Thorax, Abdomen, and Pelvis Flashcards
thoracotomy
surgical creation of an opening through thoracic wall to enter a pleural cavity, periosteum maintained for regeneration. H shape cuts through perichondrium of one or more costal cartilages shelling out segments of costal cartilage gaining entrance. incision such that the periosteum of the rib is maintained for regeneration.æ
sternal biopsy
used for bone marrow needle biopsy due to breadth and subcutaneous position. needle pierces thin cortical bone and enters vascular trabecular (spongy) bone. used to obtain specimens of bone marrow for transplantation and detection of metastatic cancer.æ
sternotomy
gaining access of thoracic cavity for surgical procedures on heart and great vessels sternum is divided in median plain and retracted and reunited and held together with wire sutures shut to maintain shape afterwards. Posterolateral aspects of 5th-7th intercostal spaces ae important sites for posterior thoractomy incisions. Have pt lie contralaterally, abducting limb forearm beside head accessing 4th intercostal. use h shaped incision to incisde superficial aspect of periosteum ensheathing rib, stripping periosteum from rib removing wide segment of rib to gain better acess if need to remove lung. median sternotomy as major exposure for open-heart surgery.
thoracic outlet syndrome
Superior thoracic aperture, outlet, emphasizing important nerves and arteries pass thorugh aperture into lower neck and upper limb. w/ various type of thoracic outlet syndrome, costoclavicular syndrome- pallor and coldness of skin of upper limb and diminished radial pulse resulting from compression of subclavian artery between clavicle and 1st rib. compression of brachial plexus and/or subclavian vessels due to abnormal cervical rib, altered first rib or scalenes attachment, etc. present with loss of feeling in their arm causing entrapment point because of first rib. Scalene, interscalene triangle, brachial plexus in nerve artery vein. Brachial plexus, subclavian artery and vein can be caught by clavicle, abnormal first rib or abnormal 7 can develop thoracic outlet syndrome. Has many squeeze points leading to many pressure blocking points.
rib fracture
not usually (1, 2, 11, or 12 because protected) caused by crush injuries, penetrating chest wounds. intense pain because of expansion and contraction of rib cage during respiration requires palliation by anesthesizing intercostal nerve block. will typically fracture either at the point of impact or around the angle of the rib. ribs are angled and when breaks and fracture point pushes internally.
rib dislocation
ex. slipping rib syndrome, dislocation of sternocostal joint are displacement of costal cartilage from sternum causing severe pain during deep breathing. produces lump-like deformity at dislocation site common in body contact sports, complications are pressure on or damage to nearby nerves, vessels, and muscles. rib seperation is dislocation fo costochondral junction between rib and costal cartilage 3-10th rib seperation can tear perichondrium and periosteum moving superiorly overriding above. involvement of costal cartilage from sternum, with rib separation involving the rib and the costal cartilage; both will be painful. If not being held in place commonly snaps
diaphragm paralysis
able to see by paradoxical movmeent. paralysis and eventual atrophy of half diaphragm because of injury to its motor supply from phrenic nerve from ipsalateral, unless have accessory phrenic nerve does not affect other half because each half has seperate nerve supple. supposed to descend on inspiration but is pushed superiorly by abdominal viscera and compressed by active side. paralyzed dome descends during expiration pushed down by positive pressure in lungs. can be short term by injecting anesthetic agent around nerve where it is on anterior surface of anterior scalene muscle. paradoxical motion: Chest wall expands, diaphragm pulls down central tendon contracts so when inspiring breath in abdomen goes out and diaphragm domes down opposite on expiration. Breathing in lowering pressure wall is brought in and as exhale .Diaphragm central tendon muscle on end phrenic nerve for each diaphragm- both hemidiaphragms go up if paralyze one wont contract and flatten down and opposite one does stomach contents come up into area when chest wall flails out.
breast changes during pregnancy
include branching of lactiferous ducts, in breast tissues during menstrual cycle and prengnacy. Mammary glands prepared for secretion by midpregnancy, do not produce milk until shortly before baby is born. colostrum, creamy white to yellowish premilk fluid, secrete from nipples during last trimester of prengnacy and during initial episodes of nursing. colostrum is rich in protein, immune agents, and growth factor for infant’s intestines. multiparous women (given birth more than two time) breast is large and pendulous. postmenopausal- small from lack of fat and atrophy of glandular tissue.
fibrocystic breast change
covering large group of benign condition in 80% of women, related to cyclic changes in maturation and involution of glandular tissue. fibroadenoma=– most common breast mass peak between 20-25 years benign neoplasms of glandular epithelium accompanied by significant increase in periductal connective tissue present firm, painless, mobile, solitary palpabel masses may grow rapidly during adolescence but should be checked later
breast cancer
carcinoma of breast are malignant tumors common in postmenopausal women, adenocarcinomas arising from epithelial cells of lactiferous ducts in mammary gland lobules-most common. if enter lymph vessel pass through 2-3 groups of lymph nodes before entering venous system spreading via lymphatics. can interfere w/ drainage caused by lymphedema may deviate nipple causing thickened, leather-like appearance of skin. prominent or puffy skin between dimples pores give orange-ppeel appearance (peau d’orange) A peau dÍorange appearance from skin edema following lymphatic involvement, vs. retraction of skin from involvement of suspensory (Cooper’s) ligaments, may be signs of advanced breast cancer. larger dimples (fingertip +) from cancerous invasion of glandular tissue and fibrosis (fibrous degeneration), causing shorteneing or places traction on suspensory ligaments. subareolar cancer cause inversion of nipple by pulling on or shortning suspensory ligaments. carries cancer to axillary to cervical and parasternal (infraclavicular and supraclavicular) leaving to supraclavicular lymph nodes, opposite breast or abdomen. posterior intercostal veins drain into azygos/hemiazygos system along body of vertebrae and internal venous plexus can spread to brain. can continguity to pectoral fascia, pectoralis major, interpectoral nodes causing breast elevation when muscle contracts and is advanced sign. ex. in men metastatisized to bone, pleura, lung, lver, and skin subareolar mass or secretion from nipple infiltrating pectoral fascia, major, and apical lymph nodes. superolateral quadrant most involved in breast cancer. Carcinoma of the breast typically arises as an adenocarcinoma of the lacteriferous duct epithelium. Auxiliary process tail of Spence Breast cancer- ductal (3-4 things adipose, suspensions ligaments (big retinaculicutus elaborated ones holding adipose and glandular tissue together, ducts, mammary lobules). Skin dimpling- cancer is grabbing onto of suspensions ligaments, nipple retraction 20 separate ducts feeding into it suggest cancer there. Large mass, contours, peak dÍorgange (small tenting) infiltration of local lymphatic sweating out and having them exaggerated.
mammography
used to detect breast masses. appearing as a large jagged density, thickened over tumor use as guide when removing breast tumors, cysts, and abscesses.æ
breast surgery
incisions placed in inferior breast quadrants when possible because less vascular than superior ones. transition between thoracic walla nd breast most abrupt inferiorly producing line/crease/deep skin fold, inferior cutaneous crease. incisions along crease are least evident hidden by overlap of breast. incisions made near areola directed radially to either side of nipple.æ
modified masectomy
whole beast is removed w/ lymph nodes, axillary fat, investing fascia over chest wall mucsles. preserve pectoralis, serratus anterior, and latissimus dorsi and long thoracic and thoracodorsal nerves. Given concerns of metastasis from breast cancer, the lymphatics of breast need to be considered. Central axillary nodes are the most frequently palpable midway between the anterior and posterior axillary folds. Overall, paralleling the venous drainage, the breast mostly drains to axillary nodes, but with the medial part of the breast draining to parasternal (internal thoracic) lymph nodes and the lower quadrants into abdominal nodes.
Radical mastectomy
masectomy (breast excision)- breast is removed down to retromamary space (simple). more extensive involves removal of breast, pectoral muscles, fat, fascia, and as many lymph nodes as possible in axilla and pectoral region.
lumpectomy or quadrantectomy-æ
breast conserving surgery tumor and surrounding tissues removes followed by radiation.
intercostal nerve block
uses local anestheis of an intercostal space by injecting local anestethtic agent around intercostal nerves and collateral branches. particualr area of skin receives innervation from two adjacent nerves, overlapping of contiguous dermatomes occurs. complete lsos of sensation does not occur unless two or more intercostal nerves in adjacent intercostal spaces are anesthetized. image reminds us that intercostal nerves are the ñvulnerableî part of the intercostal neurovascular bundle, and so could be infiltrated just deep to the rib. Given that dermatomal patterns are likely overlapping, one should block sequential nerves in order to assure loss of sensation for a particular region.
pulmonary collapse
aka Atalectasis: sufficient amount of air enters pleural cavity, surface tension adhering visceral to parietal pleura (lung to wall) is broken causing lung to collapse because of inherent elastciity (elastic recoil) when collapses (atelectasis) pleural cavity normall potential space becomes full of air. one can collapse w/out the other. can be caused following surgery ex. air in but not out. Infection or mass blocking out lungs causing it to shrink (atelctasis spirometry to expand lung and not let patients get pneumonia prone.
pneumothorax
entry of air into pleural cavity resulting from pentrating wound of parietal pleura or rupture of lung from trauma ex. bullet, knife, broken rib tearing pareital pleura, leakage from lung through opening in visceral pleura resulting in partial collapse of lung. hydrothorax- accumulation of significant amount of fluid in pleural cavity from pleural effusion Hearts failing fluid building up hydrostatically pushing into recess, infection or inflammatory infusions (transfudate and exudate) cancer making capillaries leaky. ex. Tension pneumothorax can be deadly, as a one-way valve effect of a wound can lead to air trapping, deviation of the trachea, shift of the mediastinum, and compression of the functioning lung. hyperresonant over the air-filled side, with some decreased resonance on the compressed lung side. Air in pleural cavity, chest go out lung go in, pleural cavity pressure low if make it atmospheric from inside (spontaneous pneuomothorax from a bulla), whole from outside (have space, open gagging wound lung collapsed if flap will let air in but not out building up pressure fast trachea deviating because of not hard structures leading to increased distress. Lungs like to expand, but also have recoil. Rings like to go out. Barrel chest, lungs are more stretchy than normal so as trapping air and not able to collapse as much chest wall is going out because of air trapped and lung not as recoiled.
hemothorax
caused by chest wound where blood enters pleural cavity from injury to major intercostal vessel blood does not clot well because of smooth pleural surface and defibrinating action of respiratory movements. dullness to percussion over the fluid
chylothorax
lymph from a torn (or lacerated) thoracic duct entering pleural cavity. chyle is pale white or yellowish lymph fluid in thoracic duct contianing fat absorbed by intestines. major lymphatic passage behind lung and esophagus thoracic duct might get leakage of lymph into the costal diaphragmatic recess. This may stem pleural leakage, e.g., from excessive hydrostatic pressure, as with cardiac disease, or with inflammation and leakage, as from infection or cancer. empyema- typically from bacterial pneumonia, e.g., from exudates of neutrophils forming pus (via leaking tissues from the inflammation).
thoracentesis (3-6)
with excessive pleural air or fluid contents, chest tube placement meeded and is when a hypodermic needle is inserted through intercostal space into pleural cavity to obtain sample of pleural fluid or remove blood or pus. avoiding damage to intercostal nerve and cessel inserted superior to rib, high enough to avoid colalteral branches. For pneumothorax: a small tube at the 2nd or 3rd intercostal space, more midclavicular line, given that the lung will have collapsed a bit with the air, with subsequent loss of negative intrapleural pressure. This position should also minimize targeting of the subclavian vessels and brachial plexus components, but will require going through pectoralis major. Many clinicians will put the chest tube in the 4th/5th intercostal space for pneumothorax, in addition to pleural effusion. The 5th intercostal space is low enough to capture contents, but high enough to minimize diaphragm damage. Midaxillary around 5th interspace donÍt put near sternum because of heart, donÍt want to go lower diaphragm goes up not hit diaphragm to draw out fluid and reexpand fluid. Air goes up fluid goes down.
auscultation and variations
ausculatation of lungs (assessing air flow thorugh tracheobronchial tree into lung w/ stethoscope). percussion of lungs (tapping chest over lungs with finger) including root of neck to detect sounds in apices of lungs helps establish whether underlying tissues are air-fileld (resonant), fluid-filled (dull), or solid (flat). base of lung- inferior part of posterior costal surface of inferior lobe listening at inferoposteriro aspect of thoracic wall at level of T10. note the need to have multiple listening points so as to include different lobes of the lungs and the pleural recesses inferiorly. ex. Hollow tone- normal lung, hyperressonant- in pneumothorax . Fusion, consolidate- flatter tone
bronchi and foreign body aspiration
right bronchus is wider and shorter running more vertically than left bronchus, aspirated foreign bodies are more liekly to enter and lodge in it or a branch. Foreign body aspiration: changes in auscultation could also occur with aspiration. The right main stem bronchus is somewhat larger and more vertical than the left main stem bronchus, so that aspirated materials will tend to end up in aspects of the right lung
pleural sensitivity and innervation
Pleurisy: inflammation of the pleural surfaces can generate a pleural rub. Visceral pleura insensitive to pain because innervated by autonomic (motor and visceral afferent) reaching visceral w/ bronchial vessel receiving no nerves of sensation. parietal is sensitve to pain (costal pleura) richly supplied by branches of somatic intercostal and phrenic nerves. irritation of parietal pleura produces local pain and reffered pain to areas sharing innervation by same segments of spinal cord.
pleural injury
irriation of costal and peripheral parts of diaphragmatic pleura results in local pain and reffered pain along intercsotal nerves to thoracic and abdominal walls. irritation of mediastinal and central diaphragmatic areas of parietal pleura result in pain refferred to root of neck and over shouldr (C3-5)
pleuritis
normal: moist, smooth pleurae make no sound detectable by ausculation (listening to breath sounds). pleuritis- inflammation of pleurae makes lung surfaces rough w/ resutling friction may be heart w/ stethoscope creating sharp, stabbing pain, on exertion like climbing stairs when rate and depth of respirations increased slightly.æ
heart failure
Cor pulmonale- trouble getting blood through the lungs. Right side of heart much lower pressure than right. If pressure goes up or having trouble blood getting in right side is going to go into failure continuing working have right sided failure secondary to a lung disease. Right heart failure- backs up into legs, secondary to lung disease . Left heart failure- backup into lung harder to oxygenate, higher capillary pressure . Clubbing- sift tissue development associated w/ lung disease . Obstructive conditions such as COPD and asthma, where it is difficult to exhale,
pulmonary fibrosis
where the lung will have difficulty expanding with inhalation. idiopathic pulmonary fibrosis (IPF) chronic restrictive lung disease. chronic restrictive lung diseases include reduced compliance that cause chronic inflammation, fibrosis, need for more pressure to inflate stiffened lungs. IPF specific form of firbosing interstitial pneumonia mainly affects people over age of 50 cigarette smoking major risk factor. For example, the increased recoil of the fibrotic lung will counteract the recoil of the chest wall, and lead to a new, shrunken equilibrium point between the inward recoil of the lung and the outward recoil of the chest wall. Digital clubbing is a distinctive sign, but its formation is still controversial, presumably based on growth factors triggered by hypoxia. trouble getting lung in ex. Pulmonary fibrosis, hard lung use of accessory muscles and intercostal spaces. Work of respiration lose weight working, diaphragm high and chest is sinking in because lungs not strong. Lung is usually dense or honeyconed
pulmonary embolism
The right and left pulmonary arteries dividing into lobar and segmental branches and increasingly small vessels from there are at risk of pulmonary thromboembolism, especially stemming from deep venous thrombosis of the lower extremities. Increased risk of thromboembolism via the Virchow triad of stasis, endothelial injury, and hypercoagulability. Features contributing to the triad are often asked for in the history with a patient with a suspected pulmonary embolism. Embolism- deep femoral veins straight shot up inferior vena cava, right atrium into pulmonary trunk narrowing vessels are pulmonary arteries travels out to edge infarct not he margin or large saddle blocking pulmonary trunk along the way. Virchow- father of pathology. VirchowÍs triad risk factors for clotting stasis (bedridden), hypercoagulable (medications with potentially activating coagulation cascade or platelet adhesion), blood lining (endothelial damage activation) . obstruction of pulmonary artery by blood clot (embolus) common cause of morbidity (sickness) and mortality (death). embolus in pulmonary artery forms when blood clot, fat globule or air bubble travels in blood to lungs from leg vein. embolus passes through right side of heart to lung through pulmonary artey. embolus may block pulmonary artery or branch. immediate result is partial or complete obstruction of blood flow to lungs. obstruction results in sector of lung ventilated but not perfused w/ blood. large embolus occludes a pulmonary artery, person suffers acute respiratory distress because of major decrease in oxygenation of blood owing to blockage of blood flow through lung. medium-sized embolus may block artery supplying bronchopulmonary segment, producing pulmonary infarct, area of dead lung tissue. Lung naturally filters venous clots larger than circulating blood cells accommodating small clots by fibrinolytic (clot buster) mechanisms. VirchowÍs triad: venous stasis (bed rest), trauma (fracture, tissue injury), coagulation disorders (inherited or acquired). Caused y postoperative and postpartum immobility and some hormone medications increasing risk of blood clots most are silent and small. Larger obstruct medium sizes lead to infarct or obstruction of large vessel. W/out infarct present as tachypnea, anxiety, dyspnea, syncope, and vagus substernal pressure. Saddle embolus- completely occluding right pulmonary and partially obstructing trunk and left aa.
bronchoscopy
endoscope for inspecting interiro of tracheobronchial treaa for diagnsotic purposes can observe ridge, carina- between orifices of main bronchi. cartilaginous projection of last tracheal ring. if tracheobronchial lymph nodes in angle between main bronchi are enlarged because cancer cells have metastasized from bronchogenic carcinoma ex. carina distorted widened posterioly and immobile. Leading cause of cancer-related deaths most caused by cigarette smoking from alveolar lining cells of lungparenchyma or epithelium o trachebronchial tree. types: squamous (bronchiogenic)-impinge on adjacent structures involving sympathetic trunk and brachial plexus- pancoast syndrome compromises it to head leadin to horner syndrome, adenocarcinoma (intrapulmonary bronchi),
lung cancer
Lung cancer as arising from the epithelium of the airways (bronchogenic carcinoma) may involve diagnosis with bronchoscopy. Note the carina as a distinctive ridge at the tracheal bifurcation into bronchi. Distortion of the carina can occur with expanded nodes, cancerous infiltration, etc. bronchogenic carcinoma- common type of lung cancer aririsng from epithelium of bronchial tree, usually metastaizes widley because of arrangemnt of lymphatics tumer cells enter systemic circualtion by invading wall of sinusoid or veunle in lung and transported thorugh pulmonary veins, left heart, and aorta to rest of body (cranium and brain) lung cancer- caused by cigarette smoking.
