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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


Patients experience marked discomfort radiating along a nerve path because of spinal pressure on the connecting nerve root buy cheap pyridium line chronic gastritis diagnosis. It has been observed in association with hypertensive encephalopathy cheap pyridium online visa gastritis medication, eclampsia safe 200 mg pyridium gastritis symptoms belching, and immunosuppressive and cytotoxic drug treatment. Navigational Note: Seizure Brief partial seizure and no Brief generalized seizure New onset seizures (partial or Life-threatening Death loss of consciousness generalized); multiple consequences; prolonged seizures despite medical repetitive seizures intervention Definition: A disorder characterized by a sudden, involuntary skeletal muscular contractions of cerebral or brain stem origin. Navigational Note: Spasticity Mild or slight increase in Moderate increase in muscle Severe increase in muscle Life-threatening Death muscle tone tone and increase in tone and increase in consequences; unable to resistance through range of resistance through range of move active or passive range motion motion of motion Definition: A disorder characterized by increased involuntary muscle tone that affects the regions interfering with voluntary movement. Navigational Note: Syncope Fainting; orthostatic collapse Definition: A disorder characterized by spontaneous loss of consciousness caused by insufficient blood supply to the brain. Navigational Note: Tendon reflex decreased Ankle reflex reduced Ankle reflex absent; other Absence of all reflexes reflexes reduced Definition: A disorder characterized by less than normal deep tendon reflexes. Navigational Note: Also consider Nervous system disorders: Peripheral motor neuropathy or Peripheral sensory neuropathy Transient ischemic attacks Mild neurologic deficit with or Moderate neurologic deficit without imaging confirmation with or without imaging confirmation Definition: A disorder characterized by a brief attack (less than 24 hours) of cerebral dysfunction of vascular origin, with no persistent neurological deficit. Navigational Note: Pregnancy loss Fetal loss at any gestational age Definition: Death in utero. Navigational Note: Premature delivery Delivery of a liveborn infant at Delivery of a liveborn infant at Delivery of a liveborn infant at Delivery of a liveborn infant at >34 to 37 weeks gestation >28 to 34 weeks gestation 24 to 28 weeks gestation 24 weeks of gestation or less Definition: A disorder characterized by delivery of a viable infant before the normal end of gestation. Typically, viability is achievable between the twentieth and thirty seventh week of gestation. Navigational Note: Anorgasmia Inability to achieve orgasm Inability to achieve orgasm not adversely affecting adversely affecting relationship relationship Definition: A disorder characterized by an inability to achieve orgasm. Navigational Note: Delayed orgasm Delay in achieving orgasm not Delay in achieving orgasm adversely affecting adversely affecting relationship relationship Definition: A disorder characterized by sexual dysfunction characterized by a delay in climax. Navigational Note: Delusions Moderate delusional Severe delusional symptoms; Life-threatening Death symptoms hospitalization not indicated; consequences, threats of new onset harm to self or others; hospitalization indicated Definition: A disorder characterized by false personal beliefs held contrary to reality, despite contradictory evidence and common sense. Navigational Note: Euphoria Mild mood elevation Moderate mood elevation Severe mood elevation. Navigational Note: Insomnia Mild difficulty falling asleep, Moderate difficulty falling Severe difficulty in falling staying asleep or waking up asleep, staying asleep or asleep, staying asleep or early waking up early waking up early Definition: A disorder characterized by difficulty in falling asleep and/or remaining asleep. Navigational Note: Libido decreased Decrease in sexual interest Decrease in sexual interest not adversely affecting adversely affecting relationship relationship Definition: A disorder characterized by a decrease in sexual desire. Navigational Note: Libido increased Present Definition: A disorder characterized by an increase in sexual desire. Navigational Note: Psychosis Mild psychotic symptoms Moderate psychotic Severe psychotic symptoms Life-threatening Death symptoms. Navigational Note: Also consider Investigations: Creatinine increased Bladder perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; organ failure; urgent operative intervention indicated Definition: A disorder characterized by a rupture in the bladder wall. Navigational Note: Bladder spasm Intervention not indicated Antispasmodics indicated Hospitalization indicated Definition: A disorder characterized by a sudden and involuntary contraction