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The functioning part of the aneurysm is hyperdense cheap extra super cialis 100 mg without a prescription list all erectile dysfunction drugs, thrombotic masses are isodense cheap extra super cialis 100 mg line erectile dysfunction doctor karachi, and the third and the lateral ventricles are markedly dilated with periventricular oedema 218 Chapter 3 Cerebrovascular Diseases and Malformations of the Brain 219 9 Fig generic extra super cialis 100mg online erectile dysfunction pump implant. The examination estimated the blood refow with compression of the contralateral carotid artery on the neck (a–c) Fig. Lef internal carotid artery aneurysm (a,b), anterior cerebral–anterior communicating artery aneurysm (c). The examination estimated the blood refow with compression of the contralateral carotid artery on the neck Fig. The aneurysm is indicated by the arrow plex, and therefore the important moment in angiography is The new breakthrough in digital angiography was made estimation of the intra-aneurysmal blood fow, which is one with the invention of the 3D method of data collection and of the factors in preoperational planning of the endovascular reconstruction with subsequent computer processing of ob- occlusion (Fig. However, it should be noted that even with use of digital angiography, the reason for subarachnoid haemorrhage re- mains unknown in 10–25% of cases. Hyperdense areas in the frontomediobasal region are visualised, more lefwards cerebral artery–anterior communicating arteries (Fig. Calcifcations in them into categories depending on the degree of aneurysm’s the walls of giant aneurysms are denser in comparison with cavity flling by the thrombotic masses: functioning, partially the parietal thrombi (Fig. It is possible to make entiate between the functioning part of aneurysm’s sack and judgments regarding the particular vessels afected by vasos- the part flled with thrombotic masses. Giant aneurysm of the lef middle cerebral ar- with volume-rendering sofware in the same patient 226 Chapter 3 Fig. The anterior cerebral and anterior communicating arteries: axial rysm of anterior cerebral and anterior communicating arteries (c). Axial and sagittal reformation in the anterior cerebral and anterior cerebral–anterior communicating artery, the lef internal anterior communicating artery aneurysm (d–f) 228 Chapter 3 Fig. Carotid (a) angiography: borders spatial relationships of the internal carotid artery aneurysm and the of the sack aneurysm are uneven due to partial thrombosis. Virtual (e) endoscopy: borders of the sack ormation (b,c) in sagittal and coronal projections: large sack aneu- aneurysm are uneven due to thrombotic masses. No signs of a part of aneurysm with thrombosis Cerebrovascular Diseases and Malformations of the Brain 231 Fig. Т2-weighted imaging (a), with concomitant peripheral subacute haemorrhage (arrow). Mural Т1-weighted imaging (b) and in sagittal plane Т1-weighted imag- thrombus is seen on Т1-weighted imaging in the aneurysm Fig. It is especially evident nal due turbulent blood fow in the aneurysm’s cavity is ob- in case of a marked aneurysm’s neck (Figs. Additional com- aneurysm contours moving in the phase-encoding direction puter processing (on the workstation) helped with this pro- is a typical feature of a functioning aneurysm (Fig. Pulsatile artefacts in the phase-encod- ing direction are clearly visualised (arrows) Fig. Т1-weighted imaging (a): subarachnoid haemorrhage in the lef Sylvian fssure (hyperintense areas). Aneurysm is reliably rysm of the anterior cerebral–anterior communicating arteries on visualised only afer 3D (d) reconstruction (arrow). Т1-weighted imaging before (a–c) and afer (d–f) contrast en- hancement reveals marked hyperintense signal from the functioning part of the aneurysm afer enhancement 238 Chapter 3 Fig. Т2-weighted imaging (a,b), Т1-weighted imaging before (c) and afer (d) contrast