pericarditis
inflammation of pericardium source for pericardial effusion enerating cardiac tamponade. usually causes chest pain makes surfaces rough and resulting friction rub sound like rustle of silk when listening. normal- layers of serous pericardium make no detectable sound during auscultation.æ
pericardial effusion
inflammatory diseases produce pericardial effusion (passage of fluid from pericardial capillaries into pericardial cavity) heart becomes compressed
cardiac tamponade
with the Beck triad of hypotension, muffled heart sounds, and jugular venous distension apparent with acute tamponade. when heart becomes compressed, unable to expand and fill fully and ineffectual. potentially lethal as fibrous pericardium touch and inelastic. heart volume compromised by fluid outside heart inside pericardial cavity.æcardiomegaly- w/ slow increase in size of heart, pericardium gradullay enlarges allowing enlargement of heart to occur w/out compression.æhemopericardium- stab wounds piercing heart occur w/out compression but can cause blood to enter pericardial cavity can also produce this or may reult from perforaation of weakened area of heart muscle after heart attack. as blood accumulates, heart is compressed and circulation fails.æpericardiocentesis- drainage of serous fluid from pericardial cavity usually necessary to relieve cardiac tamponade, removing excess fluid using wide-bore needle may be inserted through left subcostal angle 5-6th intercostal space near sternum. Caused by ruptured aortic aneurysm, ruptured myocardial infarct, penetrating injury compromises bating hear and decreases venous return and cardiac output removed by tap. vascular bundle on either side is phrenic nerve. Visceral and parietal side on inside of pericardial sac. Fibrous component of parietal so over time if slowly fill it slow long distentional stretch. Acute blood in there fibrous component stretch and had tamponade. Blood and fluid lubricate it against sac. Heart sounds are distant because more between you and valves, compression not able to fill as much going back up neck veins and not as much pressure in BeckÍs triad. Aim close to sternal body but not too close avoiding thoracic aorta. Pericarditis- decreased cardiac output creaking sound
atrial septal defect
(ASDs), if they remain small, have less shunting issues with the lower pressure difference between the right and left atria. Around 10% of adults have a patent foramen ovale, which may remain asymptomatic, but also could be an opening that allows for paradoxical emboli to enter the systemic circulation if right atrial pressure is ñboostedî to greater than left atrial pressure. congenital anomalies of interatrial septum, related to closure of oval foramen (atrial septal defects). probe-sized patency (defect) appears in superior part of oval fossa. usually no clinical significance, but large ASDs allow oxygenated blood from lungs to be shunted from left atrium through defect into right atrium, causing enlargement of right atrium and ventricle and dilation of pulmonary trunk. ostium secundum defects from incomplete closure of foramen ovale, larger defects require a patch sutured. smaller use percutaneous transcatheter approach using septal occluder deployed and secured. threading catheter through IVC catheter positioned to pass directly into atrial defect and deployed.
ventricular septal defect
(VSDs) are the most common, as the membranous part of the interventricular septum is the last to fuse and so can remain patent between the two ventricles. The higher pressure generated by the left ventricle will force additional blood into the right ventricle, or a left to right shunt. perimembranous- where muscular septum and membranous septum of endocardial cushion should fuse) membranous part of IV septum develops separately from muscular part and has complex embryological origin place for ventricular septal defects causing left to right shunt of blood through defect. large shunt increases pulmonary blood flow, causing pulmonary disease (hypertension) and may cause cardiac failure.
tetralogy of Fallot
results from maldevelopment of spiral septum dividing truncus arteriousus into pulmonary trunk and aorta. involving pulmonary stenosis or narrowing of right ventricular outflow tract, overriding transposed aorta, right ventricuar hypertrophy, ventricular septal defect (VSD) surgical repair done on cardiopulmonary bypass to close VSD and provide unobstructed flow into pulmonary trunk. Stenotic pulmonary outflow tract widened by inserting patch into wall (pericardial) increasing volume of subpulmonic stenosis and/or pulmonary artery stenosis. Linear structure whereby atrium feeds into ventricle feeds into aortic and pulmonary trunk. Ventricle becomes name becoming ventral creating twist left atrium on back side. Separate right and left circulations have septa built in between atria and ventricle. Partition several round of septa premium, Secundum creating foramen ovale from umbilical cord to left atrium. Interventricular septum muscular part sticking up with membranous part Causing tetralogy of allot. Partition blows arteriouss finish membranous portion of septum but does not happen in this condition. Tetralogy of Fallot is defined by four issues of: Pulmonary stenosis, Ventricular septal defect, Overriding aorta, Right ventricular hypertrophy. The tetralogy is caused by abnormal neural crest cell migration and unequal partition of the aortic-pulmonic septum in the developing heart (causing the first three features, and the right ventricular hypertrophy compensatory from the pulmonic stenosis). Affected children may have ñtet spells,î where subsequent squatting tends to decrease a right_ left shunt and increase pulmonary flow following the increase in peripheral systemic resistance. spiral divide between aortic arch and pulmonary trunk around same size. Going down forming membranous part of interventricular septum running into muscular part. In this condition it doesnÍt occur. Neural crest cell- pharyngeal arches and doing 75/25 instead of 50/50 more on aorta side (overriding aorta) a lot bigger than the pulmonary side, pulmonary stenosis, not migrating and forming full interventricular septum leaving a defect. Pulmonitic artery so stenotic right side hypertrophy to work harder to get it to lungs. Not as much blood flow through pulmonic artery get right to left shunt because of the hypertrophy over time causing deoxygenated blood through systemic circulation, congenital heart defect usually this.æ
patent ductus arteriosus
not part of the tetralogy, but for a child with TOF, a PDA can alleviate some of the cyanosis, as blood will be driven from the higher pressure aorta into the lower pressure pulmonary arteries and hence through the pulmonary circulation back to the left atrium, thereby bypassing the stenotic pulmonary valve region.
valvular heart disease
valves of heart disturb pumping efficiency of heart. Produces either stenosis (narrowing) or insufficiency. result in increased worload of the heart. restruction of high-pressure blood flow (stenosis); and passage of blood through narrow opening into larger vessel or chamber (stenosis and regurgitation) produce turbulence setting up eddies (small whirlpools) producing vibrations that are audible as murmurs. superficial vibratory sensation-thrills may be felt on skin over area of turbulence.can be replaced surgically w/ valvuloplasty w/ artificial valve prostheses from synthetic materials or xenografted valves (pigs).
stenosis
failure of valve to open fully, slowing blood flow from chamber. can have a great effect on hemodynamics, and so create distinctive murmurpatterns, e.g., the diastolic murmur of aortic regurgitation. Aortic stenosis will be commonly seen in the elderly, due to in increased pressure. ex. mitral stenosis leads to left atrial dialtion caused by RHD
external genitalia and hypaxialmuscles that anchor and move them (and the anus). insufficiency
valvular insuffiency or regurgitation, is failure of valve to close completely owing to nodule formation or scarring and contraction of cusps so that the edges do not mee tor align. This allows variable amount of blood (depending upon severity) to flow back into chamber ejected from. Calcified valve sound reflecting pressure of ventricle with ventricle, Hypertrophy to get pressure crescendo—decrescendo. Cardiac output decreased causing left in carotid artery causing syncope. Aortic regurgitation: caused by congentially malformed leaflets, RHD< IE< anklyosing spondylitis, Marfan’s syndrome, aortic root dilation. Mitral regurgitation: caused by abnormalities of valve leaflets, rupture of paipllary muscle or chordae tendinae, papillary muscle fibrosis, IE, left ventricular enlargement.
mitral valve prolapse
insufficient or incompetent valve in which one or btoh leaflets are enlarged, redunandt or floppy and extending back into left atrium during systole. blood regurgitates into left atrium when ventricle contracts producing mumur. which classically presents with a late systolic click as the floppy valve leaflets prolapse into the left atrium and thereby suddenly tense up the chordae tendinae. AV valves leaking, causing click then murmur, leaflet has … part of leaflet floppy depending upon tension upon it causing regurgitation. When have increased pressure Click shortens and comes later left Ventricular not as taut click earlier w/ longer murmur.
aortic valve stenosis
most frequent abnormaly resulting in left ventricular hypertrophy. majority of cases of aortic stenosis result from degenerative calcification. Caused by rhemuatic heat disease (RHD), congenital bicuspid valve
pulmonary valve stenosis
(narrowing), valve cusps are fused, forming dome w/ narrow central opening. infundibular pulmonary stenosis, conus arteriosus is underdeveloped, producing restriction of right ventricular outflow. degree of hypertrophy of right ventricle is variable
coronary artery disease:
from atherosclerosis result in reduced blood supply to vital myocardial tissue. common sites for occlusion are LAD, right main, and left circumflex coronary arteries. Atherosclerosis can be triggered by trubulent blood flow at arterial branches, which triggers sheer stress on endothelium causing damage and inflammatory response. Macrophages may take up available oxidized lipids and become foam cells. Additional triggering of cytokines can stimulate smooth muscle and connective tissue proliferation that contribute to plaque development. Plaque rupture can trigger thrombosis. happens more on left because of higher workload than right
infarction of each main artery and its affect on heart and what leads it could be found in
caused by sudden occlusion of major artery by an embolus, region of myocardium supplied by occluded vessel becomes infarcted (rendered virtually bloodless) and undergoes necrosis (pathological tissue death). patterns reflect the supply areas of the different coronary arteries, e.g., LAD generating an anterior infarct involving much of the interventricular septum. Anterior infarct affects anterior LAD (left ventricular surface anterior 2/3rds of interventricular septum could lead to bundle branch block leads 2/3. Right coronary- affects posterior wall of ventricle posterior 1/3 of IVS (if right-dominant coronary circulation). Left circumflex- affects alteral wall of left ventricle can also affect posterior wall if left dominant coronary circulation in leads 5+6
angioplasty
surgeons use percutaneous transluminal coronary angioplasty, pass catheter w/ small inflatable balloon attached to tip into obstructed coronary artery. When it reaches obstruction, balloon is inflated, flattening atherosclerotic plaque against vessel’s wall, vessel stretched to increase size of lumen, improving blood flow. Thrombokinase injected through catheter dissolving blood clot after dialtion of vessel intravascular stent introduced to maintain dilation.
coronary artery bypass graft
(CABG), also called “the cabbage procedure,” offers a surgical approach for revascularization. Veins or arteries from elsewhere in the patient’s body are grafted to the coronary arteries to improve the blood supply. In a saphenous vein graft a portion of the great saphenous vein is harvested from the patient’s lower limb. Alternatives include internal thoracic artery and radial artery grafts.
referred pain
Heart insensitive to touch, cutting, cold, and heat. ischemia and accumulation fo metabolic products stimualte pain endings in myocardium. viscerable afferent pain fibers run centrally in middle and inferior cervical branches in thoracic cardiac branches of sympathetic trunk axon to their spinal nerve source (T1(Ulnar side of arm)-T4 (nipple) and the corresponding dorsal root ganglia that then are interpreted as pain in those dermatomes. With cell bodies in the same spinal ganglion and central processes that enter the spinal cord through the same posterior root. Cardiac referred pain is a phenomenon whereby noxious stimuli originating in the heart are perceived by the person as pain arising from a superficial part of the body— the skin on the medial aspect of the left upper limb, for example. s. visceral pain afferents from the heart enter the upper thoracic spinal cord along with somatic afferents, both converging in the spinal cord’s posterior horn. Angina pectoris (“strangling of the chest”) is usually described as pressure, discomfort, or a feeling of choking or breathlessness in the left chest or substernal region that radiates to the left shoulder and arm, as well as the neck, jaw and teeth, abdomen, and back. The higher brain center’s interpretation of this visceral pain may initially be confused with somatic sensations from the same spinal cord levels. Somatic pain is “mapped” on the brain’s sensory cortex, but a similar symptomatic mapping of visceral sensations does not occur. This may explain why pain from visceral structures is often mistakenly perceived as somatic pain
conducting system damage
Damage to the conducting system, often resulting from ischemia caused by CAD, produces distur- bances of cardiac muscle contraction. Because the anterior IV branch (LAD branch) supplies the AV bundle in most people and because branches of the RCA supply both the SA and the AV nodes, parts of the conducting system of the heart are likely to be affected by their occlusion. Damage to the AV node or bundle results in a heart block because the atrial excitation does not reach the ventricles. As a result, the ventricles begin to contract independently at their own rate (25–30 times per minute), which is slower than the lowest nor- mal rate of 40–45 times per minute. Damage to one of the bundle branches results in a bundle branch block, in which excita- tion passes along the unaffected branch and causes a normally timed systole of that ventricle only. The impulse then spreads to the other ventricle, producing a late asynchronous contraction.
anterior mediastinum masses
include: thymoma (thymus tumor associated w/ myasthenia gravis), thyroid mass (cause enlarged gland to extend inferiorly and displace trachea starts in tongue created in development as thyroid migrates down thyroglossal cyst w/ passageway may not have been sealed throughout developing causing mass), teratoma (remnants of germ cells, hair, teeth, parts of organs from totipotent cells), lymphoma (lymph nodes Hodgkin’s and primary mediastinal B cell tumor w associated w/ mainstream bronchus or trachea of throacic artery and vein). symptoms include: retrosternal pain, cough, dyspnes, SVC syndrome, choking sensation.
middle mediastinum masses
similar to anterior include surrounding heart from lymph nodes, aortic aneurysm (aneurysm that is atherosclerotic in origin, may rupture in any part of mediastinum), vascular dilation (enlarged pulmonary trunk or cardiomegaly), and cysts (bronchogenic at tracheal bifurcation, and pericardial cysts).
posterior mediastinal masses
associated w/ pain, neurologic symptoms or swallowing difficulty caused by neurogenic tumors (peripheral nerves or sheath cells) or esophageal lesions (diverticular and tumors)
azygos drainage
The azygos system, as it drains the body wall, can be an alternative venous pathway if either of the venaecavaeare obstructed. Hemiazygoshave accessory as well. an acces- sory azygos vein parallels the main azygos vein on the right side. Other people have no hemi-azygos system of veins. A clinically important variation, although uncommon, is when the azygos system receives all the blood from the IVC, except that from the liver. In these people, the azygos system drains nearly all the blood inferior to the diaphragm, except from the digestive tract. When obstruction of the SVC occurs superior to the entrance of the azygos vein, blood can drain inferiorly into the veins of the abdominal wall and return to the right atrium through the IVC and azygos system of veins.
abdominopelvic venous drainage routes
three collateral routes, formed by valveless veins of trunk are available for venous blood to return to heart when IVC is obstructed or ligated; inferior epigastric vein(tributaries of the external iliac veins of the inferior caval system, anastomose in the rectus sheath with the superior epigastric veins, which drain in sequence through the internal thoracic veins of the supe- rior caval system.)superficial epigastric(or superficial circumflex iliac veins, normally tributaries of the great saphenous vein of the inferior caval system, anastomose in the subcutaneous tis- sues of the anterolateral body wall with one of the tribu- taries of the axillary vein, commonly the lateral thoracic vein. When the IVC is obstructed, this subcutaneous col- lateral pathway—called the thoraco-epigastric vein—becomes particularly conspicuous). epidural venous plexus inside the vertebral column communicates with the lumbar veins of the inferior caval system and the tributaries of the azygos system of veins, which is part of the superior caval system
thoracic aneurysm
distal part of the ascending aorta receives a strong thrust of blood when the left ventricle con- tracts. Because its wall is not yet reinforced by fibrous pericardium (the fibrous pericardium blends with the aortic adventitia at the beginning of the arch), an aneurysm (localized dilation) may develop. An aortic aneurysm is evident on a chest film (radiograph of the thorax) or a magnetic resonance an- giogram as an enlarged area of the ascending aorta silhouette. Individuals with an aneurysm usually complain of chest pain that radiates to the back. The aneurysm may exert pressure on the trachea, esophagus, and recurrent laryngeal nerve, causing difficulty in breathing and swallowing. While abdominal aortic aneurysms (AAAs) are more common and due to atherosclerosis, the location of thoracic aneurysms can impact on different symptoms, e.g., impact on the trachea, left recurrent laryngeal nerve. The risk of dissection or rupture can be followed by the size of the aneurysm. Thoracic aneurysm- atherosclerosis and degenerative conditions of aorta ex. Intima (weakens media), media (swelling, Marfan syndrome connective tissue fibrolytic in elastic organs, tertiary syphilis (long ongoing inflammatory response found w/ heave. Left recurrent laryngeal might be dysphasia or hoarseness vague symptomology)), adventitia.
recurrent laryngeal nerve injury
The recurrent laryngeal nerves supply all the intrin- sic muscles of the larynx, except one. Consequently, any investigative procedure or disease process in the superior mediastinum may involve these nerves and affect the voice. Because the left recurrent laryngeal nerve hooks around the arch of the aorta and ascends between the trachea and the esophagus, it may be involved when there is a bron- chial or esophageal carcinoma, enlargement of mediastinal lymph nodes, or an aneurysm of the arch of the aorta. In the latter condition, the nerve may be stretched by the dilated arch of the aorta.
coarctation of aorta
coarctation of the aorta, the arch of the aorta or descending aorta has an abnormal narrowing (stenosis) that diminishes the caliber of the aortic lumen, producing an obstruction to blood flow to the inferior part of the body. The most common site for a coarctation is near the ligamentum arteriosum. When the coarctation is inferior to this site (postductal coarctation), a good collateral circulation usually develops between the prox- imal and distal parts of the aorta through the intercostal and internal thoracic arteries. The increased blood flow in some arteries may lead to enlargement of those vessels. can lead to a visibly increased collateral circulation within the intercostal and internal thoracic arteries through their anastomoses, and thereby may lead to rib notching. In coarctation, with the proximal aorta compromised, blood flow goes through the subclavian arteries to the internal thoracic arteries to the anterior intercostal arteries to the posterior intercostal arteries and so into the thoracic aorta distal to the obstruction. Squeezed aorta to visceral aorta gets blood out and down through workaround subclavian feed into internal thoracic into anterior intercostal posterior intercostal come off aorta and they anasthemose. Reverse flow back through posterior intercostal into aorta working around becoming tortuous pulsating eroding costal groove creating rib notching. Strong in arms but not in the feet. The marked CXR highlights the coarctation itself (blue) and the rib notching that occurs with the large amount of additional flow through the intercostal vessels as a result of this altered pathway
thoracic surface anatomy landmark lines
see sternum, clavicle, breasts, lung, and heart
Several bony landmarks and imaginary vertical lines facilitate anatomical descriptions, identification of thoracic areas, and location of lesions such as a bullet wound:
• Anterior median (midsternal) line indicates the inter- section of the median plane with the anterior thoracic wall.
• Midclavicular lines pass through the midpoints of the clavicles, parallel to the anterior median line.
• Anterior axillary line runs vertically along the anterior axillary fold, which is formed by the border of the pectoralis major as it spans from the thorax to the humerus (arm bone)
• Midaxillary line runs from the apex (deepest part) of the axilla, parallel to the anterior axillary line.
• Posterior axillary line, also parallel to the anterior axillary line, is drawn vertically along the posterior axillary fold formed by the latissimus dorsi and teres major muscles as they span from the back to the humerus.
