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Hemoglobin buffer system The buffering capacity of hemoglobin is due to the presence of imidazole groups in its histidine residues discount 100mg kamagra with mastercard erectile dysfunction kamagra. When the blood returns to the lungs buy 100mg kamagra with visa impotence occurs when, O2 tension in the lungs is high resulting in the oxygenation of Hb. These acids are effectively buffered by the bicarbonate system, but at the expense of the bicarbonate, which is called as the alkali reserve of the body. In acidemia, inorder to bring the low pH to normal, the excessive H+ ions should be excreted and bicarbonate excretion should be reduced. On the other hand, during alkalemia, the kidneys excrete the excess bicarbonate producing an alkaline urine (pH 8. The three important mechanisms attributed by the kidneys to regulate the blood pH are (i) Reabsorption of bicarbonate (ii) Buffering by phosphate buffers (iii) Formation of ammonium ions. It starts in the mouth, continues in the stomach and small intestine and is completed in the large intestine. Saliva contains ptyalin, an a amylase, which attacks the a 1-4 linkages resulting in the formation of monosaccharide glucose, disaccharide maltose and trisaccharide maltotriose. However, because of steric hindrance caused by the branches, some of the interior a 1-4 linkages are inaccessible for the enzyme. Glycogen, Starch Glucose, Maltose, Maltotriose, Limit Dextrin Glycogen Limit Dextrin When food along with ptyalin reaches the stomach, ptyalin is inactivated due to low pH. Its action is similar to that of the ptyalin, but it is more powerful because (i) It can act upon raw starch. Intestinal amylase : It hydrolyses the terminal a 1-4 linkages in polysaccharides and oligosaccharides releasing free glucose molecules. Lactase : It is b-galactosidase that hydrolyses lactose molecule to equimolar amounts of glucose and galactose. Sucrase : It hydrolyzes sucrose to equimolar amounts of glucose and fructose by hydrolyzing b 1-2 linkages. Isomaltase : It hydrolyses the a 1-6 branch points of limit dextrin and liberates maltose and glucose. There are no enzymes present in our digestive system to hydrolyze b1,4 linkages in cellulose, so it cannot be digested. The absorption rate of the monosaccharides is in the following order: Galactose > Glucose > Fructose > Mannose > Xylose > Arabinose 20 Mechanism of absorption 1. Simple Diffusion: Initially, when the concentration of glucose in the intestinal lumen is high, by simple diffusion it crosses the membrane. The steps involved in the transport of glucose are : (i) One molecule of Na+ and glucose binds to the transporter. Hormones like thyroid hormone, adrenal cortex hormones and pituitary hormones enhance the absorption of carbohydrates. It is secreted in the inactive zymogen form called as pepsinogen, which has a molecular weight of 42,500 daltons. Pepsin acts on protein to convert it to proteoses and peptones, which are low molecular weight peptides. Proteins Proteoses + Peptones It has a broader specifcity and acts on peptide linkages constituted by the carboxyl group of an aromatic / hydrophobic amino acid or amino group of a dicarboxylic acid. It is an endopeptidase that is specifc for peptide linkages formed by carboxyl groups of basic amino acids, namely arginine, lysine. It hydrolyses peptide linkages with carboxyl group of aromatic amino acids like tryptophan, tyrosine and phenyl alanine. The optimum pH for chymotrypsin is 7 - 8 Carboxy peptidase Two types of carboxy peptidases, carboxy peptidase A and B are known. Carboxy peptidase A is specifc for aromatic amino acids at the C terminal end, while carboxy peptidase B is specifc for basic amino acids at the C terminal end. Thus by the concerted action of all the above enzymes, proteins are broken down to di and tri-peptides. Di and tri peptidases present in the intestinal mucosal cells or inside the absorptive cells cleave them to amino acids. Absorption of amino acids are similar to those of carbohydrates and they need a carrier and sodium ions.

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Tracheobronchopathia Osteoplastica Multiple cartilaginous/ osseous projections into lower tracheal lumen Usually found at autopsy Rarely obstructive Tx: Bronchoscopic removal/ tracheal resection Bronchial Adenomas 26 100mg kamagra overnight delivery muse erectile dysfunction medication reviews. Most are not benign adenomas but are malignant neoplasms Long natural histories 5% of all primary pulmonary neoplasms Two groups Carcinoid tumors Bronchial mucous gland tumors 27 discount kamagra 100mg on line erectile dysfunction drugs history. Classification Carcinoid tumors Typical Atypical Bronchial gland tumors Adenoid cystic carcinoma (Clindroma) Mucoepidermoid carcinoma Bronchial gland adenoma 28. Treatment Resection: lobectomy, pneumonectomy Resect recurrent and metastatic disease Bronchoscopic resection- high rate of recurrence Ten year disease-free interval Typical carcinoids- 85-90% Atypical carcinoids or typical carcinoids with lymph node metastases- 50% 31. Mucoepidermoid Carcinoma Epidermoid and mucous producing elements Behavioral correlates with microscopic appearance Tx: Complete resection Prognosis Low-grade: good with adequate resection High-grade: poor despite therapy Rare; mainly in lobar/ mainstream bronchi 33. Biopsy: noncaseating granulomas typically around terminal bronchioles with a mixed inflammatory infiltrate G. Definition There are several procedures utlitized for the diagnosis of esophageal disease, and the approach must be tailored to the specific disease entity. Microinvasive carcinoma presents as slight discolorations of the mucosa, known as leukoplakia or erythroplakia. Manometry · Intraluminal pressures are measured using a continuous infusion catheter system while the patient is lying supine · This catheter is withdrawn at 1-cm intervals to obtain resting pressures · The catheter is reinserted, and pressures measured after swallowing at 1-cm intervals · This test is essential in delineating the various esophageal motility disorders B. Acid Perfusion Test · The distal esophagus is perfused in an alternating fashion with 0. Removal of Foreign Bodies · Rigid esophagoscope is best · Most common sites are just below the cricopharyngeus and at the diaphragm · Sharp objects carry the highest risk of perforation B. Corrosive Esophagitis · Esophagoscopy should be performed to confirm the burn, but do not pass the injured area · Dilation can be performed after burn have healed (usually 3-4 weeks) if strictures have formed D. Variceal bleeding · Electrocautery and laser therapy of bleeding varices do not prevent rebleeding · Sclerotherapy is probably best and obliterates current varices; however, rebleeding occurs in 40% of patients 6. This series of 82 patients shows that dilatation of benign strictures produces better results than in malignant strictures, although it is useful to facilitate biopsy. Several articles in this supplement cover areas such as sclerotherapy, laser photocoagulation, and electrocoagulation. A brief article which has representative case presentations to illustrate this difficult complication. Other articles in this supplement specifically address particular disease profiles on endosonography. Sources for further reading Textbook Chapters Chapter 3: Endoscopy, Bronchoscopy, and Esophagoscopy. Waterston Classification (pneumonia increases one level) Congenital Esophageal Atresia [table] 5. Treatment Appropriate dilution, no emesis Fluids, antibiotics, (steroids controversial) Fiberoptic laryngoscopy / intubation Esophagoscopy - 48 hours, stop at first evidence of burn Barium swallow 3 - 4 weeks, intermittently thereafter Later dilatation for strictures Surgery usually not necessary early Sepsis / full-thickness necrosis: cervical esophagostomy, gastrostomy with isolation, later reconstruction, (resection controversial) 8. Evaluation and Therapy If cause not obviously apparent, malignancy must be ruled out Barium swallow Esophagoscopy, brushings, biopsy If peptic: anti-reflex therapy If benign: dilatation - up to 50 Fr If mucosa / bx normal: external compression, motility disorder, submucosal lesions 10. Surgical Considerations Tight strictures, severe scarring, repeated dilatations increase risk of perforation Consider surgery, particularly in young patient Anti-reflux procedure (peptic stricture) High stricture - intra-op dilatation + anti-reflux procedure Consider motility disorder, pre-op motility studies 12. Esophageal reconstruction for benign disease: self-assessment of functional outcome and quality of life. Esophageal atresia: historical evolution of management and results in 371 patients. Esophageal Atresia and Tracheoesophageal Fistula: Surgical Experience Over Two Decades. Corrosive burns of the esophagus and stomach: a recommendation for an aggressive surgical approach. Sources for further reading Textbook Chapters Chapter 25: Surgery of the Esophagus in Infants and Children. Histology and Final Development Adventitia: outer loose connective tissue containing nerves, lymphatics, blood vessels Muscularis: two layers of muscle--outer longitudinal and an inner circular Submucosa: connects muscularis with the mucosa--strongest layer--elastic tissue; collagenous fibers; network of vessels & nerves Mucosa: squamous, columnar; Z-line 3. Lymphatics: Submucosal lymphatics form long channels that run parallel to esophageal axis May travel long distances before draining into regional nodes 5. Peristalsis Primary: normal propulsive wave in response to the stimulation of normal voluntary deglutition Secondary: normal wave without voluntary deglutition: best defense Tertiary: abnormal; may occur spontaneously or following deglutition 8. Esophageal Body Proximal striated muscle: direct innervation to its motor end plate from nucleus ambiguous Smooth muscle: indirect neural input from dorsal motor nucleus (X) via myenteric plexus Innervation: longitudinal muscle shortens; circular muscle contracts; peristalsis Duration and amplitude: weaker in proximal esophagus; stronger, longer in distal esophagus 10. Oropharyngeal Dysphagia Neurologic: central vs peripheral Myogenic Cricopharyngeal Muscle Dysfunction Iatrogenic Lower esophageal disease 13.

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