enhancement. Terefore, subsequent 3D re- In T2-weighted imaging the thrombi may have hyper- or construction of arteries is seriously complicated by a venous hypointense signal. In these situations, Cerebrovascular Diseases and Malformations of the Brain 239 Fig. Perifocal oedema is also revealed imaging (c) demonstrate a laminated character of thrombotic masses Fig. Т2-weighted imaging (a), and Т1-weighted imaging before (b) and afer (c) contrast enhancement: there is an aneurysm with small functioning part (arrow) Fig. Т2*-weighted imaging (a) reveals a large an- of methaemoglobin in the part with thrombosis. Peripheral zone is hypointense (haemosiderin de- Cerebrovascular Diseases and Malformations of the Brain 241 Fig. In some cases—especially in situations and massive subarachnoid bleedings with increased density with a multiple peripheral aneurysms and intense atheroscle- that can hide aneurysm. The presence or absence of changes that accompany aneu- However, considering the fact that as a rule, patients during rysm, such as acute and subacute haemorrhages, sequelae of this period are in a severe condition, appropriate sedation is Fig. Т2-weighted imaging (a) and Т1-weighted imaging (b) demonstrate the round area of signal change. A thin neck of a sack aneurysm is clearly seen (arrow) Cerebrovascular Diseases and Malformations of the Brain 243 Fig. Relationship of the aneurysm and the artery is better demon- strated on 3D reconstruction Fig. The hyperintense area in the right temporal lobe within optic tract and internal capsule indicates ischaemic change 246 Chapter 3 Fig. Т2-weighted imag- ing demonstrates a hyperintense area in the insular lobule of the temporal lobe necessary to avoid motion artefacts. Blood is detected on Т1-weighted imaging (b) and Т2-weighted imaging (c), and the aneurysm itself is seen (arrow). Among all classifcations, the most popular for neurosur- geons are those based on the information about malformation location, its size, sources of supply, ways of venous outfow and 3. In Russia, Matsko (1991) proposed dividing vascu- The frst attempts to create a classifcation of the brain ves- lar malformations of brain and spinal cord into angiomatous, sel malformations were completed long ago; therefore, now non-angiomatous and unclassifed malformations. All of them to some extent and Huddle 1998; Osborn 1999) have ofered a new classifca- refect the completeness of the medical knowledge concerning tion that takes into consideration clinical, anatomical and his- diagnostics and treatment of the vascular malformation on tological data, biological behaviour and visual characteristics the certain stage of development: pathological, demographic, of vascular malformations. The pseudo-enhancement efect of the Т1-weighted imaging (b) demonstrate a small sack aneurysm of the haemorrhage does not prevent visualisation of the aneurysm. The 9th day (d), it is possible to detect the functioning part of aneurysm (arrow) afer haemorrhage. Т1-weighted imaging (a): there is a markedly hy- on the background of the old haemorrhage with calcinated walls. Plexiform node lary net, and the dilated arteries immediately pass to drainage ii. Single or multiple fstula(s) evident structural changes starting from uneven thickening ii. Mono- or multipeduncular of a muscular layer and vessel’s intima to marked attenuation 2. Malformation without arteriovenous shunting or complete disappearance of the elastic membrane are ob- a. Venous malformations Vessels of the venous type, as a rule, are widened; the main i. Venous varix (without relation with malformation companying changes of a brain, such as the traces of old hae- and dural arteriovenous fstulas) morrhages, gliosis and hyperplasia of glia, are ofen detected c. Arteriovenous malformation of subtentorial region in the arterial and venous phases (d–f) 252 Chapter 3 Fig. It is necessary to note that quite ofen ies from 67% (Filatov 1973) to 78% (Yasargil 1987).

