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The Tm is defined as the maximum plasma concentration at which all of a filtered solute can be resorbed women's health new dimensions generic fertomid 50mg visa. At plasma concentrations above the Tm breast cancer ornaments order 50mg fertomid mastercard, the proximal tubule is overwhelmed and excess solute is lost in the urine women's health center fort bragg ca order fertomid mastercard. If the glucose concentra tion rises above 200 mg/dL womens health 49 buy cheap fertomid 50 mg on line, glucose is lost in the urine. If plasma glucose is below 200 mg/dL, all the glucose is resorbed and none spills into the urine. If plasma bicarbonate concentration is higher than 28 mEq/L, the proximal tubule is overwhelmed and excess bicarbonate is lost in the urine. TmTm If the plasma concentration of bicarbonate is above the, Tm then the excess bicarbonate is lost in the urine. The various etiologies of hypoaldosteronism are discussed in detail in Chapter 19. The secretion of acid in the distal tubule is limited by the minimal attainable urine pH of 4. If only free hydrogen could be secreted, an unrealistically large amount of urine would need to be produced in order to excrete the daily acid load. A negative gap indicates increased renal ammonium excretion, a good indicator of increased renal hydrogen excretion; a positive gap indicates a lack of urinary ammonia excretion. Renal tubular acidosis can be due to a failure of the kidney to resorb filtered bicarbonate. Topf 13 Metabolic Acidosis: Anion Gap Type A lactic acidosis is caused by tissue hypoxia. Initially, the liver converts glycogen stores into glucose to prevent hypoglycemia. If the fasting state is prolonged, the primary fuel is switched from glucose to ketones. Glucagon stimulates the liver to convert glycogen to glucose, fatty acids to ketones and alanine to glucose. Older patients with long-standing type 2 diabetes can also become ketotic with stress. Topf 13 Metabolic Acidosis: Anion Gap Alkalinization of the urine increases the renal clearance of aspirin by way of ion trapping. Decreased tubular salicylic acid 2 draws plasma salicylic acid into the tubular fluid. Alkalinization of the 1tubular fluid shifts Once in the tubular fluid, salicylic the equilibrium to 3 acid is converted to salicylate and wards salicylate. Topf 13 Metabolic Acidosis: Anion Gap the focus of treatment in metabolic acidosis is to treat the underlying disorder. Topf 14 Metabolic Alkalosis Addition of bicarbonate can cause metabolic acidosis when it is used to treat metabolic acidosis. A A @ Mineralocorticoids are hormones which act at the collecting tubules to stimulate the resorption of sodium and the excretion of both hydrogen and potassium. The effect of mineralocorticoids on hydrogen ion excretion is important in + the generation of metabolic alkalosis. In the disorders of excess mineralocorticoid activity, excess hydrogen excretion increases the resorption of bicarbonate, generat ing metabolic alkalosis. The disorders of excess mineralocorticoid activity are typically associated with hypokalemia, hypertension and mild hypernatremia. DiagnosisSaline-resistant H+ H+ H+ H+ H+ + H H+ H+ Hypertensive Normotensive Excess mineralocorticoid activity Intracellular hydrogen loss Rare causes 390 B | | |! This process is accomplished in the first three steps of respiration (sensing and signaling, muscles and motion, and free flow). Increased minute ven tilation causes carbon dioxide to fall and decreased minute ventilation causes carbon dioxide to rise. The A-a gradient is the difference between lveolar oxygen content and rterial oxygen content. If gas exchange between the alveoli and pulmonary capillaries were perfect (all of the alveolar oxygen crossed into the blood), the A-a gradient would be zero. However, due to normal physiologic impediments to gas ex change, the A-a gradient is normally about 10 in a healthy young adult. An increased A-a gradient indicates that an abnormality in gas exchange has inter fered with the transfer of oxygen into blood. If impaired gas exchange is the sole or a contributing cause of respiratory aci dosis, then the A-a gradient is increased. If, however, respiratory acidosis is due to a ventilation defect (one or more the first three steps of respiration), then the A-a gradient is normal. If respiratory acidosis is secondary to a defect in ventilation, then aaa the A-a gradient is. Topf 15 Respiratory Acidosis the bicarbonate increase in acute res piratory acidosis is small. Compensation, determine acute versus chronic and eval uate for the presence of other acid-base disorders. Normal A-a gradient (Ventilation defect) High A-a gradient* Sensing and signaling Muscles and motion Free flow Gas exchange Sensing defects Signaling defects 438 | | | | Rapid correction of metabolic acidosis with bicarbonate can cause respiratory alkalosis through direct stimulation of the respiratory con trol center. Acidemia directly stimulates the res 2 piratory control center to increase ventilation. Treating metabolic acidosis with bicarbonate quickly increases both plasma bicarbonate and plasma pH. However, because bicarbonate does not quickly cross the blood brain barrier, the intracellular pH remains acidotic. Persistent intracellular acidosis in the respiratory control cen ter, despite correction of