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Shaffer 39 Case 14 Spider angioma Case 15 Blue rubber bleb nevus syndrome Case 16 Leukocytoclastic vasculitis Case 17 Dermatitis herpetiformis First Principles of Gastroenterology and Hepatology A symptoms quitting smoking purchase generic cytoxan on line. Introduction the esophagus is a hollow muscular organ whose primary function is to symptoms adhd order cytoxan online from canada propel into the stomach the food or fluid bolus that it receives from the pharynx symptoms 3 months pregnant buy cytoxan 50 mg without a prescription. Symptoms of esophageal disease are among the most commonly encountered in gastroenterology. The physician must be on the lookout, however, for the more serious disorders, which can present with a similar spectrum of symptoms. This chapter will focus on the pathophysiology, diagnosis and management of the more common esophageal disorders. In the proximal one-quarter to one-third of the esophagus, the muscle is striated. There is then a transition zone of variable length where there is a mixture of both smooth and striated muscle. Sensory innervation is also carried via the vagus and consists of bipolar nerves that have their cell bodies in the nodose ganglion and project from there to the brainstem. Most of the thoracic esophagus is supplied by paired aortic esophageal arteries or terminal branches of bronchial arteries. Venous drainage is via an extensive submucosal plexus that drains into the superior vena cava from the proximal esophagus and into the azygous system from the mid-esophagus. In the distal esophagus, collaterals from the left gastric vein (a branch of the portal vein) and the azygos interconnect in the submucosa. This connection between the portal and systemic venous systems is clinically important; when there is portal hypertension, variceal dilation can occur in this area. These submucosal esophageal varices can be the source of major gastrointestinal hemorrhage. Lymphatic Drainage In the proximal third of the esophagus, lymphatics drain into the deep cervical lymph nodes, whereas in the middle third, drainage is into the superior and posterior mediastinal nodes. The distal-third lymphatics follow the left gastric artery to the gastric and celiac lymph nodes. Histology the wall of the esophagus consists of mucosa, submucosa and muscularis propria. Unlike other areas of the gut, it does not have a distinct serosal covering, but is covered by a thin layer of loose connective tissue. Beneath the epithelium are the lamina propria and the longitudinally oriented muscularis mucosa. The muscularis propria consists of an inner circular and an outer longitudinal muscle layer. The circular muscle layer provides the sequential peristaltic contraction that propels the food bolus toward the stomach. Physiology the major function of the esophagus is to propel swallowed food or fluid into the stomach. The esophagus also clears any refluxed gastric contents back into the stomach and takes part in such reflex activities as vomiting and belching. Deglutition: Primary Peristalsis the act of deglutition is a complex reflex activity. Food is chewed, mixed with saliva and formed into an appropriately sized bolus before being thrust to the posterior pharynx by the tongue. Once the bolus reaches the posterior pharynx, receptors are activated that initiate the involuntary phase of deglutition.

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Antibodies directed to medications jokes purchase 50 mg cytoxan amex which of the following (D) Human papillomavirus types 6 and 11 cellular structures would be expected in the serum of this (E) Toxoplasma gondii patientfi Which of the following is the most likely examination symptoms 14 dpo cytoxan 50 mg free shipping, the tonsils are enlarged medicine 319 pill purchase generic cytoxan on line, boggy, and coated with diagnosisfi Which of the following conditions is the most likely cause of conducting hearing loss in this patientfi What is the most tiple bouts of ear infections over the last 20 years and was likely diagnosisfi A large necrotizing mass is identified in the 23 A 40-year-old man presents with a 2-month history of a pain posterior nasopharynx, with obstruction of both eustachian less lump in his left jaw. A biopsy of the mass reveals sheets of malignant cells a 2-cm multilocular lesion with smooth cyst-like appearance, with large nuclei (shown in the image). Which of the follow smooth periphery, expansion of the bone, and thinning of ing pathogens has been associated with the development of the cortex. Physical examination reveals white plaques on the buccal mucosa, (C) Local recurrence tongue, and fioor of the mouth. A biopsy (shown in the image) (D) Malignant transformation demonstrates severe epithelial dysplasia. Herpes labialis (cold sores, fever blisters) and herpetic stomatitis are caused by herpes virus type 1. They are among the most common viral infections of the lips and oral mucosa in both children and young adults. The disease starts with painful infiamma tion of the affected mucosa, followed shortly by the formation of vesicles. Also termed thrush or monili asis, candidiasis is caused by a yeast-like fungus, Candida 25 the patient described in Question 24 is at higher risk of devel albicans, which is a common surface inhabitant of the oral oping which of the following neoplasmsfi The oral lesions typically appear as white, (D) Papilloma slightly elevated, soft patches that consist mainly of fungal (E) Squamous cell carcinoma hyphae. Diagnosis: Candidiasis 26 A 45-year-old man presents with a painless mass in the neck (shown in the image). A biopsy of the tumor reveals spreading cellulitis, or phlegmon, which originates in the sub myoepithelial cells intermingled with myxoid, mucoid, and maxillary or sublingual space but extends locally to involve cartilaginous areas. The bacteria responsible for this infection originate from the following is the most likely prognosisfi After extraction of a tooth, hairline fractures may occur in the lingual cortex of the mandible, providing microorganisms ready access to the submaxillary space. By following the fascial planes, the infection may dissect into the parapharyngeal space and, from there, into the carotid sheath. Acute necrotizing ulcer ative gingivitis (Vincent angina, choice B) does not extend to the neck. Sjogren syndrome is a chronic infiammatory disease of the salivary and lacrimal glands; it may be restricted to these sites or may be associated with a systemic collagen vascular disease. Involvement of the salivary glands leads to dry mouth (xerostomia), and disease of the lacrimal glands results in dry eyes (keratoconjunctivitis sicca). Late in the course of the disease, the affected glands become 288 Chapter 25 atrophic, with fibrosis and fatty infiltration of the parenchyma. When the process reaches the dentinoenamel junction, it spreads laterally and 5 the answer is E: Thyroglossal duct. A sub opment, the thyroid gland descends from the base of the stantial cavity then forms in the dentin, producing a fiask tongue to its final position in the neck. Only when the vascular thyroid tissue or a developmental cyst (thyroglossal duct cyst) pulp of the tooth is invaded does an infiammatory reaction may occur anywhere along the path of descent.

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