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The anterior type of lesion choroid artery purchase extra super cialis 100mg on line erectile dysfunction drugs don't work, posterior communicating artery generic extra super cialis 100 mg visa top erectile dysfunction doctors new york, and posterior – Focal cervical haematoma should be diferentiated from cerebral artery are also displaced in the inferior medial direc- a pseudo-aneurysm and dissection of the carotid artery tion in severe descending impactions cheap extra super cialis 100 mg otc impotence age 40. Infarctions of occipital – Hypodensity of the white matter and cortical layers of lobes are caused by compression of the posterior cerebral ar- the cerebral hemispheres may occur due to ischaemia tery between the brainstem and tentorium cerebelli. Coiling or vasospasm and occlusion of small perforans vessels are frequently seen. Carotid tion of cerebellar vermis and hemispheres via the tentorial and vertebral artery territories are examined (special atten- incisure and is frequently combined with infratentorial trau- tion should be paid to their petrous parts), as well as anterior matic injury. Obstructive hydrocephalus may ones), as it ascertains unevenness of walls, and changes in cal- occur afer occlusion of the Sylvian aqueduct. Impaction of cerebellar tonsils is due to displacement of the Examination of patients with suspected arteriovenous latter through the foramen magnum, which is obliterated, and fstulae should be made only with cerebral angiography. Damage of squama of right temporal bone, traumatic damage of the right frontotemporal area, oe- dema, and descending transtentorial herniation. Pathological dumping fow from the right vertebral artery to the venous system of the right posterior cervical region. Selective angiography of the verte- bral artery reveals pathological fow from the lef vertebral artery into the venous plexus at C1 level (a direct and b lateral projections) Head Trauma 887 Fig. Prolongation of T1 and T2 relaxation times is seen in brain injury; however, precise pathophysiology of intracranial the afected gyri and grey matter nuclei. As is intracranial blood fow, the central brain impaction is seen— believed, the main cause of brain death is rise of intracranial basal regions of cerebral hemispheres, midbrain, and cerebel- pressure due to difuse brain oedema (Kornienko 1981; Wal- lar tonsils are displaced downward, and both temporal lobes ner 1998; Ishii et al. Angiographic examinations (angiography, МRА, higher than that of cerebral hemispheres); with a background CТА) fail to reveal intracranial blood fow—it is absent above of hypodensive brain tissue basal cisterns may look hyperden- the supraclinoid part of the internal carotid arteries and in the sive. The Lac peak refects the activation ments of cerebral arteries of anaerobic glycolysis. In focal aneurysms), arteriosinus fstulas, sinus-thromboses, and de- lesions, necrotic detritus dissolve within 6–12 months afer layed and chronic haematomas. Cysts are surrounded by gliosis and should remember that there exist such brain injuries that can- haemosiderin cicatrices. Cystic–gliosis changes in the lef temporal area, dilatation of the lef lateral ventricle. Reduction in size and the ventricular system, without signs of its occlusion and volume fornix and hippocampus may also be found in the (Figs. Less frequently, at- Modern neuroimaging allows studying not only structural, rophy of infratentorial structures develops. The examination of the patient with the persistent minimal consciousness state, tetraparesis and hyperkinesis in the lef hand. Craniography identifes location, size, and contours of the defect and visualises any infammatory The problem of restoration of cranial integrity afer large complications (osteomyelitis) present (Fig. To avoid craniography is a capacity for precise assessment of crani- reciting of all items of this classifcation we would like to em- obasal and cranio-orbital posttraumatic skull defects. The tects size, shape, and location of posttraumatic skull defects latter are caused by resection or decompression trepanation with more precision. In addition, 3D reconstruction not Craniography in two standard projections is done initially. It is especially important in modelling of cranio-orbital bone defects before an operation. If brain tissue and meninges pouch out of the defect, then it is called meningoencephalocele (Fig. Menin- goencephalocele in the right parietal bone defect, hydrocephalic dilatation of the ventricles. Intrusion of brain tissue into the skull bone defect may lead to strangulation, oedema, and hyperaemia, as was 9. In severe injury, we observed cases when meningoencephalocele was combined with carotid cavernous In large posttraumatic skull defects (especially of skull base) fstula (Fig. Growing cranial fractures develop due to constant (in skull base fractures), from infectious lesions (in purulent otitis, mastoiditis, sinusitis), or perineurally alongside cranial nerves in craniofacial injury. Encephalitis and abscess are the result of extracerebral infection and are frequently seen in oti- tis, mastoiditis, sinusitis, skin infections, or penetrating cra- nial injuries, or may be caused by osteomyelitis. The targets of infection are contusion lesions, petechial haemorrhages, and foci of oedema. Initially this area may be restricted to the white matter or even to a certain anatomic region or