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Anal valves of Morgagni are short transverse folds of mucous membrane that connect the lower ends of the anal columns erectile dysfunction quick fix buy 50mg nizagara with amex. Anal sinus crypt-Above each anal valve there is a depression in the mucosa which is called the anal sinus impotence caused by diabetes generic 100mg nizagara free shipping. Pectinate line or dentate line is the imaginary line along which the anal valves are situated erectile dysfunction young buy generic nizagara on line. Internal sphincter-It is the condensation of the circular muscle of the lower part of the rectum and anal canal impotence treatment reviews buy nizagara 50 mg overnight delivery. Anorectal ring-At the anorectal junction puborectalis, deep part of sphincter ani externus and sphincter ani internus colMiddle Part lectively forms the anorectal ring. Sphincter ani externus or external sphincter-It is a voluntary muscle along the columns are not present here. The mucosa Relations It is related in front with the perineal body which separates it from the membranous part of the urethra and the bulbs of the penis in the male and from the lower part of the vagina in the female. Behind it is in relation with the anococcygeal ligament which separates it from the tip of the coccyx. For the whole length it is surrounded by sphincter muscles the tone of which keeps it closed. Anatomical Anal canal It extends from the pectinate line to the anal verge (lower 15 mm + 8 mm). The pectinate line indicates the site of attachment of the anal membrane in fetus. The upper part is about 15 mm long, the middle part about 15 mm long and the lower part about 8 mm long. From above the pectinate line lymph vessels drain to the internal iliac nodes and vessels from below the pectinate line drain to the Treatment superficial inguinal nodes. In infants and children-The mother is advised digital reposition of the prolapse Nerve Supply after lubricating with lignocaine jelly. It causes aseptic both sympathetic (inferior hypogastric plexus) fibrosis and mucosa gets adhered to other and parasympathetic by pelvic splanchnic layers. Below the pectinate line by the somatic (inferior rectal branch of internal pudendal complete Prolapse nerve S2, S3, S4) nerves. Complete Prolapse or Procidentia the prolapse consists of the entire thickness of the rectal wall. A sheet of Ivalon sponge (polyvinyl alcohol) sponge is then sutured to the presacral fascia and periosteum of the sacrum. Many workers believe that prolapse of the ene) mesh can be kept behind the recrectum starts as an intussusception. This is sutured in the middle to the Clinical Features presacral fascia with 3 or 4 interrupted 2-0 prolene sutures. Its aim is Treatment to reinforce the internal sphincter with a stainless steel wire at the same time narA number of operations have been designed rowing the anal opening. A steel wire or a thick silk suture is the more commonly practiced procedures are: applied all around the anus after reducing Abdominal Procedures the prolapse. Exposure to food additives, alcohol, lonizing radiation, bile acids promotes development of carcinoma. Genetic Factors proctocolectomy with ileal reservoir and Intermediate nodes along the ileocolic, ileoanal anastomosis. Chapter 35 Rectum and Anal Canal and later on 1 or 2 doses may be given 6 hours and 16 hours in the postoperative period. Colonoscopy-If the main symptom is bleeding or anemia, colonoscopy is the is detected. Treatment of polyp as well as laser Dukes clinical Staging therapy is possible during colonoscopy. Prognosis as Per Dukes Staging the Ba-enema gives good anatomical and topographical information, which not Stage 5-year survival only diagnoses a polyp or carcinoma but Stage A 80% demonstrates the site and configuration of Stage B 60% the lesion, thereby helping the planning of Stage C 30% operation. Antibiotic Prophylaxis If the history suggests that the problem Injection Cefuroxime 1. Additional risk factors are obesity, varicose veins and a previous history of thrombosis or embolism. Carcinoma of mid transverse colon - transverse colectomy ligating only the middle colic artery followed by colocolic anastomosis between ascending and descending colon. Carcinoma hepatic flexure or right transverse colon-extended right hemicolectomy is done.

