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A single erect anteroposterior X-ray of the abdomen is helpful in making the diagnosis heart attack 90 blockage purchase inderal 10 mg mastercard, with features of air-fluid levels in dilated small bowel loops seen in 82 per cent of cases blood pressure medication sleepy inderal 10mg on line. These loops of small bowel may be seen in the periphery of the film and are due to displacement of the bowel by the gravid uterus. Clinically, there is usually gross abdominal distension, with the abdominal X-ray showing a grossly dilated sigmoid colon loop that covers the entire film. If there is no clinical improvement, early recourse to laparotomy is required to prevent perforation and gangrene of the bowel. In early pregnancy the diagnosis would be similar to that of a non-pregnant female. However, as pregnancy advances, any abdominal mass may be displaced upwards and laterally, a fact that must be borne in mind when making a diagnosis. Furthermore, signs of peritonitis in abdominal swellings of an inflammatory nature can be markedly altered, possibly resulting in misdiagnosis with potential serious consequences. Abdominal swellings may be classified according to the anatomical layer of the abdomen, which comprises the: anterior abdominal wall; peritoneal cavity; retroperitoneal space. The overlying skin can be made to move independently of a lipoma, and asking the woman to tense her abdominal muscles will make the lump more prominent. Swellings can also be due to herniation of abdominal contents through areas of potential weakness of the abdominal wall, the commonest being the umbilicus. Like all herniae, these masses have an expansile cough impulse and are usually reducible on lying supine. As the neck of these paraumbilical herniae is usually wide, complications of irreducibility and strangulation are relatively uncommon. Herniation can also occur through previous incisions, including those made for caesarean sections, and usually occur at the lateral edge of the Pfannensteil scar. A condition that occurs especially with repeated pregnancy is divarification of the recti. This is a defect of the median raphe and is palpable below the level of the umbilicus. Abdominal swellings arising from the anterior abdominal wall the layers of the abdominal wall that may give rise to abdominal wall swellings is shown in Box 1. Box 1 the layers of the abdominal wall that may give rise to abdominal wall swellings Skin and appendages Subcutaneous tissue Herniation of intra-abdominal contents through the wall Lumps can arise from the skin and its appendages. Skin swellings are diagnosed by the fact that they do not move independently of the overlying skin. A punctum may be visible in sebaceous cysts, which may be tender and erythematous if they become infected. While these are relatively rare, they are important, as they cause the highest death rates of all skin cancers. Diagnostic confusion may occur as pigmented naevi may change during pregnancy owing to an increase in junctional activity with the changing hormonal levels. In the later stages of pregnancy, these conditions may be suspected when the abdominal enlargement is greater than would be expected for the gestational age. A symphysiofundal height greater than that expected for the gestational age may be due to uterine fibroids that are making the uterus larger, excess amniotic fluid, a large baby, or the upward displacement of a gravid uterus by an ovarian cyst. An appropriate symphysiofundal height is found if the generalised abdominal distension is secondary to faeces or flatus, where a history of constipation plus or minus vomiting is elicited. If the flanks are distended and there is shifting dullness on percussion when turning from the prone to the lateral position, then ascites should be considered. The advances in ultrasound allow for accurate fibroid mapping in the gravid uterus.