cerebral lobe (Fig. Further progression may lead to expansion into the grey matter or the contralateral hemisphere (generalisation) (Fig. Т1-weighted imaging may reveal hypoin- gyri is lost, and lateral ventricles may be narrowed or mod- tense signal in the area of primary infammation along with erately dilated. Accumulation of contrast medium is absent in traumatic abscesses is highly variable and comprises 2–26. Tickness of walls may above the cerebral hemispheres (80%), interhemispheric fs- be small (1–3 mm); less frequently it reaches 5–6 mm, and sure (12%), and frontal region, for epidural empyemas (Sze usually it is identical throughout the whole length. It is explained by poor vascularisation of deep brain area (containing pus) adjacent to the internal cranial surface parenchyma, and this factor determines rupture of an abscess or falx. Oedema may be seen in the Since the abscess centre becomes necrotic, Т1 and Т2 relax- adjacent white matter. Multiplanar examination (especially when coronal sec- compared with the surrounding oedema and brain tissue due tion is used) improved diagnostics for cases with paratentorial to high viscosity and cellular content of pus (Fig. Dura mater appears as hypointense rim separating brain centre of an abscess such resonance peaks as Lac, Ala, acetate, tissue and the epidural space. The pathogens of posttraumatic meningitis Clinical improvement in patients with brain abscesses cor- may be of a bacterial, fungal, viral, or parasitic nature. When infection continues to etrating skull injuries, craniotomy, and osteomyelitis of the develop, mild hyperdensity may be seen in basal cisterns, in- bone graf and the edges of bone defects. The most frequent terhemispheric fssure, and choroid plexus, which is the result locations of subdural empyemas are the convex brain surface of the combination of hypervascularity of infected meninges Head Trauma 905 Fig. Lateral and third ventri- cumulation of contrast medium in the ependyma of the lat- cles may be narrowed due to difuse brain oedema. Narrowing mulation of contrast medium is more ofen seen along the of subarachnoid spaces, and thickening and hyperintensity of walls of the lateral ventricles. Pathogenesis of posttraumatic hydrocephalus secondarily to leptomeningitis in retrograde expansion of in- is variable. Obstruction usually involves convex subarachnoid Afer surgical interventions (shunting, etc. Blood resorption and asep- tic infammation lead to sclerosis (or desolation) of arachnoid 9.

Within months he lost all hand ed order extra super cialis 100mg overnight delivery erectile dysfunction caffeine, nodular antebrachial cutaneous nerve of the forearm is shown trusted 100mg extra super cialis erectile dysfunction medication list. Note the pigmented freckles within the axilla and around the entire arm including the hand functioned very well post operatively and affected breast (Crowe’s sign) the skin overlying the involved tissue buy generic extra super cialis on-line causes of erectile dysfunction include. Both plexiform types of lesions carry a contained within the subcutaneous space and characteristi- high risk of malignant degeneration (. They have the same Multiple neurofbromatosis affects neural tissue of several unpredictable growth patterns as the nodular form. These areas including the brain, spinal cord, cranial nerves, and pe- diffuse lesions can be massive and may involve the thorax ripheral and sympathetic nerves. It may involve any organ with extension into the upper limb or the pelvis and into in the body from the skin to bone as in congenital pseudoar- the lower limb. Associated Syndromes These are often presenThat birth and may increase in number and size with increasing age. Approximately 25 % of neurof- Von Recklinghausen disease bromas are located in the head and neck region, [2] with 6. The Noonan syndrome for example is quite similar to the Turner syndrome and a clear defnition between the two will become more specifc. Of practical im- portance to the upper limb surgeon are the occurrence of com- pression neuropathies, peripheral nerve sheath tumors, and the secondary degeneration of the plexiform neurofbromas. The three syndromes discussed below are grouped together due to their increasing genotypic and phenotypic similarities. Sporadic and multiple neurofbromas in the head and neck region: a retrospective study of 33 years. He is best known for his descrip- tion of hemochromatosis and iron accumulation within body tissues. The cutaneous nodules have many the following clinical features [2]: (1) six or more skin cafe- forms as indicated and with the exception of the diffuse plexi- au-lait spots, (2) axillary or groin freckling, (3) two or more form type develop during the childhood years. Nearly all patients (97 %) exhibit enough features to allow diagnosis by 8 years of age, and almost all General musculoskeletal In addition to the multiple skin will by 20 years of age [1–4]. The incidence is approximately lesions, bone dysplasia is most commonly manifested as 1/3,000 live births. Upper extremity Painful enlarging skin tumors may be pres- Presentation Only those with striking skin manifestations ent within the upper limb. The cutaneous freckling within the of diffuse plexiform types will be evidenThat birth. The axil- axilla is more commonly associated with the Noonan varia- lary freckling (Crowe’s sign) is usually detected between 2 tion. These are typically smaller than 1cm and the anterior and posterior surfaces of the upper limb as well may also occur around the breasts, above the eyelids, and on as on the dorsal surfaces of the wrist and hand. Multiple cutaneous nodules begin to grow in early stain similar to a capillary malformation typically overlies in- childhood and can occur anywhere on the body and continue to volved regions of subcutaneous tissue. Café-au- mas do arise beneath the glabrous surfaces of the palm of the lait spots are cutaneous macules, which begin to develop within hand and the sole of the foot. To meet diagnostic criteria more than with rubbery, mobile palms or soles, which make walking or six macules greater than 5 mm (prepubertal) or > 15 mm (post- gripping challenging. The longest diameter of each surface as all the abnormal growth is within the dysplastic fat lesion is measured. At surgery there is a clear demarcation between the nor- within the iris and on slit lamp examination are pathognomonic mal and dysplastic adipose tissue planes. Malignant degeneration occurs in 2–5% of patients is typical of the diffuse plexiform type and is a clear external and almost exclusively in the plexiform type and develops in demarcation of the underlying pathology. Café-au-lait macules be quite large with involvement of the ipsilateral chest wall 24 3 Neurofbromas Fig. Spine Kyphoscoliosis and scalloping and erosions of the Secondary kyphosis, scoliosis, or a combination of both will posterior elements and/or the vertebral bodies occur due to develop with growth. Skeletal changes and secondary deformity may Peripheral neuropathies occur more commonly in this occur at any level of the pediatric spine and become apparent group of patients than suspected. Compression at the root level within the macrocephaly, Lisch nodules (iris hamartomata), and optic paraspinal regions must be considered. These lesions are typically present early and usually increase in size as the children not painful. The lifetime risk brainstem gliomas, which typically present with signs and of developing this tumor varies with reported series but it is symptoms of increased intracranial pressure. These are rapidly growing, invasive lesions with a poor prognosis with the fve-year event free and overall survival rates being 19% and 28%, respectively [7]. Use of the National Institutes of Health Criteria for Diagnosis of Neurofbromatosis 1 in children. A pectus Female pseudo-Turner syndrome deformity of the sternum and winging of the scapula may Turner phenotype with normal karyotype be present. In older patients pigmented sky in 1883 but further delineated by Noonan and Ehmke villonodular synovitis involving the more proximal joints of [1] in 1963. The incidence is diffcult to determine but Lower extremity The patient may have hypoplastic or ab- varies from 1 in 1,000 to 1 in 2,500 live births. Presentation There are overlapping features of Noonan and Craniofacial These include; epicanthal folds, eyelid ptosis, other neurofbromatosis syndromes. The typical Noonan pa- low-set and posteriorly rotated ears, deeply grooved philtrum, tient has feeding diffculties, a failure to thrive, and a mental and webbing of the neck. Giant cell tumors involving the disorder, which fortunately is mild in the majority [2]. The characteristic facial Systemic Genitourinary manifestations include cryptor- appearance includes hypertelorism, low set and posteriorly chidism and hypogonadism. Cardiovascular anomalies are rotated ears with small lobules and deeply grooved philtral common and two thirds of all patients have pulmonary valve ridges. Bleeding diathesis was reported among General musculoskeletal Short stature is common. These may include thrombocytopenia, Von Willebrand disease, and bleeding discrepancies. Vascular Malformations 4 Vascular malformations differ histologically and in their nat- anomalies is still in its embryonic stages as multidisciplinary ural history from hemangiomas, which are the most common teams are being established at most major medical centers. These are structural and Many new syndromes are being described as the large group morphologic anomalies that result either from residual em- of vascular anomalies which formerly were all called “hem- bryonic angiodysplastic cells or arrest of embryonic develop- angiomas” among other terms is now being carefully studied ment. They are usually presenThat birth, grow proportionately and redefned based on their natural history, physical fndings, with the child, and do not regress as hemangiomas do [1,2]. Vascular malformations do not proliferate by cellular hyper- plasia but have a normal rate of endothelial cell turnover and normal mast cell counts. They can change depending References on hemodynamic factors such as blood pressure and fow or hormonal factors. Hemangiomas and vascular malforma- tions in infants and children: a classifcation based on endothelial based on the histologic nature of cells they may be defned characteristics. In contrast, vascular malformations affect males and females equally and though present are not usually evi- denThat birth and are easily diagnosed by physical examina- tion and ultrasound. Vascular malformations can be divided into two groups based on hemodynamic and lymphodynamic characteris- tics:[2,3] Slow-fow lesions, which include venous, lym- phatic, and capillary malformations, or a combination of these elements, and fast-fow lesions, which include arterial and arteriovenous malformations.

