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Undifferentiated crypt cells are the most common crypt cells that may proliferate rapidly generic 160 mg super p-force free shipping, but they have poorly developed structure discount 160 mg super p-force with amex, including intracellular organelles and microvilli. Paneth cells are characterized by eosinophilic granules that remain in the crypt bases and contain growth factors, digestive enzymes and antimicrobial peptides. Goblet cells are epithelial cells that contain visible mucins that may be discharged into the intestinal lumen, and play a role in immune defense. Enteroendocrine cells contain secretory granules that may influence epithelial function through enterocyte basolateral membrane receptors. Enterocytes are polarized epithelial cells containing apical and basolateral membrane domains. The enterocytes are connected by junctional complexes, forming a permeability barrier to the contents of the intestinal lumen. This polarized distribution of membrane proteins permits vectorial transport that differs in various regions of the small intestine. The basolateral membrane also has nutrient and electrocyte transporters as well as receptors for growth factors, hormones and neurotransmitters. M-cells are epithelial cells overlying lymphoid follicles that bind, process and deliver pathogens directly to lymphocytes, macrophages or other components of the immune system. There is a complex vascular and lymphatic network extending through the villus core that is involved in signal and nutrient trafficking to and from the epithelial cell layer. This leads to propulsive activity that promotes luminal movement of material from the proximal into the distal intestine. Motility The main function of the small intestine is digestion and absorption of nutrients. The role of small bowel motility is to mix food products with digestive enzymes (chyme), to promote contact of chyme with the absorptive cells over a sufficient length of bowel and to propel undigested material into the colon. Once those particles are < 2 mm in size, they are pushed into the duodenum by co-ordination of contraction of the antrum and the relaxation of the pylorus. The rate of emptying of the stomach may be slowed by inhibition occurring from the duodenum or from the ileum. Receptors in the mucosa sense calories, osmolality, acid, fatty acid concentrations and slow emptying when these are high. Well-organized motility patterns occur in small intestine to accomplish these goals in the fed as well as the fasting. Sweeping through the stomach, it removes debris and residual material not emptied with the last meal. As the activity front reaches the terminal ileum, another front develops in the gastroduodenal area and progresses down the intestine. Diarrhea can occur when this normal fed pattern is replaced by aggressive propulsive rather than mixing contractions. The extrinsic afferent innervation of the intestine is supplied by the vagus nerve; over 80% of the vagal fibers are afferent, 20% are efferent (motor). The myenteric plexus (Auerbachs plexus) runs between the inner circular and outer longitudinal smooth muscle and most of the nerves of this plexus project to these muscle layers. The submucosal plexus (Meissners plexus and Schabadaschs plexus) runs between the inner circular muscle and the mucosa, and its nerves project to the mucosal nerves, as well as to the myenteric plexus. Serotonin-containing enterochromaffin cells may be involved in the mucosal sensing of stimuli. The fast excitatory neurotransmitter is acetylcholine, the slow excitatory transmitter, substance P. Polarized reflexes also result from the presence of a bolus in the intestinal lumen. The law of the intestine is the result of the ascending excitatory reflex and the descending inhibitory reflex of the excitatory and inhibitory motor neurons. The myocytes form a syncytium, with each myocyte connecting with another through cell-to-cell contacts, called gap junctions. There is both electrical as well as mechanical connection, so the myocytes in each layer work as a contractile unit. These are confusing terms, because when we speak of the small intestine, for example as having tone, this is really a long-lasting tonic contraction. A phasic contraction is short in duration (about 1 to 5 seconds), and this is what we mean when we say the intestine is undergoing a contraction. Iron r3+ Iron is available for duodenal absorption from vegetables (non-heme iron, Fe ) and from 2+ 2+ meat (heme iron [Fe ], ingested as myoglobin and hemoglobin). In the presence of gastric acid, the globin molecule is r2+ split off myoglobin and hemoglobin, and its Fe absorbed. Heme iron is better absorbed (1020%), and is unaffected by intraluminal factors or dietary composition. Only 1-6% non-heme iron is absorbed, and absorption is influenced by luminal events such as gastric pH and binding substances in food (polytate, phosphate, phophoproteins).

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Clinical features Peripheral neuropathy: Asymmetrical disorder of pe- Patients complain of distal paraesthesiae and numbness ripheral nerves 160 mg super p-force fast delivery, usually distal more than proximal discount super p-force 160mg with amex. The commonest causes are nerve involvement with difculty swallowing and respi- r Diabetes mellitus. Over the following weeks to months, the condi- r Vitamin B deciency (Thiamine (B )deciency in al- tion slowly improves. Other rare causes include uraemia; hypothyroidism; sys- temic diseases and vasculitis, e. Respiratory insufciency or aspiration risk (due to swal- Radiculopathy: Damage to one or more nerve roots or lowing difculties) may necessitate intubation and pos- anerve plexus. Traction injury during a difcult labour may they only fall late in respiratory failure. They are generally Clinical features r Erbs palsy (C5/6 lesions) with failure of abduction used for moderate to severe cases (i. Investigations Chest X-ray may show an apical lung lesion (Pancoast Brachial plexus injuries tumour)ora cervicalrib. The brachial plexus is formed from the nerve roots of C5T1, which form into the medial, lateral and poste- Management rior cords. Pathophysiology Aetiology/pathophysiology The carpal tunnel is a tight space through which all the Mediannerveinjuriestendtooccurnearthewristorhigh tendons to the hand and the median nerve pass. Where the median nerve passes through cause of swelling is therefore likely to cause compres- the anterior cubital fossa under the biceps aponeurosis sion of the medial nerve. The condition is commonly into the forearm it is vulnerable to damage by forearm bilateral. It then passes under the exor retinaculum (through the carpal tunnel) into the hand low lesions are caused by com- Clinical features pression in carpal tunnel syndrome (see below), cuts to Tingling and numbness in the thumb, index nger and the wrist or carpal dislocation. Characteristically the pain wakes the pa- tient at night and the patient shakes the wrist or hangs Clinical features it over the side of the bed to relieve symptoms (unlike r Low lesions: There is loss of muscle bulk in the thenar in cervical spondylosis). Symptoms are also induced by eminence, abduction and opposition of the thumb are repetitive actions, or when the wrists are held exed for weak and sensation is lost over the radial three and a sometime,forexamplewhilstknittingorreadinganews- half digits on the palmar surface. Alternatively, low lesion, the long exors of the thumb, index and tapping on the carpal tunnel (Tinels sign) may repro- middle ngers are paralysed. Usually the dominant hand is affected rst, but the con- Management dition is normally bilateral. If the nerve is severed suture or grafting should be at- Clumsiness and weakness may occur in late cases, tempted. Carpal tunnel syndrome Investigations Denition Median nerve conduction studies show impaired con- Syndrome of compression of the median nerve as it duction at the wrist. Management Age Splinting the wrist in extension, particularly at night is Usually 4050 years. Clinical features Ulnar nerve lesions Wrist drop and sensory loss over the back of the hand at Denition the base of the thumb (the anatomical snuffbox). If there The ulnar nerve arises from the brachial plexus and sup- is paralysis of triceps (weakness of elbow extension), this plies most of the intrinsic muscles of the hand. The ulnar nerve passes down the Management anterior medial aspect of the upper arm and wraps pos- Compression due to crutch palsy or Saturday night palsy teriorly round the medial epicondyle of the humerus maytakeupto3monthstorecover. Openwoundsshould where it is vulnerable to fracture of the elbow or chronic be explored immediately with nerve repair or graft. It enters the hand on the ulnar side, and can be Other trauma should be given 6 weeks, with surgery if damaged by pressure or lacerations at the wrist. Clinical features Prognosis r Low lesions (at wrist): There is wasting of all the small Lesions that do not recover can often be overcome by muscles of the hand except the thenar eminence and suitable tendon transfers. The sciatic nerve (L45, S13) is a branch of the lum- bosacral plexus and the largest nerve in the body. It Management supplies most of the muscles and cutaneous sensation If the ulnar nerve is severed, repair is may be attempted, of the leg, so that sciatic nerve lesions cause serious stretching can be avoided by transposing the nerve to the disability. Nerve entrapment is treated with Aetiology/pathophysiology decompression and transposition of the nerve. Traction injuries occur more commonly Radial nerve lesions in association with fractures of the pelvis or hip dislo- cations. It is most frequently injured by badly placed Denition intramuscular injections in the gluteal region (avoided The radial nerve supplies the extensor muscles of the by injecting into the upper outer quadrant of the but- upper arm and forearm. In walking, quadriceps weak- muscles below the knee are paralysed, causing drop foot. Peroneal nerve lesions Management Denition In traumaticdamage,explorationandrepairofthenerve The common peroneal nerve is the smaller terminal should be carried out. A footdrop splint is worn to keep branch of the sciatic nerve which supplies muscles which the ankle in a safe position, but the lower leg is very act on the ankle joint.

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