• Posterior median (midvertebral) line is a vertical line at the intersection of the median plane with the vertebral column. Scapular lines are parallel to the posterior median line and cross the inferior angles of the scapulae.
thoracic imaging
B. Describe the layers of the abdominal wall
epidermis> dermis> subcutaneous tissue (superficial fascia)> fatty layer of subcutaneous tissue (camper fascia)>deep membranous layer of subcutaneous tissue (scapa fascia)right over muscles deep to fascia on top of muscles> abdominal muscles (external, internal, transversus abominus) w/ investing deep fascia in between that is superficial, intermediate, and deep> transversalis fascia (endoabdominal fascia), extraperioneal fascia w/ fat, parietal peritoneum (innvervation of these layer 1-8 via spinal nerves leading to sharp localizing pain if involved: visceral peritoneum (everything in refferred pain pattern> peritoneal cavity. Paracentesis, e.g., to drain abdominal ascites fluid, will penetrate into here> visceral peritoneum. Involvement of this layer that covers the visceral organs will typically generate referred pain patterns. when doing surgeries no transceting muscles (irreversible eath of muscle fibers), splits between except rectus abdominis transected because muscle fibers short and nerves located and preserves. suture membranous layer of subcutaneous tissue as seperate layer because of strength, space between membranous layer and deep fascia
B2. describe layers of inguinal canal
The gonads develop superiorly and developmentally migrate to their inferior positions, as directed by an embryonic gubernaculum. The male inguinal canal contains the spermatic cord as the testis reaches its final location in the scrotum, attached by a short scrotal ligament (gubernaculum testis) within the cord. Note that there is a bit of peritoneal cavity “captured” as the tunica vaginalis. Process vaginalis- gubernaculum shorten sealing sheath behind testis descended (tunica vaginalis) and gubernaculum had testicular ligament at inferior pole of testis. Ovaries pull down and into labia majors more of round ligament of uterus hanging off of ovary and connected to uterus ovarian and into canal of round ligament. The male process of testicular migration can lead to alterations, e.g., cryptorchidism, if the testis does not complete its migration. Deep inguinal ring in transversalis fascia, superficial inguinal ring through aponeurosis external oblique, sealed processed vaginalis The female inguinal canal contains the round ligament of the uterus as its remnant of the gubernaculum. Internal spermatic fascia- transversus fascia Cremation fascia from internal oblique pull things up Aponeurosis off of external oblique external spermatic fascia
Within the context of basic embryology, describe the relationships of thoracic organs in adult
Thoracic Organs
Linear structure whereby atrium feeds into ventricle feeds into aortic and pulmonary trunk. Ventricle becomes name becoming ventral creating twist left atrium on back side. Separate right and left circulations have septa built in between atria and ventricle. Partition several round of septa premium, Secundum creating foramen ovale from umbilical cord to left atrium. Interventricular septum muscular part sticking up with membranous part Causing tetralogy of allot. Partition blows arteriouss finish membranous portion of septum but does not happen in this condition.
C. Within the context of basic embryology, describe the relationships of abdominal organs in the adult
Holding it onto the back wall. the gut, supported by a dorsal mesentery, forms as a long tube that elongates and rotates. Holding it onto the back wall. Three major vessels coming off aorta (celiac, superior mesenteric, and inferior mesenteric) developmentally create foregut w/ stomach and such. Midgut- small intestine and half of large intestine. Hindgut- last part of large intestine. In the developing proximal gut, there is an additional gastrohepatic ligament- ventral mesentery in which the liver forms close to the stomach (expanding shifts and switch places), with its adult remnant known as the lesser omentum. Can see folds of midgut coming out then rolling and coming back in. Adult segment falciparum ligament- sic cal shape between liver and stomach. spleen ligaemounts holes to stomach along way. Dorsal mesentery of stomach along greater curvature decides to expand and fold in creating double fold adhering to top of small intestine aka greater omentum The liver develops as an endodermal outgrowth of the duodenum in the ventral mesentery, dividing it into the falciform ligament between liver and umbilicus, and lesser omentum between liver and stomach. The greater omentum will be better visualized on the next slide. The stomach, duodenum and the other viscera (liver, pancreas, spleen) that develop in the mesogastrium are not part of the primary loop, so they are supplied by branches off of the celiac trunk. While all this is going on, the rest of the gut is elongating, forming a primary intestinal loop or region that is supplied by the superior mesenteric artery. From the left colic flexure distally, this developing digestive tract is supplied by the inferior mesenteric artery. Foregut developed into celiac artery, midgut into superior mesenteric artery, hindgut into inferior mesenteric artery
C. Within the context of basic embryology, describe the relationships of pelvic organs in the adult
During development, the testes in effect push through the layers of the abdominal wall, so that each layer contributes to the spermatic fascia that cover the spermatic cord and inguinal canal. From superficial to deep: From the external oblique aponeurosis: external spermatic fascia and superficial inguinal ring. From the internal oblique: cremasteric fascia and loops of cremaster muscle. From the transversalis fascia: internal spermatic fascia and deep inguinal ring. there is fusion of much of the dorsal mesentery of the abdominal gut to the parietal peritoneum of the dorsal wall, so that many structures originally in the peritoneal cavity, e.g., pancreas, duodenum, ascending and descending colon, are considered retroperitoneal. Other organs such as the kidneys develop deep to the peritoneal cavity and so are retroperitoneal in that manner. supported by a dorsal mesentery, forms as a long tube that elongates and rotates
D. Combining an understanding of visceral regions and quadrants, and visceral pain pathways, explain common abdominal pain presentations.
Heart insensitive to touch, cutting, cold, and heat. ischemia and accumulation fo metabolic products stimualte pain endings in myocardium. viscerable afferent pain fibers run centrally in middle and inferior cervical branches in thoracic cardiac branches of sympathetic trunk axon to their spinal nerve source (T1(Ulnar side of arm)-T4 (nipple) and the corresponding dorsal root ganglia that then are interpreted as pain in those dermatomes. With cell bodies in the same spinal ganglion and central processes that enter the spinal cord through the same posterior root. Cardiac referred pain is a phenomenon whereby noxious stimuli originating in the heart are perceived by the person as pain arising from a superficial part of the body— the skin on the medial aspect of the left upper limb, for example. s. visceral pain afferents from the heart enter the upper thoracic spinal cord along with somatic afferents, both converging in the spinal cord’s posterior horn. Angina pectoris (“strangling of the chest”) is usually described as pressure, discomfort, or a feeling of choking or breathlessness in the left chest or substernal region that radiates to the left shoulder and arm, as well as the neck, jaw and teeth, abdomen, and back. The higher brain center’s interpretation of this visceral pain may initially be confused with somatic sensations from the same spinal cord levels. Somatic pain is “mapped” on the brain’s sensory cortex, but a similar symptomatic mapping of visceral sensations does not occur. This may explain why pain from visceral structures is often mistakenly perceived as somatic pain
abdominal incisions
When closing abdominal skin incisions, surgeons suture the membranous layer of subcutaneous tissue as a separate layer because of its strength. Between the membranous layer and the deep fascia cov- ering the rectus abdominis and external oblique muscles is a potential space where fluid may accumulate (e.g., urine from a ruptured urethra). Although no barriers (other than gravity) prevent fluid from spreading superiorly from this space, it cannot spread inferiorly into the thigh because the membranous layer of subcutaneous tissue attaches to the pubic bone and fuses with the deep fascia of the thigh (fascia lata) along a line inferior and parallel to the inguinal ligament. Operation- nonlaproscopic down to lines alba (aponeurosis forming midline connection of muscles)– no blood vessels or nerves only connective tissue have to recline it up and connect it can cause herniation. Note that the abdominal wall muscles and their aponeuroses dominate the pattern of the anterior abdominal wall. The linea alba is a favored midline for incisions, with proper alignment of its connective tissue is needed for closure to heal. Location of incision chosen allows adequate exposure, cosmetic effect, type or operation, bones surrounding, avoiding n.,a.,v. aiming for favorable healing. instead of transecting msucles, causing irreversible necrosis (death) of muscle fibers will split between fibers. The rectus abdominis is an excep- tion and can be transected because its muscle fibers are short and its nerves entering the lateral part of the rectus sheath can be located and preserved. Cutting a motor nerve paralyzes the muscle fibers supplied by it, thereby weakening the anterolat- eral abdominal wall. However, because of overlapping areas of innervation between nerves in the abdominal wall, one or two small branches of nerves may be cut without a noticeable loss of motor supply to the muscles or loss of sensation to the skin. Abdominal wall hernias often are called ventral hernias to distinguish them from inguinal hernias. However, all are technically abdominal wall hernias. Other than inguinal hernias, most common types of abdominal hernias include:
• Umbilical hernia: usually seen up to age 3 years and after 40.
• Linea alba hernia: often seen in the epigastric region and more common in males; rarely contains
visceral structures (e.g., bowel).
• Linea semilunaris (spigelian) hernia: usually occurs in midlife and develops slowly.
• Incisional hernia: occurs at the site of a previous laparotomy scar.
incisional hernias
concern with the potential entrapment of a loop of bowel. Umbilical hernias represent a congenital weakness in that region, given the embryological herniation of the developing intestinal tract. If the muscular and aponeurotic layers of the abdomen do not heal properly, a hernia may occur through the defect. An incisional hernia is a protrusion of omentum (fold of peritoneum) or an organ through a surgical incision or scar. Innermost part of subcutaneous tissue not as fatty more thicker more easily caught caught. Transversalis fascia on inside of transverse muscle, fat…, parietal peritoneum. Weakness in abdominal wall unpleasant lump, incarceration or trapping of internal organs. Umbilical- physiologici hernia of umbilical
endoscopic surgery
Many abdominopelvic surgical procedures are now performed using an endoscope, in which tiny per- forations into the abdominal wall allow the entry of remotely operated instruments, replacing the larger conven- tional incisions. Thus, the potential for nerve injury, incisional hernia, or contamination through the open wound and the time required for healing are minimized.
abdominal protuberance
Inspection of the abdomen may indicateprotrusion (the “six Fs”Food , Fluid (duller) , Fat , Feces (firmer left colon) , Flatus (gas hypertympanic) , Fetus ). Eversion of the umbilicus may be a sign of increased intra-abdominal pressure, usually resulting from ascites (a possible indication for paracentesis)(abnormal accumulation of serous fluid in the peritoneal cavity) or a large mass (e.g., a tumor, a fetus, or an enlarged organ such as the liver). Excess fat accumulation owing to overnourishment most commonly involves the subcutaneous fatty layer; however, there may also be excessive depositions of extraperitoneal fat.
palpation
Warm hands are important when palpating the abdominal wall because cold hands make the an- terolateral abdominal muscles tense, producing involuntary spasms of the muscles known as guarding. Intense guarding, board-like reflexive muscular rigidity that cannot be willfully suppressed, occurs during palpation when an organ (such as the appendix) is inflamed and in itself con- stitutes a clinically significant sign of acute abdomen. The in- voluntary muscular spasms attempt to protect the inflamed viscera from pressure. The shared segmental nerve supply of the organ and skin and muscles of the wall explains why these spasms occur. Palpation of abdominal viscera is performed with the pa- tient in the supine position, with thighs and knees semiflexed to enable adequate relaxation of the anterolateral abdominal wall. Otherwise, the deep fascia of the thighs pulls on the mem- branous layer of abdominal subcutaneous tissue, tensing the abdominal wall. Some people tend to place their hands behind their heads when lying supine, which also tightens the muscles and makes the examination difficult. Placing the upper limbs at the sides and putting a pillow under the person’s knees tends to relax the anterolateral abdominal muscles.
direct inguinal hernias
With a direct inguinal hernia, the protrusion is medial to the inferior epigastric artery, through the wall near the superficial inguinal ring, and so is covered by peritoneum and transversalis fascia (less common, could be seen in older men with weakened lower abdominal walls) poke out superficial ring pushing through weak spot. Following processes vaginalis lateral to interior gastrinalis covered by spermatic fascia through processes vaginalis into inguinal ring, and is separate from the spermatic cord and its fascial coverings derived from the abdominal wall. Direct inguinal hernias pass through the inguinal (Hesselbach’s) triangle, demarcated internally by the inferior epigastric vessels laterally, the rectus abdominis muscle medially, and the inguinal ligament inferiorly. Often, direct hernias are more limited in the extent to which they can protrude through the inferomedial abdominal wall. They occur not because of a patent processus vaginalis but because of an “acquired” weakness in the lower abdominal wall. Direct inguinal hernias can exit at the superficial ring and acquire a layer of external spermatic fascia, with the rare potential to herniate into the scrotum.
indirect inguinal hernias
distal part of the ascending aorta receives a strong thrust of blood when the left ventricle con- tracts. Because its wall is not yet reinforced by fibrous pericardium (the fibrous pericardium blends with the aortic adventitia at the beginning of the arch), an aneurysm (localized dilation) may develop. An aortic aneurysm is evident on a chest film (radiograph of the thorax) or a magnetic resonance an- giogram as an enlarged area of the ascending aorta silhouette. Individuals with an aneurysm usually complain of chest pain that radiates to the back. The aneurysm may exert pressure on the trachea, esophagus, and recurrent laryngeal nerve, causing difficulty in breathing and swallowing. While abdominal aortic aneurysms (AAAs) are more common and due to atherosclerosis, the location of thoracic aneurysms can impact on different symptoms, e.g., impact on the trachea, left recurrent laryngeal nerve. The risk of dissection or rupture can be followed by the size of the aneurysm. Thoracic aneurysm- atherosclerosis and degenerative conditions of aorta ex. Intima (weakens media), media (swelling, Marfan syndrome connective tissue fibrolytic in elastic organs, tertiary syphilis (long ongoing inflammatory response found w/ heave. Left recurrent laryngeal might be dysphasia or hoarseness vague symptomology)), adventitia.
embryological basis for hernias
The fetal testes relocate from the dorsal abdominal wall in the superior lumbar region to the deep inguinal rings during the 9th to 12th fetal weeks This repositioning probably results from growth of the vertebral column and pelvis. The male gubernaculum, attached to the caudal pole of the testis and accompanied by an outpouching of peritoneum, the processus vaginalis, projects into the scrotum. The testis descends posterior to the processus vaginalis. The inferior remnant of the proces- sus vaginalis forms the tunica vaginalis covering the testis. The ductus deferens, testicular vessels, nerves, and lymphatics accompany the testis. The final location of the testes in the scrotum usually occurs before or shortly after birth. The fetal ovaries also relocate from the dorsal abdomi- nal wall in the superior lumbar region during the 12th week and pass into the lesser pelvis. The female gubernaculum also attaches to the caudal pole of the ovary and projects into the labia majora, attaching en route to the uterus; the part passing from the uterus to the ovary forms the ovarian ligament, and the remainder of it becomes the round ligament of the uterus. For a complete description of the embryology of the inguinal region.
hydrocele
Most common cause of scrotal enlargement. Even without the presence of an indirect inguinal hernia, there is a small persistence of the peritoneal cavity (tunica vaginalis) that can fill with fluid, causing a hydrocele. This small sac of peritoneum is originally from the processus vaginalis that covers about two thirds of the testis. Hydrocele an excessive accumulation of serous fluid within the tunica vaginalis (usually a potential space). Certain pathological conditions, such as injury or inflammation of the epididymis, may also produce a hydro- cele of the spermatic cord, an infection in the testis or epididymis, trauma, or a tumor may lead to a hydrocele, or it may be idiopathic.
hematocele
collection of blood in cavity of tunica vaginalis due to injury to spermatic vessels
varicocele
Testis pulled along w/ it blood supply, sperm duct. Venus supply broken up in pampiniform complex keeping sperm cooler in mammals. If dilation of this get varicocele. The pampiniform plexus of veins may become varicose (dilated) and tortuous. These varicose vessels, usually visible only when a person is standing, often result from defective valves in the testicular vein within the spermatic cord. The palpable enlargement, which feels like a bundle of worms, usually dis appears when the person lies down looking left side impacted more than right. Almost all varicoceles are on the left side, perhaps because the left testicular vein drains into the left renal vein rather than the larger inferior vena cava, as the right testicular vein does. Left testicular vein goes into left renal vein w/ left sided assymetry obstructed by superior mesenteric artery squeezing down on it. W/ 80% of varicoceles on left side. A varicocele is evident at physical examination when a patient stands, but it often resolves when the patient is recumbent. In contrast, a varicocele represents distended veins of the pampiniform plexus. Varicoceles more typically occur on the left side given that the left testicular vein drains into the left renal vein and not directly into the IVC as does the right testicular vein.
testicular cancer
Testicular drainage of lymph, e.g., for following testicular cancer metastasis, follows the path of the testicular arteries—back to the abdominal aorta, not to the superficial inguinal lymph nodes. It is similar for ovaries and ovarian arteries/lymphatics. While many forms of testicular cancer are highly curable, lack of palpable inguinal nodes do not rule out spread. Scrotum supplies lymph nodes labia majors and buttocks on inner thigh from great saphenous vein of lower extremity. Blood and lymphatic from lumbar area metastasize rapidly in hard to palpate lumbar area. Because the testes relocate from the dorsal abdom- inal wall into the scrotum during fetal development, their lymphatic drainage differs from that of the scrotum, which is an outpouching of the anterolateral ab- dominal skin consequently: Cancer of the testis metastasizes initially to the lumbar lymph nodes, Cancer of the scrotum metastasizes initially to the superficial inguinal lymph nodes. Most common in males from puberty until mid or late 30s
vasectomy
While sperm are formed in the seminiferous tubules of the testis, they are held to maturity in the epididymis. During a vasectomy, one wants to isolate the ductus deferens from the testicular vessels by palpation peristaltic contraction. Epididymis- where sperm grows up before ductus deferens. The ductus (vas) deferens is ligated bilaterally when sterilizing a man. To perform a vasectomy, the duct is isolated on each side and transected or a small section of it is removed. Sperms can no longer pass to the urethra; they degenerate in the epididymis and proxi- mal end of the ductus deferens. However, the secretions of the auxiliary genital glands (seminal glands, bulbo-urethral glands, and prostate) can still be ejaculated. The testis con- tinues to function as an endocrine gland for the production of testosterone. Vasectomy offers birth control with a failure rate below that of the pill, condom, intrauterine device, and tubal ligation. It can be performed as an office procedure with a local anesthetic. (Approximately 500,000 are performed each year in the United States.) One approach uses a small incision on each side of the scrotum to isolate the vas deferens; another uses a small puncture (no incision) in the scrotal skin to isolate both the right vas and left vas. The muscular vas is identified, and a small segment is isolated between two small metal clips or sutures. The isolated segment is resected, the clipped ends of the vas are cauterized, and the incision is closed (or, in the nonincisional approach, the puncture wound is left unsutured).
peritoneum
The peritoneal cavity is open and communicating, with the greater sac contrasted with the lesser sac (i.e., the omental bursa defined by the lesser omentum and posterior to the stomach). The greater omentum is a large, mobile derivation of the dorsal mesentery of the stomach. Note that the small intestine (outside of the duodenum) is freely mobile with its dorsal mesentery, as are the transverse and sigmoid colon). Organs that either developed outside the peritoneal cavity (e.g., kidneys) or are attached to the posterior abdominal wall (e.g., pancreas) can be considered retroperitoneal vs. intraperitoneal organs such as stomach and spleen. Note how the spleen developed in the dorsal mesentery of the stomach, leaving it with mesenteries. Pericolric colon- deep between righ kidney and liver hepatorenal recess. Spleen, stomach, small intestine abdominal cavity stretches of bowels, ascending, descending, duodenum (retroperitoneal fixed back there) Mesentery holding stuff to back wall and elaborations making for additional sheaths, lesser omentum between liver and stomach, big fold of omentum greater omentum
peritonitis
When bacterial contamination occurs during lapa- rotomy or when the gut is traumatically penetrated or ruptured as the result of infection and inflammation (e.g., appendicitis), allowing gas, fecal matter, and bac- teria to enter the peritoneal cavity, the result is infection and inflammation of the peritoneum—peritonitis. Exudation of serum, fibrin, cells, and pus into the peritoneal cavity occurs, accompanied by pain in the overlying skin and an increase in the tone of the anterolateral abdominal muscles. Given the extent of the peritoneal surfaces and the rapid absorption of material, including bacterial toxins, from the peritoneal cav- ity, when peritonitis becomes generalized (widespread in the peritoneal cavity), the condition is dangerous and perhaps lethal. In addition to the severe abdominal pain, tenderness, nausea and/or vomiting, fever, and constipation are present. Rhythmic movements of the anterolateral abdominal wall normally accompany respirations. If the abdomen is drawn in as the chest expands (paradoxical abdominothoracic rhythm) and muscle rigidity is present, either peritonitis or pneumonitis (inflammation of the lungs) may be present. Because the intense pain worsens with movement, people with peritonitis commonly lie with their knees flexed to relax their anterolateral abdominal muscles. They also breathe shallowly (and hence more rapidly), reducing the intra-abdominal pressure and pain.
peritoneal drainage
peritonitis may result in the formation of abscesses (localized collections of pus) in vari- ous parts of the peritoneal cavity. A common site for an abscess is in the subphrenic recesses. Sub- phrenic abscesses occur much more frequently on the right side because of the frequency of ruptured appendices and perforated duodenal ulcers. Because the right and left subphrenic recesses are continuous with the hepatore- nal recess, pus from a subphrenic abscess may drain into one of the hepatorenal recesses, especially when the individual is bedridden. A subphrenic abscess is often drained by an incision inferior to the 12th rib.
