulmonary artery to enter the hilum of the lung. It has two important relations: the azygos vein, which arches over it from behind to reach the superior vena cava, and the pulmonary artery, which lies first below and then anterior to it. The left main bronchus is nearly 2 in (5 cm) long and passes downwards and outwards below the arch of the aorta, in front of the oesophagus and descending aorta. Unlike the right, it gives off no branches until it enters the hilum of the lung, which it reaches opposite T6. The pulmonary artery spirals over the bronchus, lying first anteriorly and then above it. Note that this also applies to an endotracheal tube which, if too long for the size of the patient, will be pushed down into the right main bronchus. The lungs (Figs 18, 19) Each lung is conical in shape, having a blunt apex that reaches above the sternal end of the 1st rib, a concave base overlying the diaphragm, an extensive costovertebral surface moulded to the form of the chest wall and a mediastinal surface that is concave to accommodate the pericardium. The right lung is somewhat shorter in height than the left; this is because it is pushed upwards by the higher right dome of the diaphragm, itself pushed up by the underlying liver.

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The right extremity of the sac opens into the main peritoneal cavity via the epiploic foramen or foramen of Winslow weight loss 4 supplement discount alli 60mg. Notice that none of these important boundaries can be incised to release the strangulation; the bowel must be decompressed by a needle to allow its reduction weight loss pills history purchase alli in india. If the cystic artery is torn during cholecystectomy weight loss lunch buy cheap alli 60mg online, haemorrhage can be controlled by this manoeuvre (named after James Pringle) weight loss 4 life buy alli once a day, which then enables the damaged vessel to be identified and secured. Intraperitoneal fossae A number of fossae occur within the peritoneal cavity in which loops of bowel may become caught and strangulated. One or more of these spaces may become filled with pus (a subphrenic abscess) walled off inferiorly by adhesions. The right and left subphrenic spaces lie between the diaphragm and the liver, separated from each other by the falciform ligament. The right is the pouch of Morison and is bounded by the posterior abdominal wall behind and by the liver above. It communicates anteriorly with the right subphrenic space around the anterior margin of the right lobe of the liver and below both open into the general peritoneal cavity from which infection the gastrointestinal tract 77 may track, for example, from a perforated appendix or a perforated peptic ulcer. The left subhepatic space is the lesser sac, which communicates with the right through the foramen of Winslow. It may fill with fluid as a result of a perforation in the posterior wall of the stomach or from an inflamed or injured pancreas to form a pseudocyst of the pancreas. The right extraperitoneal space lies between the bare area of the liver and the diaphragm. It may become involved in retroperitoneal infections or directly from a liver abscess. Posterior subphrenic abscesses are drained by an incision below, or through the bed of, the 12th rib. A finger is then passed upwards and forwards between the liver and diaphragm to open into the abscess cavity. An anteriorly placed collection of pus below the diaphragm can alternatively be drained via an incision placed below and parallel to the costal margin. The gastrointestinal tract the stomach the stomach is roughly J-shaped, although its size and shape vary considerably. It tends to be high and transverse in the obese short subject and to be elongated in the asthenic individual; even in the same person, its shape depends on whether it is full or empty, on the position of the body and on the phase of respiration. The stomach projects to the left, above the level of the cardiac orifice (or cardia), to form the dome-like gastric fundus. Between the cardiac orifice and the incisura is the body of the stomach, while the area between the incisura and the pylorus is the pyloric antrum. The junction of the pylorus with the duodenum is marked by a constriction externally and also by a constant vein that crosses it, the vein of Mayo. The thickened pyloric sphincter is easily felt and surrounds the lumen of the pyloric canal. The pyloric sphincter is an anatomical structure as well as a physiological mechanism. The cardia, on the other hand, although competent (gastric contents do not flow out of your mouth if you stand on your head), is not demarcated by a distinct anatomical sphincter. The exact nature of the cardiac sphincter action is still not fully understood, but the following mechanisms have been suggested, each supported by some experimental and clinical evidence. The lesser omentum is attached along the lesser curvature of the stomach; the greater omentum along the greater curvature. The gastrointestinal tract 79 Spleen Diaphragm Suprarenal Left kidney Splenic artery Pancreas Transverse colon and mesocolon. This extensive lymphatic drainage and the technical impossibility of its complete removal is one of the serious problems in dealing with stomach cancer. Lymph nodes among the gastroepiploic vessels are removed by excising the greater omentum. However, involvement of the nodes around the aorta and the head of the pancreas may render the growth incurable. The anterior nerve lies close to the stomach wall but the posterior, and larger, nerve is at a little distance from it. The anterior vagus supplies branches to the cardia and lesser curve of the stomach and also a large hepatic branch. The posterior vagus gives branches to both the anterior and posterior aspects of the body of the stomach but the bulk of the nerve forms the coeliac branch. This runs along the left gastric artery to the coeliac ganglion for distribution to the intestine, as far as the midtransverse colon, and the pancreas. The exact means by which the vagal fibres reach the stomach is of considerable practical importance to the surgeon. The gastric divisions of both the anterior and posterior vagi reach the stomach at the cardia and descend along the lesser curvature between the anterior and posterior peritoneal attachments of the lesser omentum (the anterior and posterior nerves of Latarjet). The stomach is innervated by terminal branches from the anterior and posterior gastric nerves and it is, therefore, possible to divide those branches that supply the acid-secreting body of the stomach and yet preserve the pyloric innervation (highly selective vagotomy, see below). When divided, in the operation of vagotomy, the neurogenic (reflex) gastric acid secretion is abolished but the stomach is, at the same the gastrointestinal tract 81. Drainage can be avoided if the nerve of Latarjet is preserved, thus maintaining the innervation and function of the pyloric antrum (highly selective vagotomy). In these circumstances, the middle colic vessels are in danger of damage during mobilization of the stomach for gastrectomy.

This method remains a valuable conduit to the functioning of pain primary afferents in both health and disease weight loss pills 2015 purchase alli with paypal. Basic studies have assessed nociceptive specificity (Kaube et al 2000 weight loss fruit purchase alli 60 mg on line, de Tommaso et al 2001 weight loss while pregnant buy 60mg alli otc, Romaniello et al 2002) weight loss zucchini recipes generic alli 60mg without prescription, optimized parameters (Katsarava et al 2002), and determined the spatial organization of reflexes as a function of intensity and locus of stimulation (Andersen et al 2001). These studies have provided information about the neural organization of the nociceptive system, including the convergence of occipital and trigeminal cutaneous afferents. In addition, the amplitude of evoked reflexes has been shown to correlate with other physiological parameters such as cerebral evoked potentials or the concentration of administered analgesics and anesthetics or circulating opioids (Skljarevski and Ramadan 2002). Nociceptive reflexes share the temporal resolution that is a feature of the following methods in this section. This resolution has been used to investigate mechanisms mediating pain and pain modulation. Edwards and colleagues (2002) took advantage of the precise timing characteristics of cutaneous electrical stimulation to deliver stimuli to the sural nerve during different phases of the cardiac cycle. Using either the amplitude of the nociceptive reflex produced by specific stimulus intensities or the amount of current needed to evoke the reflex, these authors found reduced sensitivity during the systolic pressure pulse consistent with an arterial baroreceptor mechanism of hypertensive hypoalgesia. Several studies have also demonstrated modulation of lower limb or jaw muscle reflexes by deep muscle pain evoked by the infusion of hypertonic saline (Andersen et al 2000), by intramuscular electrical stimulation (Andersen et al 2006), by brief heat (Andersen et al 1998), and by simple limb movement (Don et al 2008). These studies indicate that inhibition of reflexes is not a unitary, homogeneous effect but varies depending on at least the type and location of the conditioning tonic stimulation. The nociceptive reflex is also modulated by psychological variables such as emotion, anticipation, and expectation (Rhudy et al 2006; Goffaux et al 2007, 2009) and has been observed to be suppressed in clinical pain conditions (Langemark et al 1993) and to vary between ethnic populations (Campbell et al 2008b) and during the menstrual cycle (Tassorelli et al 2002). It provides a useful marker of central summation (Biurrun Manresa et al 2010) and attenuation of temporal summation (Guirimand et al 2000, Bajaj et al 2005). Nociceptive reflexes provide considerable information, especially in concert with supraspinal and other physiological measures and subjective pain reports. Recent studies that provide normative values (Neziri et al 2010) and more sensitive analytical methods (Neziri et al 2009) have further enhanced this utility. Supraspinal Processing There is increasing growth both in the methods used to assess supraspinal processing and in the knowledge gained from these methods. The response to contact heat was delayed and attenuated in comparison to responses evoked by laser stimulation in glabrous skin, and the response to contact heat in glabrous skin was delayed in comparison to the response to contact heat in hairy skin (Iannetti et al 2006). Potentials in hairy and glabrous skin were similar when evoked by laser stimulation. A third type of study involves stimulation at the level of the spinal cord and evaluation of the timing and topography of evoked cerebral responses. The results of two studies revealed multiple spinal pathways with faster conduction velocities to the sensory cortex (Tsuji et al 2006, Valeriani et al 2007). The temporal resolution of evoked potentials should allow analysis of effects closely coupled in time, but often only one response is perceived to either two stimuli delivered at short intervals or to a single stimulus that activates multiple nociceptor afferents with different conduction velocities (Lee et al 2009). This result cannot be explained by relative refractory periods (Mouraux et al 2004) and may represent an inhibitory interaction of either fiber type on the other (Tran et al 2008). Source analysis provides information about the cerebral region evoked by electrical, laser, and contact heat stimulation (Drewes et al 2004, Chen et al 2006, Hobson et al 2010, van den Broeke et al 2010). Source analysis locates areas of activation that are also found in functional imaging studies (Brown et al 2008a, Nir et al 2008). The results of several studies have localized peaks of the potentials to generators in multiple regions of the pain "matrix," a general term describing consistently activated regions such as the anterior/posterior cingulate cortex, posterior parietal cortex, anterior insular cortex, and regions corresponding to the bilateral secondary somatosensory cortex. The field has expanded dramatically in the past decade, and the large body of functional brain imaging evidence is presented in a separate chapter (see Chapter 7). Averaging multiple trials reduces the influence of random, non-synchronized activity and reveals a waveform of about 1 second in duration that can be characterized by the amplitude and latency of positive and negative peaks. Early, short-latency components of the waveform are associated with sensory components, whereas later components have been associated with perceptual processing. These measures have been studied extensively and under certain conditions correlate with both stimulus intensity and verbal report (Kanda et al 2002). Potentials evoked by electrical, laser, contact heat, and mechanical stimulation have been used to assess a number of research goals. Many of these have examined the waveform and topography of evoked responses to stimuli applied to skin, muscle, and viscera (Arendt-Nielsen and Yarnitsky 2009). The principal advantage of these evoked methods is high resolution in the time domain. Hypertension in normal individuals is associated with reduced experimental pain ratings, an effect assumed to reflect baroreceptor modulation of pain. This figure shows the results of a study that assessed whether the baroreceptor modulation of pain observed by using measures of blood pressure within and between individuals can be observed dynamically within individuals during different phases of the cardiac cycle. Certainty was associated with activity in structures outside the pain matrix that involved semantic and prospective memory (left inferior frontal cortex, inferior temporal cortex, right anterior prefrontal cortex) (Brown et al 2008a). In addition to the temporal dynamics of cerebral responses to painful stimulation, these methods address common experimental questions, including the effects of spatial and temporal summation (Chen et al 2002); effects of cutaneous, muscle, and visceral stimulation (Arendt-Nielsen and Yarnitsky 2009, Brock et al 2010, Hobson et al 2010); and determination of conduction velocity (Tsuji et al 2006, Valeriani et al 2007). Similar to related psychophysical and reflex experiments, evoked potentials are also modulated by painful stimulation (Valeriani et al 2006, Brock et al 2010). Evoked potentials are modulated by non-pharmacological interventions such as theta-burst stimulation (Poreisz et al 2008) and by a wide variety of psychological interventions such as empathy (Bufalari et al 2007, Valeriani et al 2008), trait anxiety, and depression (Vossen et al 2006). However, modulation by known or putative analgesic agents is providing an increasingly important tool for basic pharmacological studies and for the early-phase clinical trials elaborated at the end of this section. This method showed analgesic effects of the minor analgesic acetaminophen and enhancement by caffeine. This method has also demonstrated effects on other minor nonopioid analgesics such as aspirin and ibuprofen (Staahl et al 2009b) without changes in subjective ratings, thus suggesting improved sensitivity with evoked potentials.

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