Assistant Professor, New York University School of Medicine
It gives rise to the left recurrent laryngeal nerve gastritis treatment and diet trusted gasex 100caps, which hooks around the arch of the aorta to the left of the ligamentum arteriosum gastritis diet ketosis cheap 100caps gasex overnight delivery. It ascends through the superior mediastinum and the neck in a groove between the trachea and esophagus gastritis diet 3-1-2-1 purchase gasex mastercard. It forms the anterior vagal trunk which enters the abdomen through the esophageal hiatus. Supplies mediastinal and diaphragmatic pleura on left side and diaphragmatic peritoneum d. Ventral rami of thoracic spinal nerves Anterior (ventral) primary ramus of upper 11th thoracic spinal nerves give intercostal nerves and ventral ramus of T12 is called subcostal nerve. The relationship from above downward is nerve, vein, artery the relationship from above downward is vein, artery, nerve. It supplies the skin of the floor of axilla and upper part of the medial aspect of arm. Supplies mediastinal and diaphragmatic pleura on left side and diaphragmatic peritoneum Phrenic nerve arises from the anterior primary rami of C-2,3,4, descends lying between the mediastinal pleura and fibrous pericardium and supply diaphragm. Phrenic nerve the pain of pericarditis originates in the parietal layer only and is transmitted by the phrenic nerve. The fibrous and parietal layer of serous pericardium are supplied by the phrenic nerve, visceral layer is insensitive. Passes posterior to the hilum of lung Phrenic nerve passes anterior to the hilum of lungs, vagus nerve passes posterior to it. Diaphragm receives somatic motor fibers solely from the phrenic nerve; its central part receives sensory fibers from the phrenic nerve, whereas the peripheral part is supplied by intercostal nerves. Right dome of diaphragm is at higher level (pushed up by liver) and the left dome of diaphragm is lower (pushed down by heart). Anterior to scalenus anterior Both the phrenic nerves pass anterior to the scalenus anterior muscle in the neck. Both the phrenic nerves pass anterior to the hila of both the lungs respectively on each side. Arterial Supply Thoracic wall receive their blood supply from the internal thoracic artery (either directly or via the musculophrenic artery), the superior intercostal artery (from the costocervical trunk), superior thoracic artery (from the axillary artery), descending thoracic aorta, and the subcostal artery. Additional contributions come from vessels that supply the proximal muscles of the upper limb, namely: suprascapular, superficial cervical, thoraco-acromial, lateral thoracic and subscapular arteries. Internal Thoracic Artery arises from the first part of the subclavian artery and descends directly behind the first six costal cartilages, just lateral to the sternum. It gives two anterior intercostal arteries in each of the upper six intercostal spaces and terminates at the sixth intercostal space by dividing into the musculophrenic and superior epigastric arteries. Branches of internal thoracic artery are (i) mediastinal branches,(ii) pericardial branches,(iii) sternal branches, (iv) pericardiophrenic branches, (v) anterior intercostal arteries (in upper six spaces), (vi) perforating branches,and (vii) two terminal branches,musculophrenic and superior epigastric arteries. Pericardiophrenic artery accompanies the phrenic nerve between the pleura and the pericardium to the diaphragm and supplies the pleura, pericardium, and diaphragm (upper surface). Anterior intercostal arteries that supply intercostal spaces 1 to 6 are branches of the internal thoracic artery, 7 to 9 are given by the musculophrenic artery. There are two anterior intercostal arteries in each of the intercostal spaces that run laterally, one each at the upper and lower borders of each space. The upper artery in each intercostal space anastomoses with the posterior intercostal artery, and the lower one joins the collateral branch of the posterior intercostal artery. They give muscular branches to the intercostal, serratus anterior, and pectoral muscles. Their anterior Perforating Branches(second, third, and fourth) give medial mammary branches to breast.
Parietal layer of serous pericardium lines the inner surface of the fibrous pericardium gastritis diet sheet gasex 100caps on-line, and reflects as the visceral layer on the outer surface of heart forming epicardium gastritis diet king order genuine gasex online. Self Assessment and Review of Anatomy Table 25: Differences between the parietal and serous pericardium Parietal pericardium Visceral pericardium (epicardium) It is adherent to the fibrous pericardium It is adherent to the myocardium of the heart It develops from somatopleuric mesoderm It develops from splanchnopleuric mesoderm It is innervated by the somatic nerve fibers It is innervated by the autonomic nerve fibers It is sensitive to pain It is insensitive to pain Pericardial cavity is a potential space between the visceral and parietal layers of the serous pericardium diet for gastritis and diverticulitis purchase 100 caps gasex free shipping, lined by mesothelium. It normally contains a small amount of pericardial fluid (20 mL), which allows friction-free movement of the heart during diastole and systole. The perivenous tube is an inverted J; the cul-de-sac within its curve posterior to the left atrium is termed the oblique sinus. The transverse sinus is a passage between the two pericardial tubes; the aorta and pulmonary trunk are anterior, and the atria and their great veins are posterior. Upper border of the heart is slightly oblique and atrial (mainly the left atrium). Ascending aorta and the pulmonary trunk pass anterior to it (obscuring it) and at its right extremity, the superior vena cava enters the right atrium. Right border of the heart corresponds to the right atrium and is slightly convex to the right. The inferior border separates the sternocostal(anterior) surface from the diaphragmatic (inferior) surface. Left border of the heart (obtuse margin) separates the sternocostal and left surfaces. It descends obliquely, convex to the left, from the left atrial appendage to the cardiac apex. It is round and mainly formed by the left ventricle and partly the left atrial appendage. The heart has the following three surfaces: Sternocostal (anterior), diaphragmatic (inferior) and left surface. Anterior (sternocostal) surface is formed mostly by right ventricle and right auricle and partly by left ventricle and left auricle. Anterior interventricular groove is evident on this surface which separates right and left ventricle. The left atrium is hidden on the front by the ascending aorta and pulmonary trunk. The base is separated from vertebral column by the oblique pericardial sinus, esophagus, and aorta. Some authors consider the base of the heart as the upper border of the heart where great blood vessels (superior vena cava, ascending aorta and pulmonary trunk) are attached. Cardiac apex is the blunt rounded extremity of the heart formed by the left ventricle, which is directed anteroinferiorly and to the left. The apex is located most commonly behind the fifth left intercostal space, near or a little medial to the midclavicular line. It is formed mainly by the left ventricle (2/3) and partly right ventricle (1/3) which are separated from each other by the posterior interventricular groove. Left surface is formed mainly by the left ventricle and partly by the left atrium and auricle. The wall of the heart consists of three layers: inner endocardium, middle myocardium, and outer epicardium.
The membranous labyrinth is a closed system of fluid filled intercommunicating membranous sacs and ducts filled with endolymph gastritis bacteria generic gasex 100 caps online. It lies within the complex intercommunicating bony cavities and canals (bony labyrinth) in the petrous part of the temporal bone gastritis symptoms when pregnancy buy gasex 100 caps amex. Bony labyrinth component (Containing perilymph and the membranous labyrinth) Vestibule Semicircular canals Cochlea Membranous labyrinth component (Within bony labyrinth and containing endolymph) Utricle gastritis diet лучшие buy gasex 100caps with visa, saccule Semicircular ducts Cochlear duct Structures and sensory receptors Maculae Major function Detect linear movements and static position of the head Cristae ampullares Detect rotational movements of the head Spiral organ Detect sounds the bony labyrinth has three parts: Cochlea, vestibule and semicircular canals (three). The apex (cupula) is directed towards the medial wall of the tympanic cavity and the base is towards the bottom of the internal acoustic meatus. Vestibule is a central ovoid cavity of bony labyrinth between cochlea in front and three semicircular canals behind. Each canal is about two-third of a circle and is dilated at one end to form the ampulla. Anterior semicircular canal lies in a vertical plane at right angle to the long axis of the petrous temporal bone, is convex upwards and its position is indicated on the anterior surface of the petrous temporal bone as arcuate eminence. The anterior semicircular canal of one side lies parallel to the posterior semicircular canal of the other side. The anterior and posterior semicircular canals, lying across and along the long axis of the petrous temporal bone, are each Membranous labyrinth: the cochlear duct lies within the bony cochlea, the saccule, and utricle lie within the bony the cochlear duct (basal turn) is connected to saccule by ductus reuniens. The saccule and utricle are connected to each other by Y-shaped utriculo-saccular duct, which expands to form ductus the utricle is connected to three semicircular ducts through five openings. Posterior semicircular canal also lies in a vertical plane parallel to the long axis of petrous temporal bone. Cochlear Duct (Scala Media) is a spiral anterior part of the membranous labyrinth having two and three-fourth turns. It lies in the middle part of the cochlear canal between scala vestibuli and scala tympani. The cochlear duct contains spiral organ of Corti and appears triangular in shape in cross section. Base is formed by the osseous spiral lamina (medially) and basilar membrane (laterally). The scala vestibuli and scala tympani containing perilymph lie above and below basilar membrane respectively. Cochlear duct (containing endolymph) is bathed above and below by the perilymph within the two scalae. The two scalae are continuous with each other through a narrow opening at the apex of cochlear duct called helicotrema. Head and Neck Spiral Organ of Corti has a tunnel of Corti formed by the inner and outer rod cells. The hair cells are the receptor cells of hearing located on basilar membrane and their apices possess stereocilia (hair), the inner cells are flask shaped and arranged in a single row while outer cells are cylindrical and arranged in 3 or 4 rows. Medially it is attached to osseous spiral Basilar membrane separates the cochlear duct from the scala tympani. The pitch localization along its length is 20 Hz at the apex and 20,000 Hz at the base of the cochlea. Its vibration results in deformation of the hair cell microvilli against the tectorial membrane and the stimulus is further Ninety percent of afferent fibres (peripheral processes of bipolar neurons of spiral ganglion) supply the inner hair cells the spiral ganglion is located in the spiral canal within the modiolus near the base of the spiral lamina. The shearing force between the hair cells and tectorial membrane stimulate the hair cells. Vestibular system: the saccule is a small globular membranous sac lying in the anteroinferior part of the vestibule. The utricle is an oblong membranous sac, is larger than the saccule and lies in the posterosuperior part of the vestibule.
The amnion is a large sac containing amniotic fluid in which the fetus is suspended by its umbilical cord gastritis symptoms+blood in stool cheap gasex 100 caps with mastercard. The fluid (1) absorbs jolts gastritis kronis 100caps gasex for sale, (2) allows for fetal movements gastritis daily diet best buy for gasex, and (3) prevents adherence of the embryo to surrounding tissues. The fetus swallows amniotic fluid, which is absorbed through its gut and cleared by the placenta. An excessive amount of amniotic fluid (hydramnios) is associated with anencephaly and esophageal atresia, whereas an insufficient amount (oligohydramnios) is related to renal agenesis. The umbilical cord, surrounded by the amnion, contains (1) two umbilical arteries, (2) one umbilical vein, and (3) Wharton jelly, which serves as a protective cushion for the vessels. Two thirds of twins are dizygotic, or fraternal; they have two amnions, two chorions, and two placentas, which sometimes are fused. In cases of conjoined twins, in which the fetuses are not entirely split from each other, there is one amnion, one chorion, and one placenta. Signals initiating parturition (birth) are not clear, but preparation for labor usually begins between 34 and 38 weeks. Labor itself consists of three stages: (1) effacement and dilatation of the cervix, (2) delivery of the fetus, and (3) delivery of the placenta and fetal membranes. Note the changed relations septum transversum, pericardial cavity, heart tube, and cloacal membrane Table 12: Arrangement of important structures of embryo before and after the folding in craniocaudal direction Before folding of embryo Septum transversum lies cranial to the pericardial cavity and heart tube Heart tube lies below the pericardial cavity Prochordal plate After folding of embryo Septum transversum lies caudal to the pericardia[cavity and heart tube Heart tube lies above the pericardial cavity. It contains the allantois and umbilical vessels and will be incorporated into the umbilical cord with the yolk sac (vitelline) stalk (duct). Cotyledons are the compartments (15 to 20) in the placenta formed when decidual septa grow into the intervillous spaces. These septa never reach the chorionic plate so that there is communication between cotyledons. High Yield Points Amniochorionic membrane is formed when expansion of the amniotic cavity obliterates the chorionic cavity causing the amnion to contact the chorion and the two to fuse. Chorionic cavity is the space formed between the extraembryonic mesoderm lining the cytotrophoblast (somatic extraembryonic mesoderm) and that surrounding the yolk sac and embryo (splanchnic extraembryonic mesoderm). The chorionic cavity will eventually be obliterated by expansion of the amniotic cavity and fusion of the amnion with the chorion. Villous chorion formation goes through three stages: primary chorionic villi, secondary chorionic villi, and tertiary chorionic villi. Components Maternal component of the placenta consists of: Decidua basalis, which is derived from the endometrium of the uterus located between the blastocyst and the myometrium. Decidua basalis and decidua parietalis (which includes all portions of the endometrium other than the site of implantation) are shed as part of the after birth. Decidua capsularis, the portion of endometrium that covers the blastocyst and separates it from the uterine cavity, becomes attenuated and degenerates at week 22 of development because of a reduced blood supply. It is in contrast to an area of no villus development known as the smooth chorion (which is related to the decidua capsularis). Fetal surface of the placenta is characterized by the well-vascularized chorionic plate containing the chorionic (fetal) blood vessels. Placental membrane In early pregnancy, the placental membrane consists of the syncytiotrophoblast, cytotrophoblast (Langerhans cells), connective tissue, and endothelium of the fetal capillaries.