Peritoneal adheasions
If peritondem is damaged, fibrin deposition can make it sticky, leading to adhesions. If the peritoneum is damaged, by a stab wound for example, or infected, the peritoneal surfaces become inflamed, making them sticky with fibrin. As healing occurs, the fibrin may be replaced with fibrous tissue, form- ing abnormal attachments between the visceral peritoneum of adjacent viscera or between the visceral peritoneum of a viscus and the parietal peritoneum of the adjacent abdominal wall. Adhesions (scar tissue) may also form after an abdominal operation (e.g., owing to a ruptured appendix) and limit the nor- mal movements of the viscera. This tethering may cause chronic pain or emergency complications such as intestinal obstruction when the gut becomes twisted around an adhesion (volvulus
Greater omentum involvement in adhesions and drainage
Can act as policeman of abdomen, given its large, mobile status (and extensive lymphatic). It can adhere to an inflamed organ, and it will help/prevent adhesions w/ other peritoneum-covered structures. The greater omentum, large and fat-laden, pre- vents the visceral peritoneum from adhering to the parietal peritoneum. It has considerable mobility and moves around the peritoneal cavity with peristaltic move- ments of the viscera. It often forms adhesions adjacent to an inflamed organ such as the appendix, sometimes walling it off and thereby protecting other viscera from it.
gastrointestinal embryology and associated outcomes
The primordial gut consists of the foregut (esoph- agus, stomach, pancreas, duodenum, liver, and biliary ducts), midgut (small intestine distal to the bile duct, cecum, appendix, ascending colon, and most of the trans- verse colon), and hindgut (distal transverse colon, descending and sigmoid colon, and rectum). For 4 weeks, the rapidly growing midgut, supplied by the SMA, is herniated into the proxoimal part of the umbilical cord. It is at- tached to the umbilical vesicle (yolk sac) by the omphalo- enteric duct (yolk stalk). As it returns to the abdominal cavity, the midgut rotates 270 degrees around the axis of the SMA. As the parts of the intestine reach their definitive positions, their mesenteric attachments un- dergo modifications. Some mesenteries shorten and others disappear. During development, in the region of the future stomach and duodenum, there is not only the typical dorsal mesentery, but also a ventral mesentery. The liver develops as an endodermal outgrowth of the duodenum in the ventral mesentery, dividing it into the falciform ligament between liver and umbilicus, and lesser omentum between liver and stomach. In fetal circulation, the umbilical vein (adult, ligamentum teres) travels through the inferior portion of this ventral mesenteric sheet. The stomach, duodenum and the other viscera (liver, pancreas, spleen) that develop in the foregut region are supplied by the celiac artery and celiac ganglion, with the sympathetic innervation to that ganglion via the greater splanchnic nerves from T5-T9. The midgut of jejunum, ileum, and the first half of the large intestine is elongating, forming a primary intestinal loop or region that is supplied by the superior mesenteric artery and superior mesenteric ganglion, with the sympathetic innervation to that ganglion via the lesser splanchnic nerves from T10-T11. From the left colic flexure distally, the hindgut is supplied by the inferior mesenteric artery and inferior mesenteric ganglion, with the sympathetic innervation to that ganglion via the lumbar splanchnic nerves from L1-L3. Given this information, and knowing that visceral pain afferents travel with the sympathetic neurons, one should then be able to predict that epigastric pain will typically suggest organs supplied by the celiac artery and periumbilical pain from organs supplied by the superior mesenteric artery.
Ileal diverticulum
An ileal diverticulum (of Meckel) is a congenital anomaly that occurs in 1%–2% of people. A remnant of the proximal part of the embryonic omphalo-enteric duct (yolk stalk), the diverticulum usually appears as a finger-like pouch 3–6 cm long. It is always on the antimesen- teric border of the ileum—the border of the intestine opposite the mesenteric attachment. An ileal diverticulum may become inflamed and produce pain mimicking appendicitis. A Meckel diverticulum is a remain of the yolk sac and affiliated structures that can appear approximately 60 cm proximal to the ileocecal valve syndrome of 2s (“2% of people have them, it’s 2 inches long, it’s 2 feet from the ileocecal junction valve, 2 types of mucosa and it typically presents before the age of 2”). Given the referred pain patterns set up by gut embryology, an inflamed one may initially present in a periumbilical pattern similar to appendicitis. Tip of loop of midgut that didn’t quite regress off.
ascites
Multiple space and gutters can direct flow of accumulated fluid. The generation of ascites from cirrhosis due to the normal lymph formation/reabsorption balance altered. Pressure leads to stuff weeping out because of hydrostatic pressure from vessels. Liver making albumin and blood coagulation factors. If no albumin in blood stream loose hydrostatic pressure becoming itnerstitially. Excess fluid in the peritoneal cavity is called ascitic fluid, clinically called ascites. Ascites may also occur as a result of mechanical injury (which may also produce internal bleeding) or other pathological conditions, such as portal hypertension (venous congestion) and widespread metastasis of cancer cells to the abdominal viscera. In all these cases, the perito- neal cavity may be distended with several liters of abnormal fluid, interfering with movements of the viscera.
cirrhosis
In cirrhosis of the liver, hepatocytes are destroyed and replaced by fibrous tissue. This tissue sur- rounds the intrahepatic blood vessels and biliary ducts, making the liver firm and impeding circulation of blood through it. Cirrhosis, the most common of many causes of portal hypertension, frequently develops in chronic alcoholics. Cirrhosis is a largely irreversible disease characterized by diffuse fibrosis, parenchymal nodular regeneration, and disturbed hepatic architecture. Progressive fibrosis disrupts the portal blood flow, leading to portal hyperten- sion. Major causes of cirrhosis include the following: • Alcoholic liver disease (60% to 70%), • Viral hepatitis (10%), • Biliary diseases (5% to 10%), • Genetic hemochromatosis (5%), • Cryptogenic cirrhosis (10% to 15%) Portal hypertension can lead to esophageal and rectal varices (tortuous enlargement of the esophageal and rectal veins) as the portal venous blood is shunted into the caval system using portosystemic anastomoses. Additionally, the engorgement of the superficial venous channels in the subcutaneous tissues of the abdominal wall (via the paraumbilical portosystemic route) can appear as a caput medusae (tortuous subcutaneous varices that resemble the snakes of Medusa’s head).
portal hypertension *clean answer up
The hepatic portal system draining the intestines is separate from that of the inferior vena cava, draining the lower extremities, pelvic items, and abdominal paired organs (gonads, kidneys, adrenals). There exists a number of possible anastomotic locations between the two systems. Increased flow through these anastomoses can occur with portal hypertension. While the main one of interest will be esophageal varices (distended esophageal veins) between eft azygos and esophageal veins, paraumbilical veins can offer a portal/systemic circuit and so create a spot for engorgement with portal hypertension/backup, with the clinical presentation of caput medusae. At the sites of anastomoses between portal and systemic veins, portal hypertension produces enlarged varicose veins and blood flow from the portal to the systemic system of veins. The veins may become so dilated that their walls rupture, resulting in hemorrhage. Bleeding from esophageal varices (dilated esophageal veins) at the distal end of the esophagus is often severe and may be fatal. Note that surgical amelioration for portal hypertension can include an artificial portocaval shunt. Gastroesophageal juntion- celiac artery of left gastric vein and hepatic artery and if portal is not moving left gastric vein backing up into esophageal into azygos is a work around but they are very small becoming big and swollen creating esophageal varices. result of a number of conditions, which may be “upstream” (prehepatic) or “downstream” (posthepatic), as well as intrahepatic, typically cirrhosis. Changes in liver make it hard to filter because of cirrhosis caprices and spleen is being backed up left and short gastric veins swelling. Portal vein- nutrition, surgery thromobofillic spleen swelling backing up gastric up. Portal hypertension spleen gets backed up and enlarged, harder to filter low red, white, and platelet count. These distended veins can rupture and lead to high rates of bleeding. cant process ammonia’s or conjugating bilirubin jaundice, nobly portal hypertension, hemorrhagic not making blood coagulation, not making albumin causing intracellular space. Dilating of arterial spider nevi- men, pectoral slope is, testicular atrophy estrogen not cleared out. A common method for reducing portal hypertension is to divert blood from the portal venous system to the sys- temic venous system by creating a communication between the portal vein and the IVC or by joining the splenic and left renal veins—a portacaval anastomosis or portosystemic shunt. If the portal vein becomes occluded or its blood cannot pass through the hepatic sinusoids, a significant increase in portal venous pressure will ensue, resulting in portal hypertension. Normal portal venous pressure is 3 to 6 mm Hg but can exceed 12 mm Hg (portal hypertension), resulting in dilated, tortuous veins (varices) and variceal rupture. Three major mechanisms are defined as follows:
• Prehepatic: obstructed blood flow to the liver
• Posthepatic: obstructed blood flow from the liver to the heart
• Intrahepatic: cirrhosis or another liver disease, affecting hepatic sinusoidal blood flow
Clinical consequences of portal hypertension include the following:
• Ascites, usually detectable when 500 mL of fluid accumulates in the abdomen
• Formation of portosystemic shunts via anastomotic channels
• Congestive splenomegaly (becomes engorged with venous blood backing up from the splenic vein)
• Hepatic encephalopathy (neurologic problems caused by inadequate removal of toxins in the blood by
the diseased liver)
paracentesis
Treatment of generalized peritonitis includes re- moval of the ascitic fluid and, in the presence of infection, administration of large doses of antibiotics. Surgical puncture of the peritoneal cavity for the aspira- tion or drainage of fluid is called paracentesis. After injection of a local anesthetic agent, a needle or trocar and a cannula are inserted through the anterolateral abdominal wall into the peritoneal cavity through the linea alba, for example. The needle is inserted superior to the empty urinary bladder and in a location that avoids the inferior epigastric artery.
Embryology of nerve distribution
The diaphragm forms during the second month as it divides one body cavity into separate thoracic and abdominal cavities. The future connective tissue core (central tendon) is the septum transversum, originating in the more cranial region, and so picking up the C3, 4, 5 innervation of the phrenic nerve. With differential growth of the embryo, the septum “descends” and so brings the phrenic nerve with it. Septum transversum- formal divide between thorax and abdomen, diaphragm in trampoline w/ central tendon and muscle around it. Phrenic nerve around it pulling down central tendon expanding thoracic cavity increasing intrathoracic volume and pressure. There are a number of openings in the diaphragm to allow the passage of inferior vena cava, aorta, and esophagus in particular.
Embryology of Malrotation
Malrotation of the midgut results in several congenital anomalies, such as volvulus (twisting) of the intestine. of the intestinal loop may be seen as a congenital disorder. Not packed in nicely getting confused and possibility of it not packing nicely valvular twisting around and obstruction crossing over each other and compressing it. Many congenital lesions of the GI tract cause intestinal obstruction, which commonly results from malrotation of the midgut, atresia, volvulus, meconium ileus, or imperforate anus. Vomiting, absence of stool, and abdominal distention characterize the clinical picture. Intestinal obstruction can be life threatening, requiring surgical intervention. The corrective procedure for congenital malrotation with volvulus of the midgut is illustrated.
embryology of the gut as the basis for vessel
see slide
Congenital diaphragmatic hernia
A congenital diaphragmatic hernia (most commonly posterolateral, a so-called Bochdalek hernia) can lead to herniation of abdominal contents and hence, lack of lung development on the affected side. This pulmonary hypoplasia outcome typically happens on the left, as the liver is “in the way” on the right. If no septal seal off of thoracic versus diaphragmatic cavities can get diaphragmatic hernia space filling activity abdominal contents go up compressing lung
hiatal hernia
A hiatal (hiatus) hernia A widening of the space between the muscular right crus forming the esophageal hiatus allows protrusion of part of the stomach superiorly into the posterior mediastinum of the thorax through the esopha- geal hiatus of the diaphragm. The hernias occur most often in people after middle age, possibly because of weaken- ing of the muscular part of the diaphragm and widening of the esophageal hiatus. Although clinically there are several types of hiatal hernias, the two main types are para-esophageal hiatal hernia and sliding hiatal hernia. In the less common para-esophageal hiatal hernia, the cardia remains in its normal position. However, a pouch of peritoneum, often containing part of the fundus, extends through the esophageal hiatus anterior to the esopha- gus. In these cases, usually no regurgitation of gastric contents occurs because the cardial orifice is in its normal position. In the common sliding hiatal hernia, the abdominal part of the esophagus, the cardia, and parts of the fundus of the stomach slide superiorly through the esophageal hiatus into the thorax, especially when the person lies down or bends over. Some regurgitation of stomach contents into the esophagus is possible because the clamping action of the right crus of the diaphragm on the inferior end of the esophagus is weak. A combination of the tone of the esophageal hiatus, a fibrous phrenoesophageal membrane extending from that hiatus, and the angle between esophagus and main part of stomach (angle of His) all combine to keep the lower esophageal sphincter within the hiatus to within the abdominal cavity. Increase in intra-abdominal pressure, e.g., from obesity, or loss of muscle tone or tissue elasticity, e.g., from age, can both contribute to the increased prevalence of hiatal hernias in older Americans. Hiatal hernias may either be sliding or paraesophageal, with the rare paraesophageal type more likely in lead to incarceration. The sliding hiatal hernias are often asymptomatic.Sliding, rolling, or axial hernia (95% of hiatal hernias): appears as a bell-shaped protrusion. • Paraesophageal, or nonaxial hernia: usually involves the gastric fundus Stomach above diaphragm in thoracic cavity. Esophagus held in by gravity attaching to stomach, muscles pinch off parental esophageal membrane connective tissue over lining esophagus and diaphragm holding into place sliding or hiatal hernias. Veins getting congested cant slide through
congenital megacolon (Hirschsprung disease)
Failure of neural crest cell migration to the distal colon leads to congenital megacolon (Hirschsprung disease). The lack of submucosal and myenteric plexuses leads to a colonic segment that loses intrinsic enteric nervous system control and ends up with a functional obstruction. Neural crest cells of postganglionic neurons Parasympathetic vagus or last two stretch not migrating to end. Stretch of bowel becoming aganglionic not parastatal driving neurons causing backed up of megacolon not moving past it. Congenital megacolon results from the failure of neural crest cells to migrate distally along the colon (usually the sigmoid colon and rectum). The incidence of megacolon is about 1 in 5000 live births. It is more common in boys. The condition leads to an aganglionic segment that lacks both the Meissner’s submucosal plexus and the Auerbach’s myenteric plexus. Distention proximal to the aganglionic region may occur shortly after birth or may cause symptoms in early childhood. Surgical repair involves prolapse and eversion of the segment.
splenic rupture
Although well protected by the 9th through 12th ribs, the spleen is the most frequently injured organ in the abdomen. Severe blows on the left side may fracture one or more ribs, resulting in sharp bone fragments that can lacerate the spleen. Blunt trauma to other regions of the abdo- men that cause a sudden, marked increase in intra-abdominal pressure can also rupture the spleen because its capsule is thin and its parenchyma (essential substance) is soft and pulpy. If ruptured, the spleen bleeds profusely. Rupture of the spleen causes severe intraperitoneal hemorrhage and shock. Repair of a ruptured spleen is difficult; consequently, splenectomy (removal of the spleen) or subtotal (partial) splenectomy (removal of one or more segments of the spleen) is often performed to prevent the patient from bleeding to death. Even total splenectomy usu- ally does not produce serious side effects, especially in adults, because most of its functions are assumed by other reticuloen- dothelial organs (e.g., liver and bone marrow), but the person will be more susceptible to certain bacterial infections. The spleen is not part of the gut tube, but instead is a vascular organ formed in the dorsal mesogastrium (gastric mesentery), splitting that into splenorenal and gastrosplenic ligaments. The spleen is in the left hypochondriac region with a thin capsule and no other surrounding connective tissue, and can be vulnerable to damage with left rib 9-11 fractures, e.g., following trauma. It is a very vascular organ with its internal red pulp of splenic cords to remove old and abnormal erythrocytes, and white pulp of lymphoid tissue for surveillance of the blood stream for infections. The splenic artery branches supply splenic segments without anastomoses, as can be seen in lab dissection, so that the spleen can be prone to infarction if a segment is compromised, e.g., in patients with sickle cell anemia. Spleen highly vascularized, lymph and gets rid of old dead RBCs. If lots of abnormally shaped red cells swell up, mono can swell up, spleen underneath 9-10th rib in accident, thin capsule vulnerable underneath rib. Branching pattern potentially can infarct one part of spleen and not spleen as a whole like in sickle cell anemia lead to infarct in’s of vascular things leading to shrunken spleen. Trauma to the left upper quadrant can lead to splenic rupture. The adventitial capsule of the spleen is very thin, making traumatic rupture a medical emergency, as the spleen receives a rich vascular supply and can bleed profusely.
gastrectomy
When the body or pyloric part of the stomach contains a malignant tumor, the mass may be palpable. Using gastroscopy, physicians can inspect the lining of the air-inflated stomach, enabling them to observe gastric lesions and take biopsies. Partial gastrectomy (removal of part of the stomach) may be performed to remove the region of the stomach involved by carcinoma. Because of the anas- tomoses of the arteries supplying the stomach provide good collateral circulation, one or more arteries may be ligated during this procedure without seriously affecting the blood supply of the remaining part of the stomach. Partial gastrectomy to remove a carcinoma usually also requires removal of all involved regional lymph nodes. Because cancer frequently occurs in the pyloric region, removal of the pyloric lymph nodes as well as the right gastro-omental lymph nodes also receiving lymph drainage from this region is espe- cially important. As stomach cancer becomes more advanced, the lymphogenous dissemination of malignant cells involves the celiac lymph nodes to which all gastric nodes drain.
bariatric surgery
In some cases of morbid obesity, bariatric surgery may offer a viable alternative to failed dieting. The following three approaches may be considered: Gastric stapling (vertical banded gastroplasty) involves creating a small stomach pouch in conjunction with stomach stapling and banding; this approach is performed less frequently in preference to other options, • Sleeve gastrectomy is becoming a popular option for increased weight loss because of its decreased risk for nutritional deficiencies and the ease with which it can be surgically accomplished, Most popular sleeve gastrecomy a lot less capcity looks like castric stapling but just cutting it away. • Gastric bypass (Roux-en-Y) spares a small region of the fundus and attaches it to the proximal jejunum; the main portion of the stomach is stapled off, and the duodenum is reattached to a more distal section of jejunum, allowing for the mixture of digestive juices from the liver and pancreas,This more dramatic surgery not only shrinks the stomach size (restrictive), but also bypasses a significant portion of the small intestine (and so is diversionary to set up some malabsorption). Most drastic and popular being roux-en-y getting restrictive aspect small pouch and sense of satiety manipulating proximal small intestine to cut off length. Bypassing area with malabsorptive while still allowing the pancreas to combine. • Adjustable gastric banding restricts the size of the proximal stomach, limiting the amount of food that can enter; the band can be tightened or relaxed via a subcutaneous access port if circumstances warrant. Banding reversible stratggy more of a restrictive surgery.
GERD
The terminal end of the esophagus possesses a lower esophageal sphincter (specialized smooth muscle that is physiologically different from the smooth muscle lining the lower esophagus) rather than structural allowing us to vomitIt prevents the reflux of gastric contents into the lower esophagus. However, it can become compromised, usually by a loss of muscle tone or a sliding hiatal hernia, leading to GERD and inflammation of the esophageal lining. GERD often presents with upper abdominal pain, dyspepsia, gas, heartburn, dysphagia, bronchospasm, or asthma. laxity of the smaller, more physiologic sphincter (lower esophageal sphincter), compared to the pyloric sphincter, but also the different esophageal vs. gastric mucosae, which may lead to GERD (gastroesophageal reflux disease). Esophageal cancer is a possible concern from chronic irritation/GERD. Barrett esophagus represents a metaplastic change of the esophageal epithelium from GERD, and is considered a precancerous condition. Esopahgus has stratified squamous eptihelium still not as protected as simple columnr and tight junctions with chronic inflammation damamging esophagus causing scarring and strictures. Chronic cellular turnover predisposing yourself to cancer changing over from stratified squamous epithelium to metaplasia (fairly normal tissue simple columnar epithelium but is instead in the wrong place and in the esophagus or baird esophagus risk factor for esophageal cancer not everyone with it gets cancer.
peptic ulcer disease
Duodenal ulcers are a common form of peptic ulcerpeptic ulcers are lesions of the mucosa of the pyloric canal or, more often, the duodenum. Most ulcers of the stomach and duodenum are associated with an infection of a specific bacterium, Helicobacter pylori. typically involved as the initiating process of inflammation that may eventually lead to ulceration. Peptic ulcer disease acid tolerant bacteria bacteria hang out and live in hostile enviornment trigger inflammatory response leading to breakdwon of normal protective feature of the stomach or ulceration. It is thought that the high acid level in the stomach and duodenum overwhelms the bicarbonate normally produced by the duodenum and reduces the effectiveness of the mucous lining, leaving it vulnerable to H. pylori. The bacteria erode the protective mucous lining of the stomach, inflaming the mucosa and making it vulnerable to the effects of the gastric acid and digestive enzymes (pepsin) produced by the stomach. Peptic ulcers are GI lesions that extend through the muscularis mucosae and are remitting, relapsing lesions. (Erosions, on the other hand, affect only the superficial epithelium.) Acute lesions are small and shallow, whereas chronic ulcers may erode into the muscularis externa or perforate the serosa. Although they may occur in the stomach, most occur in the first part of the duodenum (duodenitis), which is referred to by clinicians as the duodenal cap or bulb. The two most serious complications of gastric or duodenal peptic ulcers are perfora- tion and hemorrhage. ). Thick pyloric sphincter allows acid through with buffering juice not enough along with bruner glands to stop peptic ulcer formation. Can get entrapment of omental bursa with perforation.
diverticulosis
Diverticulosis is a disorder in which multiple false diverticula (external evaginations or outpocketings of the mucosa of the colon) develop along the intestine. It primarily affects middle-aged and elderly people.. Diverticulosis is a herniation of colonic mucosa and submucosa through the muscular wall, with a diverticular expansion in the adventitia of the bowel visible on its external surface. Common sites of development occur where neurovascular bundles penetrate the muscular wall of the bowel. Especially in the sigmoid colon, weakenings or diverticula (diverticulosis) can be seen where blood vessels penetrate, and with increased intraluminal pressure, e.g., from straining from a low-fiber diet, diverticula may become numerous. Longitudeinal muscle layer of colon, teniae colon, doubly layers with superior and inferior mesenteric area causing weak spots and intraluminal pressure get high loads. Diverticula are subject to infection and rupture, leading to diverticulitis. Diverticulitis- outpouching of mucosa if inflamed or perforated soiling peritoneal cavity.
volvulus
Volvulus is the twisting of a bowel loop that may cause bowel obstruction and constriction of its vascular supply, which may lead to infarction. Volvulus affects the small intestine more often than the large intestine. The mesenteric mobility of these portions of the bowel accounts for this higher occurrence at these sites. Volvulus is associated with dietary habits, perhaps a bulky vegetable diet that results in an increased fecal load. The sigmoid colon is the most common site in the large intestine. The sigmoid colon is on its own dorsal mesentery and so is at risk of volvulus. Sigmoid volvulus is often a condition of older individuals (think of with chronic constipation “weighting the loop”) and may be recurrent. Developmentally giant wrapping of midgut in peritoneal cavity can also cause volvulus or twisting, small intestine prevents twisting of it. Common in large intestine at cecum, or sigmoid colon not attached like ascending and descending are. Chronic problems- diverticulum or constipation can make it weighted top=-heavy with straining and clinical inflammation can twist off and cause surgical emergency. If surgery with adhesions small intestine could be put at higher risk.
intussusception
Intussusception is the invagination, or telescoping, of one bowel segment into a contiguous distal segment, may occur at the ileocecal junction, especially in children.In children the cause may be linked to excessive peristalsis. In adults an intraluminal mass such as a tumor may become trapped during a peristaltic wave and pull its attachment site forward into the more distal segment. Intestinal obstruction and infarction may occur. Concern had been raised regarding the risk of rotavirus vaccine and the risk of intussusception, given that an initial version was withdrawn from the market in 1999 for that reason. The current vaccines have been very successful, with some reports internationally of this still rarely occurring after vaccine administration. Different size lumens may cause intussusception. Something that swelling and was captured by peristalsis. Tumor acts as knot that is caugh t periscoping or intussesception. In children illeocecal region with lympohoid follicles in illeum compared to rest with organized lymphodi pyeyer patches, useful for survaellence, if swollen up just enough of a knot to catch and pull through large intestine. Trapped wall with venous congestion thinking about colon not as absorptive because of goblet cells, lubing load, blood plus mucus mixture might be striking finding of red currant jelly when defecating common symptom found.
appendicitis
Acute inflammation of the appendix is a common cause of an acute abdomen (severe abdomi- nal pain arising suddenly), often caused by bacterial infection. Digital pressure over the McBurney point produces the maximum abdominal tenderness. The pain of appendicitis usually commences as a vague pain in the peri-umbilical region because afferent pain fibers enter the spinal cord at the T10 level. Later, severe pain in the right lower quadrant results as the appendix becomes more inflamed rom irritation of the parietal peritoneum lining the posterior abdominal wall, the pain becomes well localized to the right lower quadrant (circumscribed tenderness to palpation). Surgical resection is the treatment of choice to prevent life-threatening complications such as abscess and peritonitis. Appendicitis is less common in infants and the elderly. Lots of lymphoid tissue and little musculature make up the wall of the appendix. Hence, with a small lumen that is easily obstructed, typically by fecaliths, the appendix can become readily inflamed and swollen in appendicitis. Appendix long and skinny with different mesentery can wrap itself in many different directions with a smal lumen. Appendix tonsil to end of small intestine beginning of large intestine w. colonic fleura and immune survelance. Partial obstruction of lumen of appendix, initial infection thin walled w/ venous congestion can start to swell. active infection lymph tissue can swell out and grow impacting vascularity get venous stasis, swelling, entrapping and arterial impaction.
colon cancer
Colon cancer is most often seen in the rectum or other distal portions of the colon, with the changing nature of the stool explaining typical findings of right-sided vs. left-sided colon cancer. Like ulcerative colitis from mucosa on out. Highlight polyps that are precursors to colon cancer with mucosal proliferation and more rapid divisions and other things being equal. Polyp in mucosa off of gland coming into play. Presentation different depending upon where going along way. Right colon going on may not kick up symptomatology or some subtle ozze positive fecal or blood test when still not obstructed or anemia. More and more distal descending colon and rectum depending upon how lesions are have apple core sign with involvement of abdominal wall and not having changes in bowel habits accordingly space filling rectum causing urge to defecate, how active mucosa and distal the tumor causes bleeding. Dragging sensation while defecating is a symptom. Different vessels to different parts of colon, right middle and left sigmoid rectal arteries. Vasculature of colon gets idea of what can be removed. Mucosal fissure originally is a good screenning tool. Liver metasasis is the first distant presenation of tumor. Right sided: cancer here can become large and fungating, with blood loss as the main symptom, as the feces are more liquid. Left sided: cancer here can become constipating, given the increased firming of the feces
Crohn’s disease
Crohn disease is an idiopathic inflammatory bowel disease that can affect any segment of the GI tract but usually involves the small intestine (terminal ileum) and colon. Young adults of northern European ancestry are more often affected. Transmural edema, follicular lymphocytic infiltrates, epithelioid cell granulomas, and fistulation characterize Crohn disease. Signs and symptoms include the following: • Diffuse abdominal pain (paraumbilical and right lower quadrant), • Diarrhea, • Fever, lethargy, malaise, • Dyspareunia (pain during sexual intercourse), • Urinary tract infection (UTI), • Malabsorption, unintentional weight lossAs with Crohn disease, ulcerative colitis is an idiopathic inflammatory bowel disease that begins in the rectum and extends proximally. Usually the inflammation is limited to the mucosal and submucosal layers of the bowel. Abdominal tenderness in the hypogastrium or left lower quadrant and bloody diarrhea are common. There are two major forms of inflammatory bowel disease (IBD). Crohn disease often affects the ileum, although transmural skip lesions may appear throughout the alimentary tract. Most common location of crohns disease in terminal illeum. Haivng abnormal inflammatory response in illeal region getts transmural that is across wall creating strictures, adhesions, and fistula (abnormal communications). Absorption of B12 from intrinsic factor receptors, receptors of bile and its recirculation where it is run through the liver. Inflammation in terminal illeal region can lead to issues with fat tolerance, pernitious anemia (B12 cofactor for DNA synthesis). Abnormal inflmmatory response to colonic fleura. Crohn’s can affect from esophagus down.
ulcerative colitis
Ulcerative colitis appears in the mucosa of the colon, almost always involving the rectum. Aka IBD. Mucosal bleeding starting in rectum working its way up triggering adhesions and abscesses events leading to carcinoma coming into play. IBD working up left side of colon compared to a ileal item. Inflammatory fever and arthritis. Bleeding or other changes to mucosa or bowel wall.
IBS
irritable bowel syndrome. Altered colonic function (irritable bowel syndrome, IBS) may be the underlying cause for abdominal pain or altered bowel habits. fewer signs of inflammation and bleeding will lead away from consideration of inflammatory bowel disease. Intermittent constipation and diarrhea no changes in bowel wall ut differences in functionality, hypersensitivity to stretcher, behr nerve endings sensitive to distentio. Functional changes not involving anatomy. Overall, careful history and physical examination is called for when the question of abdominal pain arises.
splenomegaly
When the spleen is diseased, resulting from, for example, granulocytic leukemia (high leukocyte and white blood cell count), it may enlarge to 10 or more times its normal size and weight (splenomegaly). Spleen engorgement sometimes accompanies hypertension (high blood pressure). The spleen is not usually palpable in the adult.
pancreatic cancer
Cancer involving the pancreatic head accounts for most cases of extrahepatic obstruction of the biliary ducts. Because of the posterior relationships of the pancreas, cancer of the head often com- presses and obstructs the bile duct and/or the hepatopan- creatic ampulla. This causes obstruction, resulting in the retention of bile pigments, enlargement of the gallbladder, and jaundice (obstructive jaundice). Jaundice (Fr. jaune, yellow) is the yellow staining of most body tissues, skin, mucous membranes, and conjunctiva by circulating bile pigments. Most people with pancreatic cancer have ductular adenocar- cinoma. Severe pain in the back is frequently present. Cancer of the neck and body of the pancreas may cause portal or inferior vena caval obstruction because the pancreas overlies these large veins. The pancreas’s extensive drainage to rela- tively inaccessible lymph nodes and the fact that pancreatic cancer typically metastasizes to the liver early, via the hepatic portal vein, make surgical resection of the cancerous pan- creas nearly futile. Carcinoma of the pancreas is the fifth leading cause of cancer death in the United States. Pancreatic carcinomas, which are mostly adenocarcinomas, arise from the exocrine part of the organ (cells of the duct system); 60% of cancers are found in the pancreatic head and often cause obstructive jaundice. Islet tumors of the endocrine pancreas are less common. Because of the anatomical position of the pancreas, adjacent sites may be directly involved (duodenum, stomach, liver, colon, spleen), and pancreatic metastases via the lymphatic network are common and extensive. Given its location, pancreatic disease processes may spread to the omental bursa or to the retroperitoneum—think of the pattern of deep, penetrating back pain seen with pancreatic cancer, along with obstructive jaundice if the cancer is in the pancreatic head. Gastrodudondeal artery, splenic artery. Most right around head of two parts fusing together theoretically cause jaundice presentation to get to major duodneal papilla on out. Full pancreatic tumor to trigger jaundice traveling off of local lymph nodes it has metastasized. With its close proximity to abdominal wall pain patterns going on are sending it backwards between shoulder blades as presenting factor. The extensive vascularity, and hence, lymphatics in this region can contribute to early metastasis of pancreatic cancer.
gallstones, cholecystitis?
Gallstones are concretions (L. calculi, pebbles) in the gallbladder cystic duct, hepatic ducts, or bile duct. The distal end of the hepatopancreatic ampulla is the narrowest part of the biliary passages and is the common site for impaction of a gallstone. Gallstones may produce biliary colic (pain in the epigastric region). When the gallbladder relaxes, the stone in the cystic duct may pass back into the gallbladder. If a stone blocks the cystic duct, cholecystitis (inflammation of the gallbladder) occurs because of bile accumulation, causing enlargement of the gallbladder. Pain develops in the epigastric region and later shifts to the right hypochondriac region at the junction of the 9th costal cartilage and the lateral border of the rectus sheath. Inflammation of the gallbladder may cause pain in the posterior thoracic wall or right shoul- der as a result of irritation of the diaphragm. Cholelithiasis results from stone formation in the gallbladder and extrahepatic ducts. Acute pain (biliary colic) can be referred to several sites. Common sites include the back just below the right scapula (T6-T9 dermatomes) or even the right shoulder region, if an inflamed gallbladder (cholecystitis) irritates the diaphragm. Obstruction of bile flow (bile stasis) can lead to numerous complications and jaundice, a yellow discoloration of the skin and sclera caused by bilirubin accumulation in the blood plasma. Gallstones are typically concretions from cholesterol precipitation (there can also be pigment stones from bilirubin (processed in liver dumped in bile and go out)). Depending on where gallstones lodge, cholecystitis, jaundice, or even pancreatitis can occur. If the gallbladder is inflamed and involves the right diaphragmatic undersurface, it can trigger referred right shoulder pain via the phrenic nerve. Bile modified cholesterol molecule helping to emulsify fat with both choloesterol component interacting with fat and salt hydrophillic component allowing to disolve in water allowing larger chunks of fat to smaller chunks making it esier for hepatic lipases to dissolve. Watery bile out of hepatic ducts held up in galbladder in fodled mucosa get thick sludgier bile. Out of cystic duct, common bile duct, pancreatic duct all posisble spots for blockage. Producing right upper quadrant. Fat, female, fair, forty, fertile are all risk factors. Hollow structures don’t like to get distended causing visceral pain signal depending upon location when smaller sludgier getting cuaght up along way cause problem. Estrogen effects include triggering of cholesterol saturation and decrease of gallbladder motility, hence the listing among risk factors.
cholecystectomy
People with severe biliary colic usually have their gall- bladders removed. Laparoscopic cholecystectomy often replaces the open-incision surgical method. The cystic artery most commonly arises from the right hepatic artery in the cystohepatic triangle (Calot triangle). In current clinical use, the cystohepatic triangle is defined inferiorly by the cystic duct, medially by the common hepatic duct, and superiorly by the inferior surface of the liver. Careful dissec- tion of the cystohepatic triangle early during cholecystectomy safeguards these important structures should there be ana- tomical variations. The cystohepatic triangle (of Calot) and its sentinel lymph node (of Lund or “Calot’s”) are landmarks as a way of avoiding the hepatic biliary ducts. Colosystectomy- cut off cystic duct and cystic artery not hepatic duct nor artery.
renal stones
Complications of renal stones include obstruction to the flow of urine, infection, and destruction of the renal parenchyma. Renal stones (calculi), typically of calcium oxalate, often are trapped at narrowings in the ureters as they traverse from pelvis to bladder, Excessive distention of the ureter owing to a renal calculus (kidney stone) causes severe intermittent pain, ureteric colic, as it is gradually forced down the ureter by waves of contraction. The calculus may cause complete or intermittent obstruction of urinary flow. The ob- structing stone may lodge anywhere along the ureter; however, it lodges most often where the ureters are relatively constricted: (1) at the junction of the ureters and renal pelvis, (2) where they cross the external iliac artery and the pelvic brim, and (3) where they pass through the wall of the bladder. The severity of the pain associated with calculi can be extremely intense; it depends on the location, type, size, and texture of the calculus. Depending on the level of obstruction, the pain may be referred to the lumbar (loin) or inguinal regions (groin), the proximal anterior aspect of the thigh, or the external genitalia and/ or testis. The pain is referred to the cutaneous areas in- nervated by the spinal cord segments and sensory ganglia, which supply the ureter mainly T11–L2 via the sympathetic splanchnic nerves via the visceral pain afferents due to distentin of the ureter. Ureteric calculi can be observed and removed with a nephroscope. Another tech- nique, lithotripsy, focuses a shock wave through the body that breaks the stones into fragments, which then pass with the urine. Ureteric calculi (stones) may cause complete or intermittent obstruction of urinary flow. Ureteric calculi can be removed by open surgery, endoscopy, or lithotripsy (shock waves to break the stones into small fragments that can be passed in the urine). Renal stones may form in the kidney and remain there or more often pass down the ureters to the bladder. When they traverse the ureter, the stones cause significant pain (renal colic) that typically distributes on the side of the insult radiating from “loin to groin.” The ureters narrow at three points along their course to the bladder. This is a common location for renal stones to become lodged and cause pain. depending on where the ureter is being obstructed. It is not a surprise then that flank pain is typically associated with renal/urinary disorders, or that groin pain can occur. This pain will be colicky, with waves of contraction around the obstruction. Hydrate flush out, use sonar to destroy it. Tubular strucure precipitate of calcium oxylate products along way. Obstruction points: ureteropelvic junction from renal elvis, ureter draped along psoas major and iliacs, uretero-vesical junction swopping in on side as bladder fills squeezes of uretero openings as a closed point. Flank pain kidneys in back and descending down into thigh getting innervation from t10-11 and L1=2 in illinguinal and in legs referred pain pattern type of issue.