of the bladder wall. Navigational Note: Dysuria Present Definition: A disorder characterized by painful urination. For grades higher than Grade 1, consider Renal and urinary disorders: Bladder spasm or Cystitis noninfective; Infections and infestations: Urinary tract infection. Glucosuria Present Definition: A disorder characterized by laboratory test results that indicate glucose in the urine. Navigational Note: Hemoglobinuria Asymptomatic; clinical or diagnostic observations only; intervention not indicated Definition: A disorder characterized by laboratory test results that indicate the presence of free hemoglobin in the urine. Navigational Note: Proteinuria 1+ proteinuria; urinary Adult: 2+ and 3+ proteinuria; Adult: Urinary protein >=3. Navigational Note: Renal hemorrhage Mild symptoms; intervention Analgesics and hematocrit Transfusion indicated; Life-threatening Death not indicated monitoring indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the kidney. Navigational Note: Urinary fistula Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent invasive intervention indicated Definition: A disorder characterized by an abnormal communication between any part of the urinary system and another organ or anatomic site. Navigational Note: Urinary retention Urinary, suprapubic or Placement of urinary, Elective invasive intervention Life-threatening Death intermittent catheter suprapubic or intermittent indicated; substantial loss of consequences; organ failure; placement not indicated; able catheter placement indicated; affected kidney function or urgent operative intervention to void with some residual medication indicated mass indicated Definition: A disorder characterized by accumulation of urine within the bladder because of the inability to urinate. Navigational Note: Urine discoloration Present Definition: A disorder characterized by a change in the color of the urine. Navigational Note: Azoospermia Absence of sperm in ejaculate Definition: A disorder characterized by laboratory test results that indicate complete absence of spermatozoa in the semen. Navigational Note: Breast atrophy Minimal asymmetry; minimal Moderate asymmetry; Asymmetry >1/3 of breast atrophy moderate atrophy volume; severe atrophy Definition: A disorder characterized by underdevelopment of the breast. Navigational Note: Dyspareunia Mild discomfort or pain Moderate discomfort or pain Severe discomfort or pain associated with vaginal associated with vaginal associated with vaginal penetration; discomfort penetration; discomfort or penetration; discomfort or relieved with use of vaginal pain partially relieved with pain unrelieved by vaginal lubricants or estrogen use of vaginal lubricants or lubricants or estrogen estrogen Definition: A disorder characterized by painful or difficult coitus. Navigational Note: Ejaculation disorder Diminished ejaculation Anejaculation or retrograde ejaculation Definition: A disorder characterized by problems related to ejaculation. Navigational Note: Fallopian tube obstruction Asymptomatic; clinical or Symptomatic; elective Severe symptoms; invasive diagnostic observations only; intervention indicated intervention indicated intervention not indicated Definition: A disorder characterized by blockage of the normal flow of the contents in the fallopian tube. Navigational Note: Feminization acquired Mild symptoms; intervention Moderate symptoms; medical not indicated intervention indicated Definition: A disorder characterized by the development of secondary female sex characteristics in males due to extrinsic factors. Navigational Note: Hematosalpinx Minimal bleeding identified Moderate bleeding; medical Transfusion indicated; Life-threatening Death on imaging study or intervention indicated invasive intervention consequences; urgent laparoscopy; intervention not indicated operative intervention indicated indicated Definition: A disorder characterized by the presence of blood in a fallopian tube. Navigational Note: Also consider Reproductive system and breast disorders: Premature menopause, Amenorrhea. Lactation disorder Mild changes in lactation, not Changes in lactation, significantly affecting significantly affecting breast production or expression of production or expression of breast milk breast milk Definition: A disorder characterized by disturbances of milk secretion. It is not necessarily related to pregnancy that is observed in females and can be observed in males. Navigational Note: Menorrhagia Mild; iron supplements Moderate symptoms; medical Severe; transfusion indicated; Life-threatening Death indicated intervention indicated. Navigational Note: Nipple deformity Asymptomatic; asymmetry Symptomatic; asymmetry of with slight retraction and/or nipple areolar complex with thickening of the nipple moderate retraction and/or areolar complex thickening of the nipple areolar complex Definition: A disorder characterized by a malformation of the nipple.