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A chest Leukocytosis is common following surgery and is film should be obtained to search for evidence of not a reliable indicator of sepsis in this setting buy 100mg extra super cialis with mastercard impotence at 19. Anesthetics probably alter the nor- mal behavior of hypothalamic thermoregulatory While laboratory measurements are being centers in the brain cheap extra super cialis 100mg with visa erectile dysfunction drugs list. In contrast purchase extra super cialis 100 mg free shipping erectile dysfunction protocol free, infectious agents, performed, what therapeutic and diagnostic circulating toxins, or immune reactions cause measures should be undertaken? The latter, in turn, Supplemental oxygen should be administered, and activates neurons responsible for heat production, endotracheal intubation is indicated if significant resulting in intense shivering. Four hours later, dopamine was no longer needed Regardless of its cause, shivering has the unde- and was discontinued. The patient’s subsequent sirable effects of markedly increasing metabolic recovery was uneventful. Although the ultimate thera- advisory for the prevention of perioperative peutic goal is to correct the underlying problem, peripheral neuropathies: An updated report by the American Society of Anesthesiologists Task Force on such as hypothermia or sepsis, additional mea- Prevention of Perioperative Peripheral Neuropathies. Unlike Awad H, Santilli S, Ohr M, et al: The efects of steep other opioid agonists, meperidine in small doses Trendelenburg positioning on intraocular pressure (25–50 mg intravenously) frequently terminates during robotic radical prostatectomy. These agents may have specific actions on laparoscopic and robotic radical prostatectomy: temperature regulation centers in the hypothala- Optimizing the surgical approach. Best Pract Res Clin generally preferred perioperatively because it does Anaesthiol 2010;24:267. Blood cultures are obtained and antibi- Cousins J, Howard J, Borra P: Principles of anaesthesia otic therapy is initiated to cover gram-negative in urological surgery. The patient receives empiric antibiotic comparison of anesthetic management of robot- coverage and a dopamine infusion is initiated. In assisted laparoscopic radical prostatectomy versus settings of redistributive, vasodilatory shock, addi- radical retropubic prostatectomy. The shivering ceases following adminis- Ficarra V, Novara G, Artibani W, et al: Retropubic, tration of meperidine, 25 mg intravenously. The laparoscopic, and robot-assisted radical blood pressure increases to 110/60 mm Hg and prostatectomy: A systematic review and cumulative the heart rate slows to 90 beats/min following a analysis of comparative studies. Acta Anaesthesiol postoperative complications in patients undergoing Scand 2009;53:895. Liver tests that measure hepatic a negative nitrogen balance (catabolism), synthetic function include serum albumin, respectively. Surgical anatomy defnes a total of eight falciform ligament into right and lef anatomic lobes; segments. In contrast, surgical anatomy posed of plates of hepatocytes arranged cylindrically divides the liver based on its blood supply. The caudate lobe is portal venules, bile canaliculi, lymphatics, and usually drained by its own set of veins. Bile canaliculi originate between hepatocytes In contrast to a lobule, an acinus, the functional within each plate and join to form bile ducts. An unit of the liver, is defned by a portal tract in the extensive system of lymphatic channels also forms middle and centrilobular veins at the periphery. Blood from hepatic arterioles and portal Some autonomic fbers synapse frst in the celiac venules comingle in the sinusoidal channels, which plexus, whereas others reach the liver directly via lie between the cellular plates and serve as capillar- splanchnic nerves and vagal branches before form- ies. The space Hepatic Blood Flow of Disse lies between the sinusoidal capillaries and Normal hepatic blood fow is 25% to 30% of the car- the hepatocytes. Venous drainage from the central diac output and is provided by the hepatic artery and veins of hepatic lobules coalesces to form the hepatic portal vein. A reciprocal, though somewhat limited, vein artery mechanism exists, such that a decrease in either Hepatic Aorta sinuses hepatic arterial or portal venous fow results in a Celiac compensatory increase in the other. Sympathetic activation Splenic results in vasoconstriction of the hepatic artery and vein mesenteric vessels, decreasing hepatic blood fow. Portal vein β-Adrenergic stimulation vasodilates the hepatic artery; β-blockers reduce blood fow, and, therefore, Mesenteric artery decrease portal pressure. Blood loss can be reduced Metabolic Function during liver surgery by lowering the central venous The abundance of enzymatic pathways in the liver pressure, thereby reducing hepatic venous pressure allows it to play a key role in the metabolism of car- and hepatic blood volume. In patients with conges- bohydrates, fats, proteins, and other substances (see tive heart failure, the increase in central venous pres- Figure 32–4 and Table 32–1). The fnal products of sure is transmitted to the hepatic veins and causes carbohydrate digestion are glucose, fructose, and congestion of the liver that can adversely afect liver galactose. Glucocorticoids, catecholamines, glucagon, Creation and secretion of bile and thyroid hormone greatly enhance gluconeogen- Nutrient metabolism esis, whereas insulin inhibits it. Amino acids When carbohydrate stores are saturated, the Monosaccharides (sugars) liver converts the excess ingested carbohydrates and Lipids (fatty acids, cholesterol, phospholipids, lipoproteins) proteins into fat. The fatty acids thus formed can be Vitamins used immediately for fuel or stored in adipose tis- sue or the liver for later consumption. Neurons normally utilize only 1 Clotting factors glucose, but, afer a few days of starvation, they can Acute phase proteins switch to ketone bodies, the breakdown products of Plasma cholinesterase fatty acids that have been synthesized by the liver as Immune function an energy source. The hepatic conversion of fructose and galactose into liver is capable of high rates of fatty acid oxidation glucose makes glucose metabolism the fnal com- and can form acetoacetic acid (one of the ketone mon pathway for most carbohydrates. Acetyl-CoA is also used by the lize the phosphogluconate pathway, which provides liver for the production of cholesterol and phos- energy and fatty acid synthesis. Most of the glucose pholipids, which is necessary in the synthesis of absorbed following a meal is normally stored as gly- cellular membranes throughout the body. Without this function, death usu- age capacity is exceeded, excess glucose is converted ally occurs within several days. Insulin enhances glycogen synthesis, and in protein metabolism include: (1) deamination of epinephrine and glucagon enhance glycogenolysis. Afer this period of fasting, gluconeogenesis, necessary for the conversion of excess amino acids the de novo synthesis of glucose, is necessary to pro- into carbohydrates and fats. The enzymatic pro- vide an uninterrupted supply of glucose for other cesses, most commonly transamination, convert organs. The cholinesterase), an enzyme that hydrolyzes esters, urea thus formed readily difuses out of the liver and including some local anesthetics and some muscle can then be excreted by the kidneys. Tese include albumin, α1-antitrypsin and teins (transferrin, haptoglobin, and ceruloplasmin), other proteases/elastases, and the coagulation fac- complement, α1-acid glycoprotein, C-reactive pro- tors. Consequently, Many exogenous substances, including most changes in albumin concentration can afect the drugs, undergo hepatic biotransformation, and the concentration of the pharmacologically active, end-products of these reactions are usually either unbound fraction of many drugs. Hepatic biotransformations are ofen cat- produced by the liver (see Table 32–2 , Figure 32–5 , egorized as one of two types of reactions. The conjugated compound can then be readily eliminated in urine I Fibrinogen 100 or bile. The liver is also the major Stomach site of degradation for insulin, steroid hormones (estrogen, aldosterone, and cortisol), glucagon, and antidiuretic hormone. Lastly, Acid hepatic production of transferrin and haptoglobin is important because these proteins are involved in iron Gallbladder hemostasis, whereas ceruloplasmin is important in Cystic duct copper regulation. Sphincter Bile Formation of Oddi Pancreas Bile (Table 32–3) plays an important role in Pancreatic absorption of fat and excretion of bilirubin, cho- duct lesterol, and many drugs. Tese ducts, in turn, combine to form the hepatic duct, which limited stores of vitamin K, a defciency can develop together with the cystic duct from the gallbladder in a few days. The as a coagulopathy due to impaired formation of gallbladder serves as a reservoir for bile.