The lower panel shows at higher magnification the endometrial glands that extend from the stratum basale to the surface prehypertension in your 20s order generic inderal. The glands have acquired a corkscrew shape as the endometrium increases further in thickness blood pressure medication anxiety cheap inderal master card. The stratum basale (below the dashed line) exhibits less dramatic changes in morphology. The lower panel shows uterine glands that have been cut in a plane that is close to their long axes. The lower panel shows the extravasated blood and necrosis of the stratum functionale. After about 2 days, extended periods of arterial contraction, with only brief periods of blood flow, cause disruption of the surface epithelium and rupture of the blood vessels. When the spiral arteries close off, blood flows into the stratum basale but not into the stratum functionale. Blood, uterine fluid, and sloughing stromal and epithelial cells from the stratum functionale constitute the vaginal discharge. As patches of tissue separate from the endometrium, the torn ends of veins, arteries, and glands are exposed. Arterial blood flow is restricted except for the brief periods of relaxation of the walls of the spiral arteries. In the absence of fertilization, cessation of bleeding would accompany the growth and maturation of new ovarian follicles. The epithelial cells would rapidly proliferate and migrate to restore the surface epithelium as the proliferative phase of the next cycle begins. In the absence of ovulation (a cycle referred to as an anovulatory cycle), a corpus luteum does not form, and progesterone is not produced. In the absence of progesterone, the endometrium does not enter the secretory phase and continues in the proliferative phase until menstruation. In cases of infertility, biopsies of the endometrium can be used to diagnose such anovulatory cycles as well as other disorders of the ovary and endometrium. Implantation If fertilization and implantation occur, a gravid phase replaces the menstrual phase of the cycle. If fertilization and subsequent implantation occur, decline of the endometrium is delayed until after parturition. These hormones maintain the corpus luteum and stimulate it to continue the production of progesterone and estrogens. Thus, the decline of the endometrium is prevented, and the endometrium undergoes further development during the first few weeks of pregnancy. The fertilized human ovum undergoes a series of changes as it passes through the uterine tube into the uterine cavity in preparation for becoming embedded in the uterine mucosa. The zygote undergoes cleavage, followed by a series of mitotic divisions without cell growth, resulting in a rapid increase in the number of cells in the embryo. Initially, the embryo is under the control of maternal informational macromolecules that have accumulated in the cytoplasm of the ovum during oogenesis. Later development depends on activation of the embryonic genome, which encodes various growth factors, cell junction components, and other macromolecules required for normal progression to the blastocyst stage. The cell mass resulting from the series of mitotic divisions is known as a morula [L. During the third day after fertilization, the morula, which has reached a 12- to 16-cell stage and is still surrounded by the zona pellucida, enters the uterine cavity. The morula remains free in the uterus for about a day while continued cell division and development occur. The early embryo gives rise to a blastocyst, a hollow sphere of cells with a centrally located clump of cells. This inner cell mass will give rise to the tissues of the embryo proper; the surrounding layer of cells, the outer cell mass, will form the trophoblast and then the placenta. Fluid passes inward through the zona pellucida during this process, forming a fluid-filled cavity, the blastocyst cavity.

The smooth surface of the stratified squamous epithelium (Ep) contrasts with the irregular surface of the dorsum of the tongue heart attack ekg order inderal overnight delivery. Moreover prehypertension at 20 80 mg inderal mastercard, the epithelial surface on the ventral surface of the tongue is usually not keratinized. Often, these connective tissue papillae are cut obliquely and then appear as small islands of connective tissue within the epithelial layer (see figure above). The connective tissue extends as far as the muscle without changing character, and no submucosa is recognized. The muscle (M) is striated and is unique in its organization, that is, the fibers travel in three planes. Therefore, most sections will show bundles of muscle fibers cut longitudinally, at right angles to each other, and in cross-section. Nerves (N) that innervate the muscle are also frequently observed in the connective tissue septa between the muscle bundles. The surface of the tongue behind the vallate papillae (the root of the tongue) contains lingual tonsils (not shown). These are similar in structure and appearance to the palatine tonsils illustrated in Plate 36. Although filiform papillae do not have taste buds, the other three types, namely, foliate, fungiform, and circumvallate, contain taste buds in their epithelium. The taste buds in the epithelium covering the circumvallate and foliate papillae are located in deep clefts that separate the papillae from adjacent mucosa or from each other, respectively. The secretions flush material from the moat to allow the taste buds to respond to new stimuli. Similarly, ducts of small serous glands empty into the clefts between foliate papillae. Taste buds in section appear as oval, pale-staining bodies that extend through the thickness of the epithelium. These modalities appear to be more concentrated in the specific areas of the tongue; taste buds at the tip of the tongue detect sweet stimuli, those immediately posterolateral to the tip detect salty stimuli, and those on the circumvallate papillae detect bitter and umami stimuli. Foliate papillae consist of a series of parallel ridges that are separated by narrow, deep mucosal clefts (see orientation photograph, page 529). They are aligned at right angles to the long axis of the tongue on its posterior lateral edge. This micrograph shows three papillae; each is separated from its neighbor by a narrow cleft (C). In contrast, the epithelium lining the clefts (Ep) is relatively thin and uniform. These glands, like the serous glands associated with the circumvallate papillae, have ducts (D) that empty into the base of the clefts between papillae. This higher magnification micrograph shows the taste buds located within the cleft epithelium. The taste buds typically appear as oval, pale-staining structures that extend Taste bud, tongue, human, H&E 1100. At their basal surface, they form a synapse with the afferent sensory fibers that make up the underlying nerve. They are the stem cells for the supporting and neuroepithelial cells, which have a turnover life of about 10 days. A duct runs forward and medially from each of the two glands to a papilla located on the floor of the mouth just lateral to the frenulum of the tongue. The secretory component of the submandibular glands are the acini, which are of three types: serous acini, which are protein-secreting like those of the parotid gland; mucous acini, which secrete mucin; and acini containing both serousand mucus-secreting cells. In the case of the mixed acini, the mucous cells are capped by serous cells, which are typically described as demilunes. Recent studies suggest that the demilune is an artifact of tissue preparation and that all of the cells are aligned to secrete into the acinus lumen. Traditional fixation in formaldehyde appears to expand the mucous cells with the consequent squeezing of the serous cells to form their cap-like position. The mucous acini are more tubular or elongate and sometimes can be seen to branch. They reside within the lobule but are often difficult to find because of their shortness.