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See chapter 4 for experiments performed to generic pyridium 200 mg on line gastritis diet treatment investigate the polymorphisms identified in the Gstm1 promoter discount pyridium online visa gastritis diet ketogenic. The transcriptomic and pathway analysis techniques applied in this chapter represent a significant advance on traditional microarray data analysis order pyridium from india stomach ulcer gastritis symptoms. The ability to automatically consider differential expression of multiple genes affecting specific physiological pathways in pairwise comparisons with parental and congenic strains is an extremely efficient technique for very large data sets. James Polke, 2008 Chapter 4 122 4 Gstm1 Expression and Promoter Analysis James Polke, 2008 Chapter 4 123 4. The deletions arise through unequal crossover between repeat sequences either side of the genes and result in individuals with 0, 1 or 2 copies of the genes. Further studies -/ in the Nrf2 mice showed reduced liver constitutive and inducible expression of Gsta1, Gsta2, Gstm1, Gstm2, Gstm3 and Gstm4 (Chanas et al. The work performed in this chapter investigated the differential expression of renal Gstm1 in a panel of hypertensive and normotensive rat strains and correlated reduced Gstm1 expression with hypertension and renal oxidative stress, measured by nitrotyrosine western blotting. Applied Biosystems Gene Expression Assay probe for rat Gstm1 (assay number Rn00755117 m1) and rat β-actin endogenous control probe (part number 4352340E) were multiplexed 20µl reactions in 96-well plates. Probe amplification efficiencies were confirmed and relative gene expression was calculated as described in section 2. Eighty µg of protein in reducing buffer was loaded per lane and full-range Rainbow marker was used as a size standard. Display settings for graphical output of alignments were set to shade areas of over 70% homology in a 100bp sliding window. Forward primers incorporated a MluI restriction site preceded by 3xC residues, Gstm1-1R incorporated an XhoI restriction site preceded by 3xC residues. All cloning in this chapter utilised plasmids expressing the ampicillin resistance gene, selective Luria agar and broth were used with 100 µg/ml ampicilin (Sigma). Ligation reactions were incubated at room temperature for an hour, then de-activated by heating to 65°C for 5 minutes. Cells were incubated on ice for 10 minutes, 4 µl of ligation reaction was added and cells were incubated on ice for 30 minutes, then heat-shocked at 42°C for 30 seconds before returning to ice for 2 minutes. Promoter activities were calculated as: luciferase activity (relative light units) / β-galactosidase activity (relative light units) / protein concentration (ng/µl). Lysates were collected and centrifuged to collect cellular debris, then stored on ice. The luciferase assay reaction was performed in white 96-well flat-bottomed plates. Each well was read by measuring total luminescence in a 10-second period on a Wallac Victor 2 plate reader. Background luminescence from control wells with no cell lysate or recombinant luciferase were subtracted from all readings. Background luminescence from control wells with no β-galactosidase standard or cell lysates were subtracted from all values. Ligations were performed with 1433 bp:4937 bp fragment James Polke, 2008 Chapter 4 133 ratios of 3:1 as per section 2. Transfac Professional requires a subscription for access, it is distinct from the publicly available Transfac databases in that it includes the most up-to date releases of the database and allows specialised searches to be performed. The work James Polke, 2008 Chapter 4 135 presented here was performed using release 10. This is collated into a consensus sequence for the matrix, typically 7-25 bases long. Other matrices are constructed by collating the evidence of several publications, often across several species. A score is assigned James Polke, 2008 Chapter 4 136 to each base in a motif based on the frequency of that particular nucleotide (A, T, C, or G) occurring in the core or matrix consensus sequence. Transfac scores the core sequence first, if it passes the threshold it then inspects the matrix sequence, if this also passes this threshold, the matrix is included in the output. This analysis technique has been applied in published research investigating functional effects of promoter polymorphisms (Moreno et al. Each of these spreadsheets was combined into a single Microsoft Excel spreadsheet that was used for detailed searches. On the basis of this analysis, James Polke, 2008 Chapter 4 140 four promoter regions were amplified for cloning, ranging in size from 0. Many transcription factors are represented by more than one matrix, a consequence of the fact that different evidence (gene, species etc. A curtailed list could have been generated by increasing the cut-off values for matrix alignment, however it was decided to use table A5 in the first instance as an exhaustive list to be interrogated using the results of the experimental studies to inform specific searches. In order to assess the likelihood that Nrf2/Maf or Bach1/Maf actually bind to this site, the alignments were considered in more detail. Rat Gsta2 and Gstp1 expression have been shown to be regulated by androgen (Falkner et al 1998;Falkner et al. The functional relevance of the H202R variant was considered in McBride et al, 2005. Secondly, the crystal structure of the rat Gstm1 protein was inspected; amino acid 202 is located on the surface of the protein and thus not likely to affect Gstm1 activity (Ji et al. These results can be explained by the limitatons of luciferase activity measurements despite corrections for transfection efficiency and total protein, combined with the small difference in promoter activity observed in the original experiments (2. If continuing these experiments, transfection protocols could be redesigned to ensure less variability within experimental groups. The Transfac data analysis discussed above presents hypotheses to explain the results of the in-vitro luciferase studies. The second half of the binding sequence does not have high homology with the promoters.

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It didn’t happen every night cheap pyridium 200mg with amex chronic gastritis meal plan, but a couple times a week he would thrash and scream generic pyridium 200 mg with amex gastritis lasting weeks. They made an appointment with Paulo’s primary care doctor 200 mg pyridium for sale atrophische gastritis definition, who referred him for a sleep sudy after hearing about his nighttime behavior. When it comes to diagnosing sleep disorders, often more information is needed than can be gathered in an ofce visit. Jus as your doctor evaluates your motor symptoms by observing you doing various tasks. Mos sleep sudies are done in a sleep laboratory that is set up for overnight says and is made comfortable and dark for overnight sleeping. This is usually at a hospital or sleep center, which can be found in mos communities. Some sleep tess can be done at home, but these can only tes for breathing disorders such as sleep apnea (see page 22). A sleep technologis will put sensors on your head and body, but these should not interfere with your comfort or movement. Your doctor will use this data to fgure out if you have a sleep disorder, and if so, which one. Safety comes frs: sharp objects should be removed from the sleeping environment, and furniture may need to be padded at corners. If you have severe symptoms, it can help to put soft objects, such as cushions or pillows, on the foor in case you fall out of bed while acting out. Melatonin is a hormone that is naturally produced by the pineal gland in the brain. However, melatonin levels slowly drop with age, and some older people might not produce any at all. Caution is advised with doses higher than 9mg, as the medication may cause confusion and hallucinations in the elderly. Clonazepam (brand names Klonopin, Rivotril and others) belongs to the class of medication called benzodiazepines. These drugs have sedating and muscle relaxing properties and can be used to treat anxiety. Benzodiazepines are fas-acting but habit forming, so melatonin should be tried frs. In particularly subborn cases, a combination therapy of clonazepam and melatonin may be needed. Both clonazepam and melatonin can cause morning drowsiness, which can contribute to falls. Pay attention to how you feel in the morning, especially when you frs sart treatment, and report any issues to your healthcare team. When your airway collapses during sleep, the oxygen level in your blood drops, your blood pressure rises and your heart rate slows. You end up waking up frequently, sometimes gasping for air, because the brain is not getting enough oxygen. However, you may not even know that you are waking up so many times, as the breathing pauses may be very brief, so-called microarousals. In obsructive sleep apnea, the more common form, the main culprit is the collapse of the soft tissue in the back of the throat. This can happen because of loss of muscle tone due to aging or because of fat build-up. Central sleep apnea occurs because of problems with the neurons that control breathing during sleep. This form of sleep apnea is seen in several neurological disorders, including Parkinson’s. People with complex, or mixed, sleep apnea experience both obsructive and central apneas. Breathing fow is reduced but does not sop, as happens with a complete collapse of the airway. People with untreated sleep apnea are at increased risk of high blood pressure, heart arrhythmias, heart attacks, srokes and type 2 diabetes. They are also at increased risk for automobile accidents compared with the general population. If you notice that your bed partner is snoring loudly or pausing their breathing during sleep, encourage him or her to talk to a healthcare provider. You will both sleep better if your partner seeks treatment for apnea, and this can have a positive efect on your relationship. Older adults are signifcantly more likely to have sleep apnea, and it is more common in men than women. Research suggess that sleep apnea occurs at about the same rate in the Parkinson’s population as in the general population, but the primary symptoms tend to be diferent. For example, in general, individuals who are overweight and report snoring and excessive daytime sleepiness should ask their healthcare provider about the possibility of a consultation with a sleep specialis. Another example is pos-menopausal woman, in whom fatigue is commonly the only symptom of sleep apnea. If you do a home sleep tes, you will be given the following sensors (and insructions on how to use them): A fnger probe to measure blood oxygen levels A sleep physician will interpret the results and may recommend treatment based on the fndings. Anti parkinsonian medications may help by decreasing the rigidity of the ches wall, allowing more normal movement with breath.

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Long-term outcome native valve endocarditis in adults: risk classification for mortality buy generic pyridium 200 mg on line gastritis and constipation diet. Presentation trusted pyridium 200mg chronic gastritis no h pylori, management buy pyridium 200 mg without a prescription gastritis diet natural remedies, surgery and mortality among patients with infective endocarditis and follow-up evaluation of infective endocarditis in drug addicts. Heart surgery in native left-sided endocarditis complicated by heart failure: 1999;82:714–20. Early clinical course and long-term outcome of patients of pregnancy outcomes in women with heart disease. Surgical treatment of effects of a beta adrenergic blocking agent-propranolol-in mitral active native aortic valve endocarditis with allografts and mechanical stenosis at fixed heart rates. Infective endocarditis clinical evidence, potential mechanisms, and recommendations for complicating permanent pacemaker and implantable cardioverter use. Clinical characteristics and comes after pregnancy in women with congenital aortic stenosis. Am outcome of infective endocarditis involving implantable cardiac Heart J 2009;157:474–80. The effect of valvular ment: a scientific statement from the American Heart Association. N Engl J Med 2012; echocardiographic assessment of pregnant women with valvular 367:842–9. Int J tients with cardiovascular implantable electronic devices and Gynaecol Obstet 2003;82:153–9. Early surgery versus conven postvalvuloplasty variables that predict long-term outcome. Embolic risk in subacute bacterial endocarditis: de commissurotomy during pregnancy. Use of high intensity balloon valvuloplasty for severe mitral stenosis during pregnancy: a adjusted dose low molecular weight heparin in women with me review of therapeutic options. Ann Thorac and fetal outcomes under low oral anticoagulation, a pilot observa Surg 1983;36:453–8. Anticoagulation of preg aortic valve in pregnant patients with severe aortic stenosis. Balloon valvuloplasty for pregnant patients with mechanical cardiac valve prostheses. Percutaneous balloon aortic valvuloplasty during predicting severe intracranial hemorrhage. Pregnancy valvular regurgitation during pregnancy: a longitudinal Doppler and mechanical heart valves replacement; dilemma of anti echocardiographic study. The effect of pregnancy ment in women with mechanical heart valves during pregnancy. Pregnancy in cardiac patients: possible heparin for thromboprophylaxis in pregnant women with mechan influence of volume overload by pregnancy on pulmonary circula ical heart valves. Transesophageal echocardiog heparin in pregnant women with mechanical heart valves. Am J raphy for the diagnosis and management of nonobstructive thrombosis Cardiol 2009;104:1259–63. Comparison of transthoracic abnormal coronary arteriograms in severe aortic valvular disease. Am and transesophageal echocardiography for detection of abnormalities Heart J 1977;93:683–6. A general cardiovascular risk diography in the diagnosis and management of prosthetic valve profile: the Framingham Study. N Engl J Med 1979; women with mechanical heart valves: a systematic review of the 300:1350–8. Management of matching the intensity of risk factor management with the hazard pregnant women with mechanical heart valve prosthesis: thrombo for coronary disease events. Assessment of car and pregnancy outcome in women with mechanical prosthetic heart diovascular risk by use of multiple-risk-factor assessment equations: valves treated with enoxaparin. Low molecular weight heparin for Association and the American College of Cardiology. Circulation the prophylaxis of thromboembolism in women with prosthetic 1999;100:1481–92. Coronary atherosclerosis in patients with multivessel coronary artery disease in the era of valvular heart disease. Veterans Adminis coronary atherosclerosis–analysis in patients with valvular regurgi tration Cooperative Study of Surgery for Coronary Arterial Occlu tation. Asymptomatic left function in ischemic mitral regurgitation–a precatheterization main coronary artery disease in the Coronary Artery Surgery Study assessment. Effect of coronary artery bypass disease in patients undergoing operations for mitral valve degener graft surgery on survival: overview of 10–year results from rando ation. Eur Heart J 2005;26: and selective coronary angiography in ascending aortic aneurysm or 1866–72. Rapid noninvasive diagnosis atrial fibrillation on survival following mitral valve repair for and surgical repair of acute ascending aortic dissection. Does coronary angiography repair in patients with preoperative atrial fibrillation. J Thorac Cardiovasc Surg 1997; coronary computed tomographic angiography: a report of the 114:179–85. J Am Coll Cardiol modified maze and mitral valve procedure through a port access 2006;47:2020–4. A randomized study coronary artery disease in patients referred for cardiac valve surgery. Effectiveness of the coronary angiography with multidetector computed tomography to maze procedure using cooled-tip radiofrequency ablation in patients detect significant coronary stenosis before valve surgery.

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The relationship of the distal common bile duct to purchase pyridium 200 mg online gastritis zucker the head of the pancreas is also variable buy pyridium 200 mg fast delivery gastritis diet education. It most commonly lies within the pancreatic tissue order online pyridium gastritis diet , but may also lie posteriorly within a groove in the pancreatic tissue. A natural narrowing may be present at the point of fusion of the ventral and dorsal ducts. The normal pancreatic duct is smooth and tapered with side branches that are also smooth and tapered. Shortening, irregularity or dilatation of these ducts correlates with disease states such as chronic pancreatitis. The main ultrasonographic features of these parenchymal changes are alternating echo-poor and echo-rich areas and an irregular pancreatic margin rather than the usual uniform echogenicity and smooth margin. These high flow vessels are situated in awkward positions and if they are torn the application of proximal and distal vascular control is often neither advisable nor possible. The portal vein itself can be further defined as the hepatic portal vein and the pancreatic portal vein. This groove may be further accentuated by the presence of a tumour within the head of the pancreas. The inferior mesenteric vein may also contribute to this junction, although it classically joins the splenic vein and occasionally joins the superior mesenteric vein directly. Ligation of the inferior mesenteric vein is often a necessary step in mobilization of the body and tail of the pancreas. It is important to recognize the common sites at which these vessels join the portal vein when performing a resection of the pancreatic head. The posterior superior vein commonly drains directly into the portal vein near the superior border of the pancreas after crossing anterior to the bile duct. This latter vessel is both a common landmark and a source of trouble if Surgical management of hepatobiliary and pancreatic disorders 36 not dealt with carefully. It is formed by the confluence of the right gastroepiploic vein and an unnamed middle colic vein. Ligation of the gastroepiploic vein near this junction facilitates exposure of the superior mesenteric vein and pancreatic portal vein. Some studies seem to indicate that an anterior superior vein may not be present in all cases and that venous drainage in the corresponding region is directly into the gastrocolic trunk. The gastroduodenal in turn is a branch of the common hepatic artery and arises within the porta hepatis, where it marks the transition to the hepatic artery proper. It runs in the same general direction as the latter vessel, but when viewed from behind the mobilized and anteriorly retracted pylorus appears to run transversely. Ligation of the gastroduodenal artery is a necessary step for pancreaticoduodenectomy and can be helpful in controlling bleeding from difficult duodenal ulcers. According to some authors, preservation of the right gastric artery is crucial during a pylorus preserving pancreatico-duodenectomy. The anterior and posterior inferior pancreaticoduodenal arteries form the inferior blood supply to the head of the pancreas and duodenum. They arise either as a single trunk or separately directly from the superior mesenteric artery. The anterior arcade follows the course of the duodenal wall, passing posterior to the inferior pancreatic head as it overhangs the duodenum. The posterior arcade passes anterior to the common bile duct before it enters the pancreas and follows the margin of the head of pancreas posteriorly. The most frequent arterial anatomical variant related to the head of the pancreas is a replaced or accessory right hepatic artery arising from the superior mesenteric artery (25% of the population) (Fig. The pulse of an accessory or replaced right hepatic can normally be palpated in the porta hepatis posterior to the bile duct. Failure to identify such a vessel can result in ligation of part of the hepatic blood supply during pancreaticoduodenectomy. Surgical anatomy of the pancreas 37 With respect to the identification of vascular variants, some surgeons have advocated preoperative angiography. Trede reports examples of its failure to demonstrate an accessory right hepatic artery and points out that when such an artery is identified its position anterior to, posterior to or within the head of the pancreas cannot be ascertained. Very rarely this condition can be associated with collateral blood flow to the liver provided by the superior mesenteric artery through the pancreaticoduodenal Figure 2. However, this rare situation can be identified intraoperatively when blood flow to the liver ceases upon temporary occlusion of the gastroduodenal artery. The origin of this artery is variable, arising from the splenic artery in 38%, directly from the coeliac trunk in 22%, the common hepatic in 22%, the superior mesenteric artery in 12. Nerve supply to the pancreas the pancreas receives both sympathetic and parasympathetic input. The parasympathetic input to the pancreas is by way of vagal fibres passing through the right and left coeliac ganglia which are situated adjacent to the coeliac axis. The sympathetic input is from the greater and lesser splanchnic nerves which are formed by branches from the T4 through T10 and T9 through L2 sympathetic ganglia, respectively. The supply to the body and tail is from the left coeliac ganglion via the plexus associated with the splenic artery and directly from the left ganglion and coeliac plexus to the posterior body. The parasympathetic nerves along the arteries enter the pancreatic parenchyma along with the arteries and end on intrinsic ganglia which lie near the parenchyma, in keeping with their role in stimulating secretion of pancreatic juice.


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