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Extending from the lateral uter- b ine margin purchase precose with paypal diabetes zentrum mergentheim, the broad ligament connects with the lat- eral pelvic wall buy precose 50mg with mastercard diabetes mellitus signs of hypoglycemia. Thus buy genuine precose diabetes mellitus pathophysiology, the subperitoneal continuity is formed from the pelvic extraperitoneum to the broad ligament to the pelvic organs. The specialized portions of the broad ligament are the mesosalpinx containing the fallopian tubes; the suspensory ligament of the ovary containing the ovarian vessels, lymphatics, and nerves; and the mesometrium containing the uterus. The cardinal ligaments (transverse cervical liga- ments) are the inferior thickened portion of the broad ligament extending from the cervix to the pelvic diaphragm. Direct spread and lymphatic spread from carcinoma uterus to the sacrum and the round ligaments extend of vagina. Tumors of the lower third of the vagina involve inguinal nodes; tumors of the vaginal vault Invasive cervical cancer represents approximately involve the hypogastric and obturator nodes; tumors 15% of gynecologic cancer deaths. Hema- number two cause of cancer death, behind breast can- 14 togenous spread is most frequent to the lungs, while cer, for women in their third decade. For age- 13 adjusted cancer death rates, there has been a steady spread to the liver and bones is less frequent. Direct extension of cervical cancer occurs after the The uterus is located in the lower pelvis, anterior to the cancer breaks through the basement membrane and rectum and posterior to the urinary bladder. It is penetrates the cervical stroma directly or through vas- divisible by the internal os into two regions, the cervix cular channels. The fundus is that portion of the body of Stromal invasion progresses until the carcinoma the uterus above the entrance of the fallopian tubes. Vaginal extension initially is to the upper vagina tion is surrounded by parametrium, which separates but eventually extends to the lower portion. Coursing the broad ligament to involve the ureters and extend to within the broad ligament are the uterine vessels, lym- the lateral pelvic side walls (Fig. The ureters are anterior sion is along the extraperitoneum of the pelvis to the 352 15. Patterns of Spread of Gynecologic Disease women, average age 60 years, with increased risk in patients with diabetes mellitus and hypertension. This mass is friable and necrotic causing bleeding, which is the presenting symptom in 90% of patients. The natural history is for the tumor to spread along the endometrial surface and invade the myometrium. The depth of invasion is of significance as the incidence of lymphatic spread increases as the cancer invades the myometrium, 19 especially with greater than 50% involvement. Subperitoneal spread to parametrium from cervical cervix, which is associated with increase in extrauterine cancer. Fixation to the lateral side wall also occurs Breech of the uterine serosa can lead to direct spread with coalescence of pelvic adenopathy and a cervical across fascial planes to adjacent organs including the mass. Direct extension to contiguous organs is uncom- urinary bladder and sigmoid colon. The fundus and superior portion of the Lymphatic spread within the subperitoneal space uterus drain with the ovarian vessels and lymphatics occurs from the cervical lymphatic plexus to the lower to the upper abdominal paraaortic nodes. The middle uterine segment to three groups of draining lympha- and lower regions drain through the broad ligament tics. The upper lymphatics follow the uterine artery, along uterine vessels to the internal iliac nodes. Occa- cross the uterus, and drain to the upper internal iliac sionally, disease spreads to the superficial inguinal (hypogastric) nodes. The lower lymphatics drain to Hematogenous spread is uncommon, especially at the superior and inferior gluteal nodes. Recurrence is most often to the liver, drain cephalad to the common iliac nodes and para- lung, bone, and brain. Supraclavicular node involvement is frequent and represents nodal spread from the para- the peritoneal cavity with resultant intraperitoneal aortic nodes to the cisterna chyli via the thoracic duct spread. Patients with negative nodes have a 90% 5-year survival; those with pelvic nodes have a 50–60% Fallopian Tube 5-year survival; those with paraaortic nodes have a 16,17 20–45% 5-year survival. Fallopian tube carcinoma is the least common site of a Distant recurrence is most frequent to the lung, liver, primary gynecologic malignancy. Lumbar spine involvement is most often by the most common site of origin and mostly present 18 as papillary serous adenocarcinomas. The fallopian tubes, approximately 12 cm long, reside at the edge of the mesosalpinx in the superior Cancer of the Uterine Body lateral portion of the broad ligament.

On the left cheap 50 mg precose visa diabetes of america, note the posterior extent of the lesser sac bounded by the splenorenal ligament within which distal splenic vessels course (arrowhead) cheap 50mg precose with mastercard diabetes prevention program ymca. Radiologic–Anatomic Classification of Intraperitoneal Abscesses Supramesocolic Inframesocolic Right subphrenic Pelvic Anterior Paracolic Posterior Right Right subhepatic Left Anterior Infracolic Posterior Right (Morison’s pouch) Left Left subphrenic Lesser sac Modified with permission from Meyers and Whalen purchase precose without prescription definition of uncontrolled diabetes mellitus. It is important to recognize that only after Mori- son’s pouch is contaminated does the infected material reach the right subphrenic space (Fig. The fluid extends around the inferior edge of the liver or laterally from Morison’s pouch along the inferior reflection of the right coronary ligament and then ascends in the flank to the space above the dome Fig. The triangular-dependent recess of Morison’s pouch is opacified by a small amount of contrast medium. This is bounded posteriorly by the kidney (K), medially by the descending duodenum (D), and inferiorly by the proximal transverse colon (C). The outline particularly of gaseous collections at this site has been referred to as the Doge’s cap sign, since its configuration typically has the shape of a peaked cap reminiscent of ‘‘Il corno,’’ the renaissance headgear worn by the Doge of Venice. Intraperitoneal Spread of Infections and Seeded Metastases passage from the right subphrenic space across the midline to the left subphrenic space is prevented by the falciform ligament. These dynamics of flow explain the incidence and location of intraperitoneal abscesses reported empiri- cally in large clinical series. The frequency of subphre- nic and subhepatic abscesses is two to three times greater on the right than on the left, and the most common site is Morison’s pouch. Abscesses localized solely to the right anterior subhepatic space are rela- tively uncommon. Clinical evi- dence of abscesses limited to the right subphrenic space, however, is not uncommon, but it can be assumed that some contamination of the right posterior subhepatic space had already occurred, perhaps manifested only by some residual inflammatory adhesions. In addition to the ana- tomic pathways and action of gravity, variations in intraperitoneal pressure also determine the distribution of peritoneal fluid. Fluid surmounts the sacral promontory and flank muscles to extend upward, 25 whether the patient is horizontal or erect. The hydrostatic pressure of the contents of the abdominal cavity together with the flexibility of a portion of the abdominal wall determines, for the most part, the pressure within the abdominal cavity. The intraperitoneal pres- sure in the upper abdomen is subatmospheric and decreases further during inspiration. This negative subdiaphragmatic pressure and its relation to breath- ing are maintained in the horizontal or erect position. This is explained by the outward movement of the ribs during inspiration, which enlarges the space in the upper abdomen more than it is decreased by the des- 27 cent of the diaphragm. Salkin subsequently con- firmed these observations in humans, noting in a series of 50 cases that most showed an intraperitoneal pres- Fig. Right subphrenic abscess, following perforation of a sure of from 0 to À30 mm H2O and that pressure is less 28 duodenal ulcer. It is demarcated by the attachments pressure averages 8 cm H2O and in the upright posi- of the falciform ligament anteriorly (arrow) and the superior tion pressure in the lower abdomen is almost three coronary ligament posteriorly (curved arrow). These pressure Radiologic Features 83 differences with positional and respiratory variations the lesser sac itself. Hydrostatic pressure encountered most often following perforated poster- differences between the lower and the upper abdomen ior ulcers of the stomach or duodenal bulb and pan- are capable then, even in the upright position, of con- creatitis (Figs. Lesser sac abscesses typically distend the space and Fluid introduced into the right supramesocolic area displace the stomach anteriorly and the transverse 18 follows similar pathways. Meyers noted that adhesions devel- directly into Morison’s pouch, with progression to oping along the peritoneal fold raised by the left gas- the right subphrenic space and, via the right paracolic tric artery often clearly partition an abscess to one of gutter, to the pelvis. This has 13 major path of communication by which infection since been confirmed by others. It was not until the development of ally extend into its lower recess between the leaves of peritoneography by Meyers that the effects of intraab- the greater omentum (Fig. Left Subphrenic Abscesses Lesser Sac Abscesses Abscesses in the left subphrenic space may result from Anatomically, Morison’s pouch communicates with perforated anterior ulcers of the stomach or duodenal the lesser sac via the epiploic foramen. Noninfected bulb, but they are seen particularly as complications of intraperitoneal fluid originating within the greater gastric or colonic surgery as a consequence of an peritoneal cavity may thus readily gain entrance to anastomotic leak and of splenectomy. However, this slit-like con- The most consistent aspect of flow of fluid arising in nection is easily sealed off by adhesions, so the lesser the left upper quadrant is that it is preferentially direc- sac is not usually contaminated in generalized perito- ted upward to the subphrenic area, where an abscess nitis unless the primary infection arises in the walls of typically coalesces (Fig. Contrast enema performed in a child following perforation of the rectosigmoid junction (R ¼ rectum; S ¼ sigmoid colon). Acute pancreatitis with development of lesser sac c pseudocysts and extension into greater omentum.

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The challenge is to find and than aspirin); the commonest adverse reaction was avoid these precose 50 mg without prescription diabetes mellitus or diabetes insipidus, and precose 25 mg generic diabetic ketoacidosis lab values, indeed cheap precose line diabetes medications erectile dysfunction, the present systems for detecting gastrointestinal bleeding. Many drugs possess anticholinergic activity either directly (atropine, oxybutynin) or indirectly It is important to avoid alarmist or defeatist reactions. Thefirst-generation H1-receptoran- biliary stones or hernia and to refuse to accept any risk at tihistamines (chlorphenamine, diphenhydramine) are no- all from drugs for conditions of comparable severity. Drugs wholly caused by drugs, are dangerously ill already; justifi- may also affect performance through cerebral depression able risks may be taken in the hope of helping them; ill- (antiepileptics, opioids), hypoglycaemia (antidiabetics) informed criticism in such cases can act against the interest and hypotension (antihypertensives). This is often more obvious Car driving is a complex multifunction task that in- when reviewing the conduct of treatment after the event, cludes: visual search and recognition, vigilance, informa- i. It is plain that tury, said that ‘medicine is an art founded on conjecture prescribers have a major responsibility here, both to warn and improved by murder’. Although medicine has ad- patients and, in the case of those who need to drive for their vanced rapidly, there is still a ring of truth in that statement, work, to choose medicines with a minimal liability to cause as witness anyone who follows the introduction of new 11 impairment. Patients who must drive when taking a drug drugs and observes how, after the early enthusiasm, there of known risk, e. It is also essential that patients Aspects of the above appear throughout the book as is be advised of the additive effect of alcohol with prescribed indicated. How the patient feels is not a reliable guide to recovery of Age skills, and drivers may be more than usually accident prone without any subjective feeling of sedation or dysphoria. The very old and the very young are liable to be intolerant The criteria for safety in aircrew are much more stringent of many drugs, largely because the mechanisms for dispos- than are those for car drivers. The young are not Resumption of car driving or other skilled activity after simply ‘small adults’ and ‘respect for their pharmacokinetic anaesthesia is a special case, and an extremely variable variability should be added to the list of our senior citizens’ rights’. The emphasis on psychomotor and physical aspects (in- jury) should not distract from the possibility that those Sex who live by their intellect and imagination (politicians and even journalists may be included here) may suffer cog- Females are more likely to experience adverse reactions to nitive disability from thoughtless prescribing. The porphyrias comprise a number of rare, genetically de- • The known nature of the drug may forewarn. The capacity of the body to (porphyria cutanea tarda, erythropoietic protoporphyria eliminate certain drugs, e. Use of these and other drugs may raise variegate porphyria and hereditary co-proporphyria) are longer-term issues of mutagenicity, carcinogenicity and characterised by severe attacks of neurovisceral dysfunction teratogenicity. Ingredients of a formulation, rather than precipitated principally by a wide variety of drugs (also by the active drug, may also cause adverse reactions. Clinical effects arise from Examples include the high sodium content of some the accumulation of the precursors of haem synthesis, antacids, and colouring and flavouring agents. Induc- The environment and social habits tion of the haem-containing hepatic oxidising enzymes of the cytochrome P450 group causes an increased demand Drug metabolism may be increased by hepatic enzyme in- for haem. Therefore drugs that induce these enzymes duction from insecticide accumulation, e. Apparently unexplained at- bials used in feeds of animals for human consumption tacks of porphyria should be an indication for close en- have given rise to concern in relation to the spread of resis- quiry into all possible chemical intake, including tant bacteria that may affect man. Penicillin in the air of recreational substances such as marijuana, cocaine, amfeta- hospitals or in milk (see below) may cause allergy. Great care in prescribing for these patients is required if Allergic reactions to drugs are the result of the interaction of serious illness is to be avoided and it is therefore essential drug or metabolite (or a non-drug element in the formula- that patients and their clinicians have access to information tion) with patient and disease, and subsequent re-exposure. Drug Lack of previous exposure is not the same as lack of his- lists should be reviewed regularly, and a recent initiative tory of previous exposure, and ‘first dose reactions’ are in Europe has made a consensus-based list of safe drugs among the most dramatic. Immune responses If no recognised safe option is available, use of a to drugs may be harmful in varying degrees (allergy) or drug about which there is uncertainty may be justified. The clinician should assess the severity antibodies to penicillins but, fortunately, comparatively of the conditionandtheactivityoftheporphyriaandmakea few react clinically to penicillin administration. Measure porphyrin and porphobilinogen before tigens in combination with a body protein. Repeat the measuremenThat regular intervals or if the ratory tract, gastrointestinal tract, blood and blood vessels. Allergic reactions in general may be classified according If there is an increase in the precursor levels, stop the to four types of hypersensitivity, and drugs can elicit reac- treatment and consider giving haem arginate for acute tions of all types. Addi- bodies, activating but not damaging the cell to which they tionally, attention to nutrition, particularly the supply of are fixed and causing release of pharmacologically active carbohydrate, relief of pain (with an opioid), and of hyper- substances, e.

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The body • Version refers to the axis of the cervix relative to the narrows to a waist called the isthmus purchase precose no prescription diabete type 2 symptoms, below which lies vagina buy precose master card diabetic diet low sodium. The cavity communicates with the cervical canal via the internal os and the cervical Relations canal communicates with the vagina via the external os discount precose master card blood glucose gestational diabetes. The peritoneum is refected up over the anteroinferior surface of the uterus forming Size and shape the vesicouterine pouch before passing of the posterior surface of the uterus and up over the rectum to form the Vascular supply rectouterine pouch of Douglas. Uterine arteries give rise to the arcuate arteries seen in the outer one-third of the uterus. Lymph supply Right ovary • Fundus: para-aortic nodes • Body/cervix: internal and external iliac nodes, a few Uterus accompany the round ligament through the inguinal canal to the superfcial inguinal nodes Rectum Nerve supply Bladder • Derived from inferior hypogastric plexus especially uterovaginal plexus which lies in the broad ligament Fig. Size and position of the uterus can be determined as well by a thin layer of connective tissue as gross pathology. Lined by columnar (non- • The muscular myometrium forms most of the uterine ciliated) epithelium and tubular glands. The functional layer surrounding the echogenic line has become more hyperechoic due to increased mucus and glycogen within the glands as well as increased number of interfaces caused by the tortuosity of the spiral arteries (Fig. A central localizer Endometrium point on each image shows the precise location in all three of uterus planes. Central echogenic line due to opposed endometrial surfaces surrounded by thicker hypoechoic functional – compares to reproductive age but no cyclical layer bounded by outer echogenic basal layer. The central echogenic line is due to the interface of the opposing surfaces of the endometrium. The functional layer of the endometrium surrounding the echogenic line is hyperechoic at this stage. Small follicles in low signal outer stroma Endometrium Outer myometrium Left ovary Inner myometrium Uterus Fig. Volume Weight Size Follicles • In nulliparous females they may have branches running 0. It connects the superior end of the ovary to Double in size in the lateral pelvic wall. Tese drain into the inferior vena cava on the right • Anterior: obliterated umbilical vein and the renal vein on the lef. Nerve supply • Ovarian plexus formed from the aortic, renal, superior and inferior hypogastric plexuses. Medullary portion of ovary Internal anatomy •The ovary consists of a central vascular medulla and an outer cellular cortex. Uterus didelphys Uterus bicornis bicollis Congenital anomalies •The fused caudal ends of the two Müllerian ducts form the uterus/cervix/upper vagina. Uterus bicornis unicollis Uterus unicornis unicollis Imaging during pregnancy Accurate sagittal and transverse measurements of the mother’s pelvic inlet and outlet can help in predicting the likelihood of a vaginal delivery. Tese measurements include: • the sagittal inlet (between the promontory and the top of the pubic symphysis) • the maximum transverse diameter of the inlet • the bispinous outlet (the distance between ischial spines) • the sagittal outlet (the distance between the tip of the coccyx and the inferior margin of the pubic symphysis). Diagnostic imaging may also be required during pregnancy · thick echogenic ring to assess the abdominal or pelvic viscera or the placenta. However, if it is non-diagnostic then further imaging with • Menstruation – corpus luteum involutes. In early pregnancy the 276 Chapter 14: The female pelvis Placenta Vertebral column Fetal head Myometrium Amniotic fluid Bladder Fig. Lumbar spine Twin 1 Twin 2 Placenta praevia - low lying placenta covering Bladder internal cervical os Fig. Fluoroscopy coracoclavicular ligament with: allows real-time dynamic radiographic assessment of the • a bony protuberance, the conoid tubercle osseous anatomy and assessment of the joints using fuoro- • a lateral roughening, the trapezoid line. High-resolution 3D · spine: posteriorly, dividing the posterior surface into reconstructions of the upper limb allow interrogation in any supra- and infra-spinous fossae desired plane. It is • Tree types of morphological normal variations of the particularly optimal for visualization of small and superfcial acromion process have been classifed by Bigliani, with a structures (ligaments, tendons) as well as muscle compart- fourth type more recently classifed by Vanarthos (Fig. Tese regions are connected by the shoulder, elbow and wrist joints overlain by transitional zones, the axilla, antecu- Proximal humerus bital fossa and carpal tunnel, which facilitate the passage of • Two bony protuberances, the greater and lesser tubercles, neurovascular structures ( Fig.