congenital renal anomalies
Altered developmental processes during the relative ascent of the kidneys from the pelvis, or fusion of the inferior poles of the kidney, can present with patterns such as horseshoe kidney. Nephrogenic ridge become adult kidneys while ascneding. Leading to potential sticking points horshoe kidney more pelvic than otherwise obstructing inferior mesentery. Simple crossed ectopia with twisted pathway sticking point for stones as well. Bifid renal pelvis and ureter are fairly common. These anomalies result from division of the metanephric diverticulum (ureteric bud), the primordium of the renal pelvis and ureter. The extent of ureteral duplication depends on the completeness of embryonic division of the metanephric diverticulum. The bifid renal pelvis and/or ureter may be unilateral or bilateral; however, separate openings into the bladder are uncommon. Incomplete division of the metanephric diverticulum results in a bifid ureter; complete division results in a supernumerary kidney. The kidneys are close together in the embryonic pelvis. In approximately 1 in 600 fetuses, the inferior poles (rarely, the superior poles) of the kidneys fuse to form a horseshoe kidney. This U-shaped kidney usually lies at the level of the L3–L5 vertebrae because the root of the inferior mesenteric artery prevented normal relocation of the kidneys. Horseshoe kidney usually produces no symptoms; however, associated abnormalities of the kidney and renal pelvis may be present, obstructing the ureter. Sometimes, the embryonic kidney on one or both sides fails to reach the abdomen and lies anterior to the sacrum. Although uncommon, awareness of the possibility of an ectopic pelvic kidney should prevent it from being mistaken for a pelvic tumor and removed. Although pheochromocytomas are relatively rare neoplasms composed largely of adrenal medullary cells, which secrete excessive amounts of catecholamines, they can occur elsewhere throughout the body associated with the sympathetic chain or at other sites where neural crest cells typically migrate. Common clinical features of pheochromocytoma include the following: Vasoconstriction and elevated blood pressure Headache, sweating, and flushing, Anxiety, nausea, tremor, and palpitations or chest pain. x
referred abdominal pain
Pain arising from a viscus such as the stomach var- ies from dull to severe. The pain is poorly localized; it radiates to the dermatome level that receives visceral sensory fibers from the organ concerned. Pain from the diaphragm radiates to two different areas because of the difference in the sensory nerve supply of the diaphragm. Pain resulting from irritation of the diaphragmatic pleura or the diaphragmatic perito- neum is referred to the shoulder region, the area of skin sup- plied by the C3–C5 segments of the spinal cord. These segments also contribute anterior rami to the phrenic nerves. Irritation of peripheral regions of the diaphragm, innervated by the inferior intercostal nerves, is more localized, being referred to the skin over the costal margins of the anterolateral abdominal wall. The iliopsoas muscle has extensive and clinically important relations to the kidneys, ureters, cecum, appendix, sigmoid colon, pancreas, lumbar lymph nodes, and nerves of the posterior abdominal wall. When any of these structures is diseased, movement of the iliopsoas usually causes pain. When intra-abdominal inflammation is suspected, the iliopsoas test is performed. The person is asked to lie on the unaffected side and to extend the thigh on the affected side against the resistance of the examiner’s hand. Pain resulting from this maneuver is a positive psoas sign. An acutely inflamed appendix, for example, will produce a positive sign. Irritable bowel syndrome (IBS) is characterized by intermittent abdominal pain, constipation, or diarrhea caused by altered motility of the bowel. IBS accounts for about 50% of all visits by patients to gastroenterologists. Referred pain is that pain appearing in areas of the body surface that send sensory impulses to the same segments of the spinal cord that receive the visceral sensory impulses from the diseased organ., one would expect epigastric pain for items supplied by the celiac artery/ganglion, periumbilical pain for items supplied by the superior mesenteric artery/ganglion, and lower abdominal pain for items supplied by the inferior mesenteric artery/ganglion. These are going to be midline pain patterns, given the developmental origin. In contrast, renal pain patterns typically lateralize, given their retroperitoneal development. As indicated by the orange diaphragmatic involvement, one can also have a somatic origin of referred pain, as phrenic nerve (C3-4-5) is sensory from diaphragm. As disease spreads to involve the parietal peritoneum and the spinal nerves, localization improves. A general rule is that a previously well patient that has severe abdominal pain for six hours may need surgery. The tables below, are not intended to be comprehensive, but to introduce you to the concept of clinicoanatomical correlations and hence, a useful starting point to remember (that should be a big hint for these being the sources of test questions!). Celiac, superior and inferior mesenteric sympathetic fibers w/ pain fibers T5-T9,11. Burning screams stomach and acid. Cramping- hollow tubes, intestine, ureters, gallstone. Tearing- AAA, esophagus (malory weis tears). Diaphragm motor and sensory with phrenic in diaphragm and upper quadrant shoulder pain C3,4,5 dermatome. Spleen up against ribs upper quadrant. Stomach differential locations depending upon build epigastric pain behind shoulder blades. Dudodenum head of pancreas epigastric region. Liver and galbladder right upper quadrant. Appendix periumbilical and right lower quadrant vast ajority developmentally of gut midgut and half of large intestine big loop innervated by superior mesenteric ganglion and lesser splanchinic nerve to periumbilical region. Cecum and ascending colon right lower quadrant type of pain. Kidney and ureter L1-L2 located in inguinal region down to genitofemoral illioinguinal. Types of pain: cramping or colicky pain: characteristic of obstruction of hollow structures, e.g., intestine, burning pain: active peptic ulceration, tearing pain: rupture of esophagus, dissecting aneurysm
Common acute abdomen categories:
acute appendicitis: initial umbilical pain; later, tenderness in the right lower quadrant (inflamed parietal peritoneum sensitive to stretching, hence rebound tenderness).
perforated peptic ulcer: sudden, severe, midepigastric in location that soon involves the entire abdomen. Board-like abdominal rigidity
acute cholecystitis: severe right upper quadrant pain, associated with nausea/vomiting.
acute pancreatitis: deep, unrelenting epigastric pain, radiating to the back
acute small intestinal obstruction: peristaltic pain, epigastric and umbilical regions
mesenteric infarct: early on in the process, pain of ischemic intestine is disproportional to minimal findings, with peritoneal signs appearing with subsequent necrosis or perforation
acute diverticulitis: intermittent left lower quadrant pain (cramping)
large bowel obstruction: gradual onset of lower abdominal cramping pain, abdominal distention
inflammatory bowel disease: Crohn disease, often in the ileal/cecal region, so RLQ; ulcerative colitis, with its rectal/distal colon predominance, often presents as LLQ referred pain
renal colic: rhythmic flank pain that radiates towards the groin, following the course of the ureter
ruptured tubal pregnancy: lower abdominal and pelvic pain, often unilateral (ectopic pregnancy will be addressed again in the pelvis and perineum)
diaphragmatic hernia
In congenital diaphragmatic hernia (CDH), part of the stomach and intestine herniate through a large posterolateral defect (foramen of Bochdalek) in the region of the lumbocostal trigone of the diaphragm. Hernia- tion almost always occurs on the left owing to the presence of the liver on the right. This type of hernia results from the complex development of the diaphragm. Posterolateral defect of the diaphragm is the only relatively com- mon congenital anomaly of the diaphragm, occurring approxi- mately once in 2,200 newborn infants. With abdominal viscera in the limited space of the prenatal pulmonary cavity, one lung (usually the left lung) does not have room to develop normally or to inflate after birth. Because of the consequent pulmonary hypoplasia (undersized lungs), the mortality rate in these infants is high (approximately 76%).
psoas abscess
An abscess resulting from tuberculosis in the lum- bar region tends to spread from the vertebrae into the psoas sheath, where it produces a psoas abscess. As a consequence, the psoas fascia thickens to form a strong stocking-like tube. Pus from the psoas abscess passes inferiorly along the psoas within this fascial tube over the pelvic brim and deep to the inguinal ligament. The pus usually surfaces in the superior part of the thigh. Pus can also reach the psoas sheath by passing from the posterior mediastinum when the thoracic vertebrae are diseased. Given the extensive attachments of psoas major to lumbar vertebrae, osteomyelitis from the lumbar vertebrae (classically tuberculosis, with MRSA now a major pathogen involved in this) can enter into the psoas fascial sheath and generate a psoas abscess that can present in the anterior thigh. Quadratus lumboran- back stabilizer, illiacus, psoas major meets with illiacus making illiopsoas creating hip flexor with deep fascial sheeth and something on vertebrae getting caught up in psoas sheath making abscess at bottom of muscle attachment commonly caused by Tb or MRSA.
abdominal surface anatomy
The umbilicus is where the umbilical cord, from the placenta, entered the fetus and is the reference point for the transum- bilical plane. It indicates the level of the T10 dermatome and is typically at the level of the IV disc between the L3 and L4 vertebrae; however, its position varies with the amount of fat in the person’s subcutaneous tissue. The linea alba is a subcutaneous fibrous band extending from the xiphoid process to the pubic symphysis that is demarcated by a mid- line vertical skin groove as far inferiorly as the umbilicus. The pubic symphysis can be felt in the median plane at the inferior end of the linea alba. The bony iliac crest at the level of the L4 vertebra can be easily palpated as it extends pos- teriorly from the anterior superior iliac spine. In an individual with good muscle definition, curved skin grooves, the semilunar lines (L. linae semilunares) demarcate the lateral borders of the rectus abdominis and rectus sheath. The semilunar lines extend from the inferior costal margin near the 9th costal cartilages to the pubic tubercles. Three trans- verse skin grooves may overlie the tendinous intersections of the rectus abdominis. The interdigitating bellies of the serratus anterior and external oblique muscles are also visible. A skin crease, the inguinal groove, indicates the site of the inguinal ligament. The groove is located just inferior and parallel to the ligament, marking the division between the anterolateral abdominal wall and thigh;
liver
The liver lies mainly in the right upper quadrant, where it is hidden and protected by the thoracic cage and diaphragm. The normal liver lies deep to ribs 7–11 on the right side and crosses the midline toward the left nipple. The liver is located more inferiorly when one is erect because of gravity. Its sharp inferior border follows the right costal margin. When the person is asked to inspire deeply, the liver may be palpated because of the inferior movement of the diaphragm and liver. Fold of liver of coronary ligaments holding it to hemidiaphragm moving up and down when breathing. Kidney lower because of liver.
pancreas and spleen
The spleen lies superficially in the left upper abdominal quad- rant between the 9th and the 11th ribs. Its convex, costal surface fits the inferior surface of the diaphragm and the curved bodies of the ribs. In the supine position, the long axis of the spleen is roughly parallel to the long axis of the 10th rib. The spleen is seldom palpable through the anterolateral abdominal wall unless it is enlarged. The neck of the pancreas overlies the L1.
kidney and ureter
The hilum of the left kidney lies near the level of the transpyloric plane, approximately 5 cm from the median plane. The transpyloric plane passes through the superior pole of the right kidney, which is approximately 2.5 cm lower than the left pole. Posteriorly, the superior parts of the kidneys lie deep to the 11th and 12th ribs. The levels of the kid- neys change during respiration and with changes in posture of 2–3 cm in a vertical direction. The kidneys are generally im- palpable. In lean adults, the inferior pole of the right kidney is palpable by bimanual examination as a firm, smooth, somewhat rounded mass that descends during inspiration. The left kidney is usually not palpable unless it is enlarged or displaced. The ureters occupy a sagittal plane that intersects the tips of the transverse processes of the lumbar vertebrae.
stomach
The surface markings of the stomach vary because its size and position change under various circumstances. The surface markings in the supine position include themarked by the angular incisure (Fig. 2.21A), which lies just to the left of the midline. • Pyloric part of the stomach: usually lies at the level of the 9th costal cartilage at the level of the L1 vertebra. The pyloric orifice is approximately 1.25 cm left of the midline. • Pylorus: usually lies on the right side. Its location varies from the L2 to the L4 vertebra. A heavily built hypersthenic individual with a short tho- rax and long abdomen is likely to have a stomach that is placed high and more transversely disposed. In people with a slender, asthenic physique, the stomach is low and verticalCardial orifice: usually lies posterior to the 6th left costal cartilage, 2–4 cm from the median plane at the level of the T10 or T11 vertebra Fundus: usually lies posterior to the 5th left rib in the mid- clavicular plane. Greater curvature: passes inferiorly to the left as far as the 10th left costal cartilage before turning medially to reach the pyloric antrum. Lesser curvature: passes from the right side of the cardia to the pyloric antrum. The most inferior part of the curvature is
nerve patterns in abdomen
Parasympathetic nervous system (cranial nerves or S2,3,4 pelvic region): mostly vagus nerve (CN X) from the medulla oblongata as the preganglionic fibers to ganglia embedded in the target organ wall, so that the very short postganglionic neurons act in a localized fashion. The sensory neurons traveling with the parasympathetic nerves are typically associated with reflexive activities. Sympathetic nervous system (T1-L2, or stop off sympathetic trunk or aortic ganglion): Splanchni nerve (greater T5-T9 fibers above sympathetic trunk, lesser T10-T11, lumbar splanchic nerves L1-L3). Represent: celiac, superior mesenteric, inferior mesenteric ganlion foregut liver spleen stomach galbladder. Midgut- small intestine half of large. Hindgut- half of large intestine. preganglionic neuron cell bodies, in the lateral horn of the spinal cord, travel via splanchnic nerves to a preaortic ganglion, from which the postganglionic neuron travels to the target. Density of pain fibers not as much as on outside body detemrine someowhere in here T5-T9. The visceral sensory nerves traveling with the sympathetic neurons are more often associated with perception of visceral pain, including from distension or from colic. The relative location of epigastric, periumbilical, or groin pain from visceral organs can be “calculated” from the sympathetic innervation of the involved organs as a result. Liver stomach T5-T9, smal intestine and colon T10-T11 periumbilical up leser splanchic nerve after duodenum halfway across colon. With the image on the right: note that the celiac ganglion supplies the embryological foregut (stomach and liver), the superior mesenteric ganglion the embryological midgut (most of the small intestine and the proximal half of the large intestine), and the inferior mesenteric ganglion the embryological hindgut (the distal large intestine).
renal embryology
The kidneys develop in their own intermediate mesoderm deep to the peritoneal cavity. Male internal genitalia hook into mesinephric ducts to supply vas deferens. Adult starts lower and ascends into mature kidney. Horsehoe kidney doesn’t make it out of pelvis. The kidneys have several stages, with the mesonephric stage supplying the future male spermatic pathway tubing (epididymis, ductus deferens, seminal vesicle), contrasting with the inferior metanephric kidney as the future adult kidney. The cloaca will contribute to the future bladder as well as a number of perineal structures. Note that there is some movement and differential growth that leads to the relative ascent of the metanephric kidney out of the pelvis. Remember that we also saw relative growth accounting for the comparative descent of the diaphragm.
abdominal imaging
radiographs of the abdomen demonstrate normal and abnormal anatomical relationships, such as those resulting from tumors. Computed tomography (CT) scans, ultrasound, and magnetic resonance imaging (MRI) studies are also used to examine the abdomi- nal viscera. MRI studies provide better differentiation than CT scans between soft tissues. Abdominal arteriography, radiography after the injection of radiopaque material directly into the bloodstream, detects ab- normalities of the abdominal arteries. Vessel studiesmay also be performed using MRI. To examine the colon, a barium enema is given after the bowel is cleared of fecal material by a cleansing enema
male vs. female pelvis
The male and female bony pelvos differ in several respects. These sexual differences are related mainly to the heavier build and larger muscles of men, and to the adaptation of the pelvis, particularly the lesser pelvis, in women for childbearing. Hence, the male pelvis is heavier and thicker than the female pelvis and usually has more prominent bone markings. Male pelvis made up of: Palpable: prostate, seminal vesciel and glands. Bladder behind pubic symphysis prostate deep to perineal membrane and muscle within is voluntary urethral sphincter. Corpus cavernosum paired, single corpus spongiosum making up glans penis head and spongyurethra penile urethra. Urinary sphincter and prostatic urethra sections of the tube. The close relationship of prostate, bladder, rectum, all superior to the perineal membrane and the deep perinea space/pouch/compartment, vs. the location of the male erectile tissue in the superficial perineal space/pouch/compartment In contrast, the female pelvis is wider and shallower and has a larger pelvic inlet and outlet. The shape and size of the pelvic inlet are significant because it is through this opening that the fetal head enters the lesser pelvis during labor. Femal pelvis: longer pubic rami, greater pubic arch angle, to create a larger pelvic inlet and pelvic outlet open inlet coccyx is pushed back. Female Pelvis made up of: Note the rectouterine pouch as the deep location of the abdominopelvic cavity, near to the vaginal posterior fornix, as well as the anteverted (overall uterine axis angled forward relative to vagina) and anteflexed (body angled forward relative to cervix) position of the uterus. Also note that the ovarian vessels are separate from the internal iliac vessels that supply the pelvic structures, reflecting the relative descent of the ovaries during development. women compared to men have shorter urethra and a straighter shot putting at higher risk of stress incontinence if disrupted supports and a shorter shot with potential communciation to outside world or urinary infections.