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They hospital room 1 hour to 2 hours before the anesthesiologist to evaluate the medical con- includeBarbiturates(thiopentone) erectile dysfunction kidney stones buy cheap nizagara 100 mg online,benzodianticipated induction of anesthesia erectile dysfunction drugs in canada nizagara 25mg otc. For dition and unique needs of each patient and to azepines (midazolam) buying erectile dysfunction pills online purchase 50mg nizagara, propofol does kaiser cover erectile dysfunction drugs discount nizagara 50mg on-line, etomidate outpatient surgery premedication is usually select an appropriate technique of anesthesia. General aneStHeSia Ideally, all patients should enter the preoperative period free from apprehen- General anesthesia describes a triad of three Thiopentone sion, sedated but easily arousable, and fully major and separate effects: unconsciousness Thiopentone is the most commonly used barcooperative. Thiopentone sodium occurs as a pale yellow powder with a bitter taste resembling Hydrogen sulphide. It is not an analgesic, rather antianalgesic and consciousness is regained within5to10minutesbecauseofredistribution of the agent from the brain to peripheral tissues especially muscle and fat. Cardiovascular system: It causes myocardial depression and peripheral vasodilation, especially when large doses are administrated rapidly. Arterial pressure decreases and profound hypotension may occur, especially Clinical Effects a. Perivenous injection-Causepain,redness, swelling even necrosis and ulceration, as 0. Intraarterial injection-Inadvertent intraarterial injection of thiopentone is dangerin a patient with hypovolemia or cardiac ous as there is precipitation of solid crysdisease. Indeed a short period of apnea is common follow- Treatment ing induction of anesthesia with barbitu- a. Anaphylactoid reactions-very rare, about corneal, conjunctival, eyelash and eyelid 1on15000administrations. Complications Dose Ketamine It is a phencyclidine derivative, introduced by CorssenandDominoin1965. In solution Metabolism formitisavailableinconcentrationof10,50 Thiopentone is eliminated almost entirely and100mgketaminebasepermlofsodium after its metabolic degradation in liver, less chloride containing the preservative benzethan0. Vivid and unpleasant hallucinationsareknownwithKetamineandcanbe prevented by premedications with injectionofdroperidolorbenzodiazepineslike midazolam,lorazepamordiazepam. Cardiovascular system-The heart rate, blood pressure and cardiac output will increase. Respiratory system-Transient apnea may occur but respiration is well maintained thereafter. Benzodiazepines Three benzodiazepines commonly used in anesthesia are midazolam (short acting) Lorazepam (intermediateacting) and diazepam (longacting). All benzodiazepines have hypnotic, sedative, anxiolytic, amnesic anticonvulsant and centrally acting muscle relaxant properties. It is metabolized by the hepatic microsomal enzymetoformnoketamine,whichisthen hydroxylated to form hydroxynorketamine. Lessthan4percentofketaminecanberecovered from the urine and less then 5 percent of injectedketamineundergoesfecalexcretion. For induction in shock and poor risk patients with severe dehydration, anemia, cardiovascular instability, etc. Induction of anesthesia: Midazolam is lized in the liver and decomposed products the agent of choice for its faster onset of are excreted in urine and bile. The differing physicochemical propPropofol (Phenol derivative) erties of the different volatile agents will this drug became commercially available in affect their pharmacological effects (Table 1986. N2O, desflurane and sevoflusoluble and is formulated in a white, aqueous rane will cause rapid onset and recovery emulsion containing soyabean oil and egg of central nervous system effects. The larger the coeffifor outpatient anesthesia (minimum cient, the greater the affinity of the drug for hangover). Part I General Surgery Ideal Inhalational Anesthetic Agent An ideal inhalational anesthetic agent would becharacterizedby: 101 Section 4 Specialties Related to Surger y Halothane sensitizes myocardium to the dysrhythmic effects of catecholamines. It depresses the central nervous system, vasomotor centre and sympathetic ganglion. It is a matter of regret that none of the inhalational anesthetic agents fulfill the properties of an ideal agent. Halothane should always be used through specialized vaporizer, known as Goldman vaporizer. Like all inhalational anesthetics, apart from N2O it is associated with malignant hyperpyrexia. Ether Convulsion Contraindications Enflurane PyrexiafollowingadministrationofHalothane and history of jaundice are absolute contraindications. Diethyl Ether this is probably the most extensively used volatile anesthetic agent in terms of quantity. The reason for this is its wide safety margin, low cost and ease of administration. Itiskeptinambercoloredbottle,wrappedin black paper, as it forms peroxide and toxic aldehyde in presence of light. It may cause hepatotoxicity and hypothermia Halothane but less commonly than halothane.