This emaciated infant died as a result of marasmus chronic gastritis zinc buy gasex 100 caps overnight delivery, complicated by gastroenteritis gastritis fever buy gasex paypal. Cutaneous changes (1) Alternating zones of hyperpigmentation and hypopigmentation in areas of desquamation give the skin a "flaky paint" appearance gastritis symptoms pain back buy gasex 100 caps fast delivery. Definition: Total calorie deprivation with a dietary deficiency of both protein and carbohydrates 2. Extreme muscle wasting ("broomstick extremities") (1) Due to the breakdown of muscle protein for energy. Note the loss of muscle and subcutaneous tissue consistent with total calorie deprivation. Cause is unknown; however, it is probably multifactorial (sociocultural, psychological, familial, genetic factors, possibly altered serotonin metabolism). Laxative abuse is common and often results in a laxative bowel and hypokalemia, the latter precipitating cardiac arrhythmias and possible death. Osteoporosis (loss of both organic bone matrix [osteoid] and mineralized bone) (1) In women, this is caused by hypoestrinism (see Chapter 24). Lack of estrogen leads to decreased osteoblastic activity and increased osteoclastic activity. Euthyroid sick syndrome (see Chapter 23); decreased thyroid hormone associated with bradycardia, hypotension, cold intolerance, and the changes in the skin, nails, and hair just listed. Most common cause of death: ventricular arrhythmia usually related to hypokalemia from laxative abuse B. Definition: Characterized by bingeing (overeating/drinking) followed by self-induced vomiting 2. Predominantly seen in teenage girls and young women; female/male ratio is 10: 1 c. Etiology is unknown; probably multifactorial (sociocultural, psychological, and familial) d. More common in Western society, where there is a strong cultural pressure to be slender. Complications related to vomiting (1) Eroded enamel due to acid injury (2) Hypokalemia and metabolic alkalosis (see Chapter 5) (3) Parotid and salivary gland swelling (4) Hematemesis (vomiting blood) from tears/rupture of the distal esophagus (see Chapter 18) b. Unlike anorexia nervosa, emaciation and amenorrhea are not present unless the patient also has anorexia nervosa. Electrolyte abnormalities from vomiting: hyponatremia, hypokalemia, metabolic alkalosis (increased serum bicarbonate; see Chapter 5) b. Because both metabolic alkalosis and metabolic acidosis may be present, the pH may be normal (see mixed arterial blood gas disorders in Chapter 5). Most common cause of death is a ventricular arrhythmia, usually related to hypokalemia from laxative abuse and vomiting. Worldwide epidemic; prevalence increases with advancing age and levels off after the sixth decade, when weight begins to decline. Obesity in adolescence is significantly associated with an increased risk of severe obesity in adulthood. Evidence suggests that weight loss can reverse or arrest the harmful effects of obesity. Risk factors for increased morbidity/mortality in obesity are associated with the type of fat distribution. Energy balance dysfunction (1) Energy balance involves complex neuron circuits in the arcuate nucleus and the paraventricular nuclei of the hypothalamus of the brain, which control food intake and energy expenditure. Increased incidence of cholecystitis and cholesterol stones occurs, because bile is supersaturated with cholesterol.