male vs. female internal genitalia development
Homology between male and female genitalia. Male tubinga nd female tubing different. Male tubing connected from gonad out mesonephric tubules from kidney or wolfian duct elaborate onto seminal vesciles. Females additional ducts to side or paramesenphric or mullerian ducts opening and patent w/ lumens to the side of mesonephric ducts fusing midline forming body of uterus and vagina. Fallopian tubes not directly connected to ovaries having osteon and opening w/ fimbriae around sweeping it in during ovulation. Mucus secreting gland bulbourethral or bartholomew paraski gland similar. Gubernaculum shared as male gonad goes down to scortum or pelvic position of female gonad and ovarian ligament of uterus of round ligament ending up in the labia majora. As a reminder, in the superficial perineal space are the erectile organs and associated musculature of the external genitalia. Two masses of erectile tissue are the midline bulbs (fused in males) and lateral crura (crus, singular). The bulbs are connected to the inferior surface of the perineal membrane, while the crura are attached to the inferior ischiopubic rami. In males, the urethra is surrounded by the corpus spongiosum, or tubular prolongation of the bulb of the penis. At its tip the corpus spongiosum expands into the glans penis (head), with the penile crura alongside extending as corpora cavernosa that are more dorsal to the ventral corpus spongiosum. In females, homologous erectile tissues contribute to the clitoris. Glans penis, glans cliterus Prepuce in both Scrotum and labia majora Urogenital groove stays patent vestibule and vaginal groove, Midline groove running down shaft of penis creating continuosu cylinde
pelvic fractures
Pelvic fractures can result from direct trauma to the pelvic bones, such as may occur during an automobile accident, or from forces transmitted to these bones from the lower limbs during falls on the feet. Pelvic fractures may cause injury to pelvic soft tissues, blood vessels, nerves, and organs. Clinically, the term pelvic fractures is used to describe fractures of the pelvic ring and does not typically include acetabular fractures, which are a separate type of fracture, usually from high-impact falls or automobile crashes. Pelvic fractures may be high or low impact; high-impact fractures often involve significant bleeding and may be life threatening. Pelvic ring fractures are classified as stable, involving only one side of the ring, or unstable, involving both parts of the pelvic ring. Given the strength of the pelvis, it is not surprising that pelvic fractures typically occur after high force impact, e.g., motor vehicle accident, or in the elderly, e.g., from a standing position. Extensive vascularity from the internal iliac vessels lining the inside of the pelvis will often lead to high levels of bleeding from a pelvic fracture. Unstable pelvic problems with weight bearing damage to stuff in pelvic brim and abdomen. Internal illiac vessels against wall in true pelvis passabilities w/ fracture possibly compromising.
pelvic floor
Inside the pelvis, the layer we knew in the abdomen as transversalis fascia continues downward from the abdominal cavity, becoming obturator fascia when it covers the obturator internus muscle. Along down the inner surface of obturator internus muscle, muscle fibers spring from the obturator fascia to form a thin muscular cone, the levator ani muscle, the main muscle of the pelvic diaphragm. Fascia covering bladder, uterus, pelvic opening- all transversalis fascia and convertted becomes obturator fascia covering obturator internus then goes out to greater trocanter of the hip. Major muscle support in pelvic outlet levator ani helps cover up. Puborectalis slings around rectum force against rectum against sternal anal sphincter to prevent s-spilling. Smaller coccygeas muscle connects to coccys. Piriformis hip rotator near sciatic. Perineal membrane before obturator itnernus along with voluntary urethral sphincter.
pelvic floor injuries
During childbirth, the pelvic floor supports the fetal head while the cervix of the uterus is dilating to permit delivery of the fetus. The perineum, levator ani, and pelvic fascia may be injured during childbirth. In addition, thickenings of pelvic fascia that help to support the cervix, e.g., the transverse cervical (cardinal) ligaments, can also be impacted with pelvic trauma. Pelvic fascia overall, other cervical ligaments, and the perineal body may be injured. Episiotomy has been considered useful to minimize such injury in an instrument-assisted delivery, but the episiotomy cut is not used as routinely during delivery as was previously. Uterus and vagina is smooth muscle and distendible, perineal setup with bowl shaped structure between pubic symphysis ischial tuberosity and… levator ani supporting everything. Perineal membrane superficial to anal sphincter ties in thicking of perineal membrane with superior anal sphincter and perineal body arch point where a lot of forces are brought together at edge of vagina nd anal and a tear weakens support of urogenital triangle and anal triangle of perineum rupturing into rectum and lacerations. Epiosiotomy posterolateral to have controlled distention space and stearing away from rectum and perineal body much less popular. Having cleaner laceration that is sewable if postnatal care and hangup with vaginal distention not having to cut. Disruption of muscular and fascial support.
stress incontinence
It is the pubococcygeus, the main intermediate part of the levator ani, that is usually torn. This part of the muscle is important because it encircles and supports the urethra, vagina, and anal canal. Weakening of the levator ani and pelvic fascia resulting from stretching or tearing during childbirth may alter the position of the neck of the bladder and urethra. These changes may cause urinary stress incontinence characterized by dribbling of urine when intra-abdominal pressure is raised during coughing and lifting, for instance. One of the outcomes of the stretching or damage to pelvic fascia can be stress incontinence. The short urethra of women depends on a “sling-like” support of pubocervical fascia to help maintain closure. The position of the urethra may be altered such that increased intra-abdominal pressure can lead to dribbling urine. Fascial thickening around cervix and urethra. Involuntary smooth msucle sphincter and voluntary smooth muscle sphincter because of how it is straight down with fascia covering and holding it in. Fascial thickening called ligaments becoming distinct with fascial sling increasing intraabdominal pressure kink off urethra to prevent gushing, if repeated childbirth fascia stretched and torn sphinccter keep from leaking raised pressure causes gush of urine. Involuntary loss of urine after an increase in intraabdominal pressure is often associated with a weakening of the support structures of the pelvic floor, including the following: Medial and lateral pubovesical ligaments, Pubovesical fascia at the urethrovesical junction (blends with the perineal membrane and body), Levator ani (provides support at the urethrovesical junction), Functional integrity of the urethral sphincter. Common predisposing factors for stress incontinence include multiparity, obesity, chronic cough, and heavy lifting.
uterine prolapse
A more dramatic outcome with loss of cervical support, and particularly with stretching or damage to levator ani, can be uterine prolapse. Uterine prolapse- women with a little bit of prolapse beceuase of levator ani stretched and other ligaments distended. Transverese and uterosacral reaching around back neck of cervix holding things into place. Chronic raised intraabdominal pressure due to obesity have some descent or frank prolapse also presses on bladder occluding it. Wedge or pesery or vaginal inser to support it upward, tac back in, hysterectomy. Uterine prolapse may occur when the support structures of the uterus, especially the cardinal ligaments, uterosacral ligaments, and levator ani muscle, are weakened. prevlant in parous women, in late reproductive and older age groups with risk from birth trauma, obesit, chronic cough, lifting, and weak ligaments
episiotomy
During vaginal surgery and labor, an episiotomy (surgical incision of the perineum and inferoposterior vaginal wall) may be made to enlarge the vaginal orifice with the intention of decreasing excessive tearing of the perineum and perineal muscles. Episiotomies are still performed in a large portion of vaginal deliveries. It is generally agreed that episiotomy is indicated when descent of the fetus is arrested or protracted, when instrumentation is necessary (e.g., obstetrical forceps), or to expedite delivery when there are signs of fetal distress. However, routine prophylactic episiotomy is widely debated and declining in frequency. Occasionally, if there is danger of significant tearing of the perineal body during childbirth, the physician may perform an incision called an episiotomy to enlarge the vaginal opening to accommodate the head of the fetus. Despite the fact that nearly every primiparous birth results in at least a minor injury to the vagina, perineum, or vulva, routine episiotomy is performed much less frequently than it was several decades ago. When performed, episiotomies usually are either directly in the midline through the perineal body or posterolateral, to avoid the perineal body.
cystoscopy
The interior of the bladder and its three orifices can be examined with a cystoscope, a lighted tubular endoscope that is inserted through the urethra into the bladder. The cystoscope consists of a light; an observing lens; and various attachments for grasping, removing, cutting, and cauterizing. Benign prostatic hypertrophy (BPH) occurs in about 20% of men by age 40, increasing with age to 90% of males older than 80. BPH is really a nodular hyperplasia, not hypertrophy, and results from proliferation of epithelial and stromal tissues, often in the periurethral area. This growth can lead to urinary urgency, decreased stream force, frequency, and nocturia. Symptoms may necessitate transurethral resection of the prostate (TURP), in which the obstructing periurethral part of the gland is removed using a resectoscope.
BPH
The prostate is of medical interest because be- nign enlargement or benign hypertrophy of the prostate (BHP) is common after middle age. An enlarged prostate projects into the urinary bladder and impedes urination by distorting the prostatic urethra. The middle lobule usually enlarges the most and obstructs the internal urethral orifice. Prostatic cancer is common in men older than 55 years of age. In most cases, the cancer develops in the postero- lateral region. This may be palpated during a digital rectal examination (Fig. B3.3). A malignant prostate feels hard and often irregular. In advanced stages, cancer cells metas- tasize (spread) to the iliac and sacral lymph nodes and later to distant nodes and bone. The prostatic plexus, closely as- sociated with the prostatic sheath, gives passage to para- sympathetic fibers, which give rise to the cavernous nerves that convey the fibers that cause penile erection. A major concern regarding prostatectomy is that impotency may be a consequence. All or part of the prostate, or just the: Uvula, Internal urethral orifice, Internal urethral sphincter, Opening of prostatic utricle, Opening of ejaculatory duct, Seminal colliculus, Openings of prostatic ducts into prostatic sinus, Urethral crest Bulbo-urethral gland, Intermediate part of urethra, Anterior view. The two pea-size bulbo-urethral glands (Cowper glands) lie posterolateral to the intermediate part of the urethra, largely embedded within the external urethral sphincter . The ducts of the bulbo-urethral glands pass through the perineal membrane adjacent to the intermediate urethra and open through minute apertures into the proximal part of the spongy urethra in the bulb of the penis. Their mucus-like secretion enters the urethra dur- ing sexual arousal, contributing less than 1% of semen. hypertrophied part, is removed (transurethral resection of the prostate [TURP]). Benign prostatic hypertrophy (BPH) occurs in about 20% of men by age 40, increasing with age to 90% of males older than 80. BPH is really a nodular hyperplasia, not hypertrophy, and results from proliferation of epithelial and stromal tissues, often in the periurethral area. This growth can lead to urinary urgency, decreased stream force, frequency, and nocturia. Symptoms may necessitate transurethral resection of the prostate (TURP), in which the obstructing periurethral part of the gland is removed using a resectoscope.
rectal exam
Many structures related to the antero-inferior part of the rectum may be palpated through its walls (e.g., the prostate and seminal glands in males and the cervix in females). In both sexes, the pelvic surfaces of the sacrum and coccyx may be palpated. The ischial spines and tuberosities may also be palpated. Enlarged internal iliac lymph nodes, pathological thickening of the ureters, swellings in the ischio-anal fossae (e.g., ischioanal abscesses and abnormal contents in the rectovesical pouch in the male or the recto-uterine pouch in the female) may also be palpated. Tenderness of an inflamed appendix may also be detected rectally if it descends into the lesser pelvis (pararectal fossa). While cystoscopy can offer a view of urethra and urethral openings, as well as the internal bladder, digital rectal exam can lead to palpation of the prostate, and possibly the seminal vesicles (glands). The nodularity of prostate cancer, typically originating in the posterior lobe, or the firm enlargement of benign prostatic hyperplasia (BPH) involving the middle lobe, can both be appreciated. Relax Digitorectal exam with prostatic view palpating posterior of prostate comes into play w/ seminal vesciel, gland. Prostate issues older male, prostatic hyperplasia or cancer from a digitorectal exam view prostatic cancer more peripheral palpating posterior can pick up a nodule w/ a capsule like endometrial slow growing and fairly ensconced pick it up before it had a chance to lymphatically spread. Benign hydroplastic hyperplasia with firm smooth msucle prostate and fibrous interwoven in prostate composed of glands (prostate specific antigen enzyme prvent coagulation of sperm) actively growing part of prostate w/ hyperplasia around urethra hesitancy dificulty voiding might feel enlarged along way.
pelvic examination
Following inspection of superficial structures, given the distensibility of the vagina, a speculum is used to visually inspect the cervix and the vagina as part of a pelvic examination to enable inspection of the cervix and obtain a Pap smear. Identify cervical component of uterus bent forward over top of bladder and cervix is aiming forward or anteverted normal tilt prevent forces of gravity. If it was posterior when standing would be easier to prolapse. Slit shaped indicating the person had at least had one child. Underneath labia majora had erectile tissue and bartholin glands or entroitus of vagina with infection occuring golf ball or larger. Distensible structures down in region, opening to outside world has to consider infection and long term drainage to something infected and large will get ongoing drip. A bimanual exam can help to determine uterus and adnexae dimensions as well as tenderness. As this image indicates, the uterus is typically anteverted and anteflexed. Epithelial combination of stratified squamous epithelium and columnar epithelium as you go into cervix. HPV basal layer multiply along with cell and further out statified squamous epithelium becoming warts or anogenital warts becoming cervical cancer as strains seperately multiple and proliferate along with cells they invade integrated into cell genome. Slow growing gives us opportunity to sample histoloically or DNA sampling to pick it up before cervical cancer can proliferate.
pap smear
A spatula is placed on the external os of the uterus and rotated to scrape cellular material from the vaginal surface of the cervix. This is followed by insertion of a cytobrush into the cervical canal that is used to gather cellular material from the supravaginal cervical mucosa. The cellular material is placed on glass slides for microscopic examination. A Pap smear (Papanicolaou test) can be part of the speculum exam, allowing histological examination of altered epithelial cells, or other localized tests of the cervical epithelia, e.g., viral DNA testing for HPV (human papillomavirus). Pap smear and prepare on slide, pinching and feeling between ovary or almond sized item and not a large cyst above uterus.
distention of the vagina
The vagina can be markedly distended by the fetus during childbirth, particularly in an anteroposterior direction. Lateral distention of the vagina is limited by the ischial spines, which project posteromedially, and the sacrospinous ligaments extending from these spines to the lateral margins of the sacrum and coccyx. The interior of the vagina can be distended for examination using a vaginal specu- lum (Fig. B3.4). The cervix, ischial spines, and sacral promon- tory can be palpated with the gloved digits in the vagina and/ or rectum (manual pelvic examination).
endometriosis
Endometriosis is a progressive benign condition characterized by ectopic foci of endometrial tissue, called implants, that grow in the pelvis—on the ovaries and in the rectouterine pouch, uterine ligaments, and uterine tubes—or in the peritoneal cavity. As with the uterine lining, these estrogen-sensitive ectopic implants can grow and then break down and bleed in cycle with the woman’s normal menstrual cycle. The endometrial lining of the uterus is partially shed in menstruation (or may spread into the pelvis and beyond as endometriosis), which along with pelvic inflammatory disease (PID) and ectopic pregnancy, is a major consideration in pelvic pain. Retrograde flow, altered immunological response to tissue, hematogenous or lymphatic spread, or even metaplasia (change from one tissue type to another as we saw in Barrett esophagus) have all been implicated. Retrograde flow with endotrial lining if apparently normal tissue having menstrual pattern within uterine cavity common spots ovaries, rectouterine pouch, various scatter backflow w/ clumps of endometrial tissue spread or metaplasia transition of one structure to another from gastric to pelvic can show up in lung. Bleeding and inflammatory response hampering fertilization, Because might come up in deposition on ovaries doing localized laparoscopic can cut down enough on load that it can be restored manipulative activity forming adhesions. Open patency of fallopian tube retrouterine ppouch very easily come up on.
culdocentenesis
An endoscopic instrument (culdoscope) can be inserted through an incision made in the posterior part of the vaginal fornix into the peritoneal cavity to drain a pelvic abscess (collection of pus) in the rectouterine pouch ( culdocentesis). Similarly, fluid in this part of the perineal cavity (e.g., blood) can be aspirated at this site
hysterectomy
Hysterectomy (excision of the uterus) is performed through the lower anterior abdominal wall or through the vagina (Fig. B3.5). Because the uterine artery crosses anterior to the ureter near the lateral fornix of the vagina, the ureter is in danger of being inadvertently clamped or severed when the uterine artery is tied off during a hysterectomy. The point of crossing of the artery and the ureter is approximately 2 cm superior to the ischial spine.
dysfunctional uterine bleeding
Dysfunctional uterine bleeding (DUB) involves an irregular cycle or intermenstrual bleeding (painless) with no clinically identifiable cause. The etiology and pathogenesis are extensive and include local uterine, ovarian, or adnexal disorders, as well as systemic and pregnancy-related disorders. Hormonal imbalance is a common cause.
fibroids
Leiomyomas are benign tumors of smooth muscle and connective tissue cells of the myometrium of the uterus. These “fibroids” are firm and can range in size from 1 to 20 cm. The composite drawing shows various sizes and sites of potential leiomyomas. Smooth muscle leiomyomas (fibroids) of the myometrium of the uterus are benign, but may cause symptoms because of their size or position. Whirls of smooth muscle benign swirl circumsribed are impacting with one large fibroid myelooma distended abdomen submucosa filling up endometrium pedunculated or torsion can create pelvic pain in that orientation may not have symptomatology depending upon where growing.
cervical cancer
Cervical cancer as triggered by HPV infection initially spreads locally and slowly and so can be monitored by Pap smears. Local extension of cervical cancer can affect organs such as the ureters, the bladder, and the rectum. HPV inserting itsel fin oncogenetic strains doesn’t insert correctly w/ cancer screening picking it up mostly on cervical surface where after speculum exam can visualize it or glandular columbar epithelium in cervical canal to sample pap smear to find item if inside uterus. If werent identified and keep going rectum and bladder nearby ureter even if metastatically spread could spread.
endometrial cancer
Endometrial carcinoma is the most common malignancy of the female reproductive tract. It often occurs between the ages of 55 and 65 years, and risk factors include the following: • Obesity (increased estrogen synthesis from fat cells without concomitant progesterone synthesis) • Estrogen replacement therapy without concomitant progestin • Breast or colon cancer • Early menarche or late menopause (prolonged estrogen stimulation) • Chronic anovulation • No prior pregnancies or periods of breastfeeding • Diabetes Endometrial cancer may penetrate locally within the uterine cavity before wider spread, and present as postmenopausal bleeding. For both cervical cancer and endometrial cancer, hysterectomy is typically involved. As seen in lab, the ureter is under/posterior to the uterine vessels in the broad ligament near the lateral fornix of the vagina, and so needs to be isolated during the procedure. Most common gyenocological cancer more challenging because thick myometrium srrounding endometiral cavity so not a lot of symptomatology having abnormal bleeding, older women most common postmenopausal vague pelvic bone muscle only not perhaps spreading due to open patency of fallopian tubes may be getting ghematogenous spread from uterine vessels off of illiac onto pelvic nodes and wall. Once it gets to ovaries easy to spread to pelvis.
ovarian cancer
Ovarian cancer is the most lethal cancer of the female reproductive tract. From 85% to 90% of all malignancies occur from the surface epithelium, with cancerous cells often breaking through the capsule and seeding the peritoneal surface, invading the adjacent pelvic organs, or seeding the omentum, mesentery, and intestines. Additionally, the cancer cells spread via the venous system to the lungs (ovarian vein and inferior vena cava) and liver (portal system) and via lymphatics. Risk factors include the following: • Family history of ovarian cancer • High-fat diet • Age • Nulliparity • Early menarche or late menopause (prolonged estrogen stimulation) • White race • Higher socioeconomic status. In contrast to cervical or endometrial cancer, ovarian cancer often spreads throughout the peritoneal cavity by the time of presentation, given the communicating position of the ovaries. Pelvic discomfort because challenge of ovary several fold not buried unexposed w/in pelvic cavity communicating w/ abdominal cavity testis and ovary drag lymphatic vessels down from lumbar region ovarian vein to inferior vena cava and communicationg to rest of body there migrating up to lumbar region where it is hard to palpate with epithelial origin malignant cells in peritoneal fluid over omentum, pericaldrum gutters and intestines of play. Killig people w/ ovarian cancer due to GI metastasize of blowing up of stomach or bowels or lack of function. Bigger and worse presentation.