Electron microscopic examination of the thin segments of various nephrons reveals further differences blood pressure nicotine order cheap inderal line, namely blood pressure high in the morning quality 40mg inderal, the existence of four types of epithelial cells. Morphologic differences, such as microvilli, mitochondria, and degree of cellular interdigitation, probably reflect specific active or passive roles in this process. The thin descending and ascending limbs of the loop of Henle differ in structural and functional properties. The cells have almost no interdigitations with neighboring cells and few organelles. The ultrafiltrate that enters the thin descending limb is isosmotic, whereas the ultrafiltrate leaving the thin ascending limb is hyposmotic to plasma. This limb is much less permeable to Na and urea; however, it does permit small amounts to enter the nephron at this site. Because the interstitial fluid in the medulla is hyperosmotic, water exits this nephron segment by osmosis, causing the luminal content of Na and Cl to become progressively more concentrated. The cells of this limb do not actively transport ions; thus, the increased tubular fluid osmolality that occurs in this nephron segment is caused in large part by the passive movement of water into the peritubular connective tissue. The thin ascending limb of the loop of Henle is highly permeable to Na and Cl due to the presence of Na /K /2Cl cotransporters in the apical plasma cell membranes. Counter ions, in this case, Na (the majority) and K, follow passively to maintain electrochemical neutrality. The hyperosmolarity of the interstitium is directly related to the transport activity of the cells in this nephron segment. This diagram shows the various types of epithelia and the region where they are found in the thin limb of the short and long loops of Henle. The diagrams of the epithelium do not include nuclear regions of the epithelial cells. For this reason, the thin ascending limb is sometimes referred to as the diluting segment of the nephron. In addition, epithelial cells lining the thick ascending limb produce an 85 kDa protein called uromodulin (Tamm-Horsfall protein) that influences NaCl reabsorption and urinary concentration ability. Uromodulin also modulates cell adhesion and signal transduction by interacting with various cytokines. It also inhibits the aggregation of calcium oxalate crystals (preventing kidney stone formation) and provides a defense against urinary tract infection. In individuals with inflammatory kidney diseases, a precipitated uromodulin is detected in urine in the form of urinary casts (see Folder 20. The distal straight tubule (thick ascending limb), as previously noted, is part of the ascending limb of the loop of Henle and includes both medullary and cortical portions, with the latter located in the medullary rays. The distal straight tubule, like the ascending thin limb, transports ions from the tubular lumen to the interstitium. The apical cell membrane in this segment has electroneutral transporters (synporters) that allow Cl, Na, and K to enter the cell from the lumen. Some K ions leak back into the tubular fluid through K channels, causing the tubular lumen to be positively charged with respect to the interstitium. This positive gradient provides the driving force for the reabsorption of many other ions such as Ca2 and Mg2. Note that this significant movement of ions occurs without the movement of water through the wall of the distal straight tubule, resulting in separation of water from its solutes. In routine histologic preparations, the large cuboidal cells of the distal straight tubule stain lightly with eosin, and the lateral margins of the cells are indistinct (Plate 77, page 736). The nucleus is located in the apical portion of the cell and sometimes, especially in the straight segment, causes the cell to bulge into the lumen. As noted above, these cells have extensive basolateral plications, and there are numerous mitochondria associated with these basal folds. They also have considerably fewer and less well-developed microvilli than proximal straight tubule cells (compare. The apical surface of the cell displays some microvilli (Mv), but they are not sufficiently long or numerous to give the appearance of a brush border (compare with. As in the proximal tubule cell, the mitochondria account for the appearance of basal striations in the light microscope. The cells of the distal convoluted tubule resemble those of the distal straight tubule (thick ascending limb) but are considerably taller and lack a well-developed brush border. Similar to the distal straight tubule, the epithelium in the distal convoluted tubule is also relatively impermeable to water.