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The carbonic acid is formed in the presence of carbonic anhydrase when water combines with car bondioxide which diffuses into the cell from peritubular plasma erectile dysfunction co.za order nizagara pills in toronto. The secreted hydrogen ion combines with the filtered bicarbonate to form carbonic acid erectile dysfunction drugs injection order nizagara 100mg fast delivery, which then breaks down to form water and carbon dioxide in the presence of car bonic anhydrase in the tubular membrane erectile dysfunction zinc generic nizagara 50 mg without prescription. Carbon dioxide either diffuses into the plasma or combines with water in the renal tubular cell to generate hydrogen ion and bicarbonate erectile dysfunction most effective treatment buy nizagara 50 mg with visa. Therefore, its total buffering power is far less than that of the bicarbonate system. The respiratory mechanism is a rapid response system that allows carbon dioxide to be transferred from pulmonary venous blood to alveolar gas and excreted in expired gas. In effect, respiratory regulation of acid base balance is a physiological type of buffer system. The overall buffering power of the res piratory system is one to two times as great as that of all the chemical buffers combined. Of these two mechanisms, the first is quantitatively more impor tant in maintaining acidbase balance. Both become consider ably concentrated in the tubular fluid because of their relatively poor reabsorption and because of removal of water from the tubular 44 fig. Therefore, even though the phosphate buffer is very weak in the blood, it is a much more powerful buffer in the tubular fluid. It will be seen that for each hydrogen ion bound by the phosphate buffer, a new carbonate ion is formed by the epithelial cell and transported into the blood. This contributes to the correction of aci dosis when excess hydrogen ions are secreted. The epithelial cells of all the tubules besides those of the thin segment of the loop of Henle continu ally synthesize ammonia and this diffuses into the tubular urine. The ammonia (which is lipid soluble and so moves freely across the tubular mem brane), then reacts with hydrogen ions to form ammonium ions which are charged + and lipid insoluble. Physiological Basis of Surger y Where pK = the negative logarithm of the dissociation constant for carbonic acid (6. Acidosis-It is a disturbance which tends to add acid or remove alkali from body fluids. In metabolic acidosis, there is quantita tive decrease in plasma bicarbonate con centration and when not complicated by other acidbase disorders, it lowers the blood pH. In metabolic alkalosis there is quantita tive increase in plasma bicarbonate concen tration and when not complicated by other acid base disorders it raises the blood pH. Primary event and compensatory response for acidbase disorders can also be represented as follows (Table 6. The terms acidosis and alkalosis, therefore have to be qualified whenever they are used if they are to have any meaning. Etiology the causes of metabolic acidosis can be divided into those associated with a nor mal anion gap and those associated with an increased anion gap. In the body to maintain electrical chemical neutrality the number of cations equals the number of anions. But anions other than chlo ride and bicarbonate are not usually meas ured in the routine biochemistry department. A normal anion gap in the presence of low bicarbonate ion concentration indicates the presence of hyperchloremic metabolic acidosis. An increase in anion gap indicates that the retention of anions other than chlo ride. Compensatory Process It is not a primary acidbase disorder but a change that follows a primary disorder. A compensatory process attempts to restore the blood pH to normal and is not appropriately termed acidosis or alkalosis. Metabolic acidosis uncompensated Metabolic acidosis compensated Metabolic alkalosis uncompensated Metabolic alkalosis compensated Respiratory acidosis uncompensated Respiratory acidosis compensated Respiratory alkalosis uncompensated Respiratory alkalosis compensated Type Table 6. Acute renal failure-There is excess retention of sulfuric or phosphoric acids in blood. Proximal tubular acidosis (loss of bicarbonate and associated Na+ due to reduced Na+/H+ exchange in proximal tubule. Carbonic anhydrase inhibitors causing reduced Na+/H+ exchange throughout the nephron. The administration of bicar bonate solutions should be reserved Pathogenesis solely for situations in which bases have 1. In volume and chloride depletion, mainte been lost or the degree of acidosis is nance of metabolic alkalosis is most often severe. Because during edly reduced renal function, resulting volume depletion renal conservation of from severe Na and H2O depletion, renal sodium takes precedence over other home ostatic mechanisms such as correction of regeneration of bicarbonate is impaired alkalosis. The volume deficit and consequent hyperaldosteronism stimulate proton secretion in these seg ments, generating and maintaining the alkalosis. Hyperaldosteronism - Mineralocorticoids like aldosterone stimulate renal hydro gen secretion by K+ H+/Na+ exchange in the distal tubule. In patients with excess mineralocorticoid activity, elevation of plasma bicarbonate is initiated by urinary loss of protons as ammonium and titrable acidity. Stimulation of tubular acid secre tion also enhances bicarbonate reabsorp tion thereby sustaining the metabolic alkalosis. Patients with excess mineralocorticoid activity are not volume or chloride defi cient. Hence this type of metabolic alka losis does not respond to sodium chloride administration. Alkalosis due to administration of alkali cannot be sustained unless large amounts are given or renal function is compromised, in which case alkalosis may be sustained with small exogenous loads. Physiological Basis of Surger y which gets accentuated by thoracic and upper abdominal incisions.

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Frequent sites of involvement are pelvic bones erectile dysfunction at the age of 20 discount nizagara online amex, lower lumbar vertebrae condom causes erectile dysfunction buy nizagara line, the rib cage and skull erectile dysfunction psychological causes discount nizagara 50mg online. Urology the treatment of choice is androgen deprivation as the prostate gland is very androgen sensitive erectile dysfunction qof purchase nizagara 100 mg with mastercard. The main treatment options are orchidectomy or the administration of hormones viz. This agent is rarely used now because of unpleasant side-effects like stroke, venous thrombosis, etc. In the first 10 days testosterone level may rise and it is wise to give flutamide or cyproterone acetate for this period. The age and clinical condition of the patient also play an important part in any decision on treatment. Pelviclymphnodedissectioncanbecarried out immediately prior to radical prostatectomy. In lymph node negative cases 5 year survival is almost 100 percent with radical radiotherapy. As the disease has spread to the nodes, it is difficult to remove them surgically. Theinnerendsofsexcords join to form a cellular plexus, called the rete cord, which is situated close to the blind ends of the mesonephric tubules. Meanwhilethesexcordsandtheretecord are canalized to from the seminiferous tubules and rete testes. Maldescended testis (Ectopic or deviated testis) this is less common than the undescended testis. The testis may take any one of the abnormal positions along four gubernacular fails (iliac, perineal, pubic and femoral) other than that at the scrotum. Anorchism (cryptorchism)-Both testes are retained in the abdomen and the individual is sterile. Retractile testes: the retractile testis is a normal testis with an excessively active cremasteric reflex resulting in the testes being drawn up to the external inguinal ring. Notreatmentisnecessaryforthiscondition as the testis comes down to normal position when cremasteric hyperactivity subsides around puberty. Factors Helping in the Descent of Testis Theexactcauseisstillunknownbutthefollowing factors may be conjointly responsible for decent. Pull of the gubernaculum-A mesenchymal strand, the gubernaculums testis, extends from the caudal end of the developing testis along the course of its descent to blend into the scrotal fascia. It is suggested that it acts as a guide (gubernaculums = rudder) or that its swelling dilates the inguinal canal and scrotum. Activecontractionofthearchedfibersof internal oblique muscle squeezes the slipperyconvexsurfaceoftestisandhelpsits rapid descent along the inguinal canal. The testis fails to reach the bottom of the scrotum and lies arrested at some place in the normal pathway of its descent. Position from (A) to (D); also indicate the different positions of undescended testis. The vas passes from the tail of the epididymis to traverse the scrotum, inguinal canal and comes to lie upon the side wall of the pelvis. It then turns medially to the base of the bladder and joins the more laterally placed seminal vesicle to form the ejaculatory duct which traverses the prostate to open into the urethra at the verumontenum or colliculus seminalis. The testes is divided into 200 to 300 lobules each containing one to three seminiferous Macroscopic Anatomy tubules. Each tubule has a basement membrane the testis lies anteriorly in the scrotum and has the epididymis attached to its posterior and contains several layers of developing surface. The fibrous capsule, the tunica albuginea and each basal layer of cells consist of spermatogonia is invaginated laterally and anteriorly into a which divide to form primary spermatocysts, double serous covering the tunica vaginalis. These in turn fluid between the parietal and visceral layers devide to form spermatids which eventually mature into spermatozoa. In between the seminiferous tubules lie Blood Supply the interstitial cells of Leydig which secrete the testicular artery arises from the aorta. The seminiferous tubules each about 2 feet anastomoses with the artery to the vas supplying the vas deferens and epididymis, which (62cm) in length anastomose posteriorly into arises from the inferior vesical branch of the a plexus termed rete testis from which about internal iliac artery. This anastomosis is impor- a dozen efferent ducts arise, pierce the tunica tant because ligation of the testicular artery is albuginea at the upper part of the testis and pass not necessarily followed by testicular atrophy. The efferent ducts fuse to form a considerthespermaticcord,thepampiniformplexus to the testicular vein.

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