tubal ligation
Ligation of the uterine tubes is a surgical method of birth control. Abdominal tubal ligation is usually performed through a short suprapubic incision at the pubic hairline. Laparoscopic tubal ligation is done with a laparoscope, which is similar to a small telescope with a powerful light. It is inserted through a small incision, usually near the umbilicus.
regional pelvic anesthesia
Several types of regional anesthesia are used to reduce pain during childbirth. Lumbar epidural and low spinal blocks anesthetize somatic and visceral afferent fibers distributed below waist level, not only anesthetizing the uterus, entire birth canal, and perineum but also the lower limbs. A caudal epidural block is a popular choice for participatory childbirth. It must be administered in advance of childbirth, which is not possible with precipitous birth. The anesthetic agent is administered using an indwelling catheter in the sacral canal, enabling administration of more anesthetic agent for a deeper or prolonged anesthesia if necessary. Within the sacral canal, the anesthesia bathes the S2–S4 spinal nerve roots, including visceral pain fibers from the uterine cervix and upper vagina, and somatic pain fibers of the pudendal nerve. Thus, the birth canal is anesthetized but the lower limbs are not usually affected. Because visceral pain fibers to the uterine fundus ascend to lower thoracic and upper lumbar spinal levels, they are also not affected and sensations of uterine contraction are still perceived. Ischioinguinal enrve before spraying over labia majora. Pudendal nerve blocks (C) and local infiltration of the perineum provide only somatic anesthesia of the perineum. Cpature pudendal nerve before spraying across ischioanal fossa. Much of the lymphatic drainage of the pelvis parallels the venous drainage and drains into lymph nodes along the internal iliac vessels. The major exception is the drainage from the ovaries and the adjacent uterine tubes and upper uterus, and from the testes and scrotal structures, which flows directly back to the aortic (lumbar) nodes of the midabdomen. Because some lymph from the uterus may drain along the round ligament of the uterus to the inguinal nodes, In terms of regional anesthesia, there are several considerations. Local anesthesia for the perineum would include infiltration of anesthetic at both the pudendal and ilioinguinal nerves. Pelvic anesthesia usually epidural putting needle as far as epidural space and not cerebrospinal fluid less chance of headache at LL4-L5 potentially around L4-L5 knocking out several but not all nerves along way. Ilioinguinal nerve came off of L1, pudendal nerve S2,3,4 keeps things off floor. Numb L1,4,5 might have to numb higher epidural to catch ilioinguinal nerve may get distended during delivery. Referred pain patterns T12, L1, L2 cramping contraction up there blocking out sacrum. Ventral and dorsal forami sacral nerves come out of them gap above coccyx or sacral hiatus can do caudal epidural block infiltrating witihin hiatal region getting into Ss below pelvic pain line but wont impact cramping of distended uterus.
PID (Pelvic Inflammatory Disease)
Recurrent or chronic infections of the uterine tubes or other adnexa (uterine appendages) result in cystic dilation (hydrosalpinx) and can account for approximately 40% of female infertility cases. Chronic pelvic inflammatory disease (PID) can cause scarring, causing problems with fertility, pelvic pain, or tubal (ectopic) pregnancy. The most affected age group is 15 to 25 years of age, and risk factors include the following: • Early sexual activity • Failure to use condoms • Multiple sexual partners • Sexually transmitted diseases (STDs) Unilateral or bilateral adnexal masses are usually sausage shaped and may be palpable. The open communication along the female reproductive tract can lead to the spread of disease from more external organs, e.g., pelvic inflammatory disease (PID), commonly with sexually transmitted organisms that generate a strong inflammatory response, such as the Gram-negative diplococcus Neisseria gonorrhoeae or the intracellular pathogen Chlamydia trachomatis.
urethral trauma
Fractures of the pelvic girdle often cause a rupture of the intermediate part of the urethra. This results in extravasation of urine and blood into the deep perineal pouch. The fluid may pass superiorly through the urogenital hiatus and distribute extraperitoneally around the prostate and bladder. Rupture of the spongy urethra in the bulb of the penis results in urine passing (extravasating) into the superficial perineal space. The attachments of the perineal fascia determine the direction of flow of the extravasated urine. Urine and blood may pass into the loose connective tissue in the scrotum, around the penis, and superiorly, deep to the membranous layer of subcutaneous connective tissue of the inferior anterior abdominal wall. The urine cannot pass far into the thighs because the membranous layer of superficial perineal fascia blends with the fascia lata (deep fascia) enveloping the thigh muscles, just distal to the inguinal ligament. In addition, urine cannot pass posteriorly into the anal triangle because the superficial and deep layers of perineal fascia are continuous with each other around the superficial perineal muscles and with the posterior edge of the perineal membrane between them. Although rare, direct trauma to the corpora cavernosa can occur. Rupture of the thick tunica albuginea usually involves the deep fascia of the penis (Buck’s fascia), and blood can extravasate quickly, causing penile swelling. Urethral rupture is more common and involves one of three mechanisms: • External trauma or a penetrating injury • Internal injury (caused by a catheter, instrument, or foreign body) • Spontaneous rupture (caused by increased intraurethral pressure or periurethral inflammation)
urinary extravasation
Rupture of the male urethra can lead to urine extravasation into various pelvic or perineal spaces that are largely limited by the perineal, pelvic, and lower abdominal wall fascial planes. The superficial fascia on the abdominal wall has a superficial fatty layer and a membranous deep layer. In the perineum, the deep membranous layer is known as Colles fascia. Colles fascia is connected to the posterior and lateral edges of the perineal membrane. Hence, if the penile bulb or spongy urethra is hurt in a straddle injury, extravasated urine and blood will accumulate inferior to the perineal membrane in the superficial perineal space (pouch), but not spread into the thighs or towards the anus. Conversely, trauma to the prostate, as with transurethral prostatectomy (TURP), can lead to extravasation within the pelvic cavity, as contained by the pelvic fascia. Crushing injuries of external genitalia onto pubic symphysis, big prostate w/ foley catheter prostate rupture perineal membrane and muscle blood is trapped in them. Badder smooth and such due to lots of fat and fascia hold it all into place so when this happens raises ballder. Tom sawyer bad day w/ white picket fence if rupture superficial perioneal space rupturing corpus cavernosum. Perineal membrane prevent baclkleakage tying into fascia on top of the thigh (fascialotta- lot of fascia). Potential spaces get identified and fill w/ blood. Urinary extravasation rptured through deep fascia through three deep penile cylinders leaking in membranous fascia trap between deep muscle up abdominal walla nd looser connective tissue and skin around penis or bleeding into and around scrotum. Scarpa and camper fascia different names deeper in pelvis. Wrinkling of scotum dartos muscle taking over fatty part of fascia wrinkle or relax scortumdepending upon temperature, A lot of anatomy potential space identified by more fluids or portal hypertension or closeby approximations overutilized because of blockage to normal flow.
ischioanal abscess
The ischio-anal fossae are occasionally the sites of infection, which may result in the formation of ischio-anal abscesses. These collections of pus are painful. Diagnostic signs of an ischio-anal abscess are fullness and tenderness between the anus and the ischial tuberosity. A peri-anal abscess may rupture spontaneously, opening into the anal canal, rectum, or peri-anal skin.fat-filled presence of the ischioanal fossa. The ischioanal fossa, through which pudendal nerve and internal pudendal artery and vein travel, allows for expansion of pelvic/anal contents. Anal glands open at the pectinate line, and if they are obstructed and infected, can lead to perianal and ischioanal abscesses. Pectinate lines w/ anal folds, really well developed anal glands less devleoped in humans. Potential vulnerabiity to migrate our way through mucosa if there is a weak spot things will happen. Chronic strain, bacterial infestation after external anal sphincter into ischial anal fossa internal artery, vein, or nerve right by creating a fossa.
hemorrhoids
Internal hemorrhoids (“piles”) are prolapses of the rectal mucosa containing the normally dilated veins of the internal rectal venous plexus. They are thought to result from a breakdown of the muscularis mucosae, a smooth muscle layer deep to the mucosa. Internal hemorrhoids that prolapse through the anal canal are often compressed by the contracted sphincters, impeding blood flow. As a result, they tend to strangulate and ulcerate. Owing to the presence of abundant arteriovenous anastomoses, bleeding from internal hemorrhoids is usually bright red. External hemorrhoids are thromboses (blood clots) in the veins of the external rectal venous plexus and are covered by skin. Predisposing factors for hemorrhoids include pregnancy, chronic constipation, and any disorder that impedes venous return, including increased intra-abdominal pressure. The anastomoses among the superior, middle, and inferior rectal veins form clinically important communications between the portal and the systemic venous systems (Fig. 3.48). The superior rectal vein drains into the inferior mesenteric vein, whereas the middle and inferior rectal veins drain through the systemic system into the inferior vena cava. Any abnormal increase in pressure in the valveless portal system or veins of the trunk may cause enlargement of the superior rectal veins, resulting in increase in blood flow or stasis in the internal rectal venous plexus. In portal hypertension, the portocaval anastomosis among the superior, middle, and inferior rectal veins, along with portocaval anastomoses elsewhere, may become varicose. It is important to note that the veins of the rectal plexuses normally appear varicose (dilated and tortuous) and that internal hemorrhoids occur most commonly in the absence of portal hypertension. Because visceral afferent nerves supply the anal canal superior to the pectinate line, an incision or a needle insertion in this region is painless. However, the anal canal inferior to the pectinate line is quite sensitive (e.g., to the prick of a hypodermic needle) because it is supplied by the inferior rectal nerves, containing somatic sensory fibers.Hemorrhoids (piles) are symptomatic varicose dilations of submucosal veins that protrude into the anal canal and can extend through the anal opening (external hemorrhoid). Hemorrhoids can bleed; the blood may pool and clot, yielding a “thrombosed” hemorrhoid. Anal columns and the associated pectinate line indicate the difference between painless internal hemorrhoids and painful external hemorrhoids, as this region of the anal canal represents the merger point between endodermal and ectodermal structures, and hence, visceral sensory vs. somatic sensory innervation. There is also a potential portocaval venous connection, as the superior rectal vein drains into inferior mesenteric veins, while the middle and inferior rectal veins seen here will drain back via the internal iliac vein to the IVC. Exposure to bacteria as well as outside world have entry highly vascularized for WBCs, some hurt a lot more than others dependig upon ectoderm meets up w/ endoderm and innervation off of body wall compared to refferred and viscerall. Internal hemmorhoids compared to external hemmerhoid lines, which hurt more than external. Internal pudendal artery and vein pudendal nerve through ischioanal fossa separate sets of internal and external hemmorhoids, inferior rectal vein vs. superior rectal vein superior mesenteric artery and vein becoming part of portal system or tie in is hemmoroids long after esophageal varicoses. Can cause emergency if thrombosed. Preparation H can shirnk muscles so not engorged.
hypospadias
Hypospadias and epispadias are congenital anomalies of the penis. Hypospadias is much more common (1 in 300 male births, but this figure varies widely from country to country) and is characterized by failure of fusion of the urogenital folds, which normally seal the penile (spongy) urethra within the penis. The defect occurs on the ventral aspect of the penis (corpus spongiosum). Hypospadias may be associated with inguinal hernias and undescended testes. Failure of the developmental ventral fusion of urethral folds results in hypospadias. The degree of severity of hypospadias is demonstrated on the location of the location of the external urethral meatus.
epispadias
Epispadias is rare (1 in 120,000 male births) and is characterized by a urethral orifice on the dorsal aspect of the penis. It is thought to occur from a defective migration of the genital tubercle primordia to the cloacal membrane early in development (fifth week). The rarer dorsal impact of epispadias is often associated with bladder malformation (exstrophy) as its developmental basis is earlier, e.g., at the point of formation of the lower abdominal wall, the cloacal membrane, and the genital tubercle. Could get ventral orifice if whole thing doesn’t combine. Bladder and genital tubercle more dramatic or rarer situation of epispadius bladder plus genital tubercle having issues forming bladder or urethra indicating. Urination could have been scarring or scarring or cording perodi disease of scrring or fibrosis of penis distorted or distended.
urethral catheterization
Urethral catheterization is performed to remove urine from a person who is unable to micturate. It is also performed to irrigate the bladder and to obtain an uncontaminated sample of urine. When inserting the catheters and urethral sounds (slightly conical instruments for exploring and dilating a constricted urethra), the curves of the male urethra must be considered.
erectile dysfunction
Inability to obtain an erection (impotence) may result from several causes. When a lesion of the prostatic plexus or cavernous nerves results in an inability to achieve an erection, a surgically implanted, semirigid, or inflatable penile prosthesis may assume the role of the erectile bodies, providing the rigidity necessary to insert and move the penis within the vagina during intercourse. Erectile dysfunction (ED) may occur in the absence of a nerve insult. Central nervous system (hypothalamic) and endocrine (pituitary or testicular) disorders may result in reduced testosterone (male hormone) secretion. Autonomic nerve fibers may fail to stimulate erectile tissues, or blood vessels may be insufficiently responsive to stimulation. In many such cases, erection can be achieved with the assistance of oral medications or injections that increase blood flow into the cavernous sinusoids by causing relaxation of smooth muscle. Erectile dysfunction (ED) is an inability to achieve and maintain penile erection sufficient for sexual intercourse. Its occurrence increases with age, and some of the probable causes are illustrated. Normal erectile function occurs when a sexual stimulus causes the release of nitric oxide from nerve endings and endothelial cells of the corpora cavernosa, thus relaxing the smooth muscle tone of the vessels and increasing blood flow into the erectile tissues. As the erectile tissue becomes engorged with blood, it compresses the veins in the tunica albuginea so that the blood remains in the cavernous bodies. The available drugs to treat ED aid in relaxing the smooth muscle of the blood vessels of the erectile tissues. Erectile dysfunction can also occur from damage to the nerves innervating the perineum (e.g., a complication of prostatic surgery). Afferent impulses conveying stimulation/arousal sensations are conveyed by the pudendal nerve (S2-S4, somatic fibers), whereas the autonomic efferent innervation of the cavernous vasculature is via the pelvic splanchnics (S2-S4, parasympathetic fibers). As a reminder, parasympathetic innervation from S 2,3,4 will drive erection by relaxing trabecular smooth muscle in the erectile tissue. Disruption of autonomic, hormonal, or vascular function can lead to erectile dysfunction. Erectile dysfunction- autonomic activity in erectile tissue penile or clitoral, parasympathetic allow feeling, sympathetic ejaculation. Blood filled cylinder corpus cavernosum and spongiosum must be able to relax smooth muscle allowing filling from vessels once feed in with one way valve compressing off venules preventing egress (chronic venous obstruction) engorging cylinders deep fascia surrounding It. Interfering w/ blood flow or autonomic inenrvation have problems w/ erectile dysfunction through athreoscleoris shypertension and diabetes, autonomic nervous system if stimulated too much alpha 1 vasoconstriction or sympathetic stress cutting off blood before it gets down there. Damage to nerves coming in or spinal cord superior to S2,3,4 can notice from schematic, deep perineal muscle w/ prostate deep to that and autonomic plexus of lumbar sacral nerve more sympathetic and pelvic splachnic. Parasympathetic S2,3,4. prostatic surgery chance of hitting into blood supply and nerve supply could nick or injure those affecitng ED.
male circumcision and indications
An uncircumcised prepuce covers all or most of the glans penis. The prepuce is usually sufficiently elastic to allow retraction over the glans. In some males, it is tight and cannot be retracted easily (phimosis), if at all. Secretions (smegma) may accumulate in the preputial sac, located between the glans penis and prepuce, causing irritation. In some cases, retraction of the prepuce constricts the neck of the glans so that there is interference with the drainage of blood and tissue fluid (paraphimosis). The glans may enlarge so much that the prepuce cannot be distracted. Circumcision, surgical excision of the prepuce, must be performed. Circumcision exposes most, or all, of the glans and is the most common minor surgical operation performed on male infants. Although it is a religious practice in Islam and Judaism, it is often done routinely for nonreligious reasons. Male circumcision is the removal of the foreskin of the penis. Generally, this is not a medically indicated procedure but is done at the request of the parents or because of a religious preference. he prepuce will cover the glans penis, and is removed with circumcision. While typically an infant procedure, circumcision may be required with inability to retract the foreskin (phimosis) or constriction from a retracted foreskin (paraphimosis).
Bartholin gland infection
The greater vestibular glands (Bartholin glands) are usually not palpable, except when infected. Bartholinitis, inflammation of the greater vestibular glands, may result from a number of pathogenic organisms. Infected glands may enlarge to a diameter of 4–5 cm and impinge on the wall of the rectum. Normally, the greater vestibular glands (Bartholin glands) are not visible or palpable, as they provide mucus at the vaginal orifice. If a cyst or abscess forms, they can become enlarged or tender.
pelvic imaging
MRI provides excellent evaluation of male and female pelvic structures. It also permits the identification of tumors and congenital anomalies. The female pelvis is commonly examined using ultrasonography. The viscera may be examined by placing a transducer on the lower abdomen, just superior to the pubic symphysis. For the nongravid uterus, the full bladder serves as an acoustical “window,” conducting transmitted and reflected sound waves to and from the viscera, the uterus retroverted by the full bladder. Currently, viscera is studied most often by means of a slender transducer passed into the vagina. Ultrasonography is the procedure of choice for examining the developing embryo and fetus.
abdominal aortic aneurysm
Rupture of an aneurysm (localized enlargement) of the abdominal aorta causes severe pain in the abdomen or back. If unrecognized, a ruptured aneurysm has a mortality rate of nearly 90% because of heavy blood loss. Surgeons can repair an aneurysm by opening it, inserting a prosthetic graft (such as one made of Dacron), and sewing the wall of the aneurysmal aorta over the graft to protect it. Aneurysms may also be treated by endovascular catheterization procedures. Aneurysms (bulges in the arterial wall) usually involve the large arteries. The multifactorial etiology includes family history, hypertension, breakdown of collagen and elastin within the vessel wall (which leads to inflam- mation and weakening of the arterial wall), and atherosclerosis. The abdominal aorta (infrarenal segment) and iliac arteries are most often involved, but the thoracic aorta and the femoral and popliteal arteries can also have aneurysms. Symptoms include abdominal and back pain, nausea, and early satiety, but up to 75% of patients may be asymptomatic. If surgical repair is warranted, an open procedure may be done using durable synthetic grafts (illustrated) or an endovascular repair, in which a new synthetic lining is inserted using hooks or stents to hold the lining in place. AAA (abdominal aortic aneurysm) may occur inferiorly on the abdominal aorta as the tunica media degenerates and weakens from atherosclerosis. AAAs are defined as an infrarenal diameter > 3 cm, as aneurysms are characterized as being >50% dilation of the normal diameter. Ultrasound screening may be useful in affected individuals. Older individuals w/ hypertension, atherosclerosis leading to medial damage balloon with stretch distended farther.