extracellular pH, stimulates respiration. Since hyperventilation continues in the absence of metabolic acidosis, a pri mary respiratory alkalosis develops. Interestingly, respiration can actually following the admin + istration of bicarbonate. Plasma bicarbonate is lowered by intracellular buffering and the renal excretion of bicarbonate. If the measured plasma bicarbonate is below predicted, then a concurrent metabolic acido sis is present. If the measured plasma bicarbonate is above predicted, then a concurrent metabolic alkalosis is present. The other signs and symptoms of respiratory alkalosis are related to increased pH. Central nervous system symptoms are due to decreased cerebral blood flow caused by alkalemia. Symptoms are more common in patients with conscious hyperventilation due to anxiety. Symptomatic hyperventilation from anxiety can be treated by having the patient breathe into a paper bag. The flow of sodium into the tubular cell is the rate-limiting step in potas sium secretion. The of potassium in the distal nephron depends on excretion establishing favorable electrical and gradients. In this situation, the plasma potassium is low, but total body potassium can be normal. Movement of potassium into cells can be caused by: •alkale ia •insulin •catechola ines. For every hydrogen ion secreted, a bicarbon ate is resorbed, causing metabolic alkalosis. Due to the action of mineralocorticoids on hydrogen excretion (bicarbon ate resorption), all of the disorders of excess mineralocorticoid activity are associated with metabolic alkalosis. In the collecting tubule, the secretion of hydrogen ion causes the resorption of. Several formulas and tables can be used to estimate total body potassium deficit based on the plasma potassium. A good rule of thumb for replacing potassium is to subtract the current potassium level from 4. Using an underestimation is a safeguard against the possibility that the plasma potassium inaccurately reflects total body potassium deficits. After the initial dose, the plasma potassium must be re checked to assess therapeutic response.
Only standard adult transthoracic echocardiography services should be provided in the community menopause weight 50mg fertomid otc, therefore the following exclusion criteria applies: Age less than 18 Known complex congenital heart disease A congenital disorder in which cardiac disease may be suspected E women's health volunteer opportunities buy fertomid 50 mg overnight delivery. Down’s syndrome menstruation after tubal ligation buy fertomid 50 mg on line, Noonan’s syndrome women's health boutique torrance buy generic fertomid 50 mg on line, William’s syndrome Finally, the quality of echo report provided is highly dependent on the experience and skill level of the Cardiac Physiologist performing the scan. Call made by: Date of call: Time of call: If the Referrer wishes to discuss the results with the Clinician who completed the report please contact them via the Patient Referral Centre on 0333 202 0300. The thickening and endocardial motion of each segment should be described as normal, hypokinetic, akinetic or dyskinetic Basal Segments Mid-cavity Segments Apical Segments 1. Normal Values for Age Related Diastolic Parameters Measurement 16 – 20 years 21 – 40 years 41 – 60 years > 60 years 1. Mitral Stenosis regurgitation severity with eccentric jets and overestimate severity with central. Aortic Stenosis jets, underestimated due to poor Doppler alignment Measurement Mild Moderate Severe Peak velocity (m/s) < 2. Tricuspid Stenosis Measurement Severe Mean pressure drop (mmHg) ≥ 5 Inflow velocity-time interval (cm) > 60 Valve area (cm)2 < 1. Pulmonary Stenosis Pulmonary Mild Moderate Severe Stenosis Peak velocity (m/s) < 3 3 – 4 > 4 11. When this occurs, state the tricuspid annular diameter in endsystole (> 4 cm significant) and the end-systolic tenting distance (> 0. If alignment of the basal segment and annulus is suboptimal, significantly underestimated values will be obtained. Pulmonary Regurgitation A proportion of athletes will have dilated right hearts due to physiological adaptation. Ultimately pulmonary artery systolic pressure can only be accurately defined by invasive measurements. If any of these measurements are abnormal state pulmonary hypertension cannot be excluded. Hypertension systolic pressure can only be accurately defined by invasive measurements. Write: ‘Suggest Urgent Cardiology Referral’ in Appendix 1: Equality Impact Assessment the Report. If this is not possible, then referral to the Secondary Care Cardiology Department is appropriate. If this is not possible, then referral to the Secondary Care Cardiology Check ventricular septum visually & with colour from all possible views i. With over 25 years’ experience, our fexible and dynamic approach is helping to meet some of health’s most pressing challenges – reducing waiting times, speeding up diagnoses, saving money and improving the overall patient experience. Our ventures team is committed to investing in emerging technologies and services from across the world to improve patient outcomes. The detailed principles of ultrasound are not covered but it is hoped the reader will gain information that will allow better understanding of the reasons for requesting an echo and how the results should be interpreted in a clinical context. Visible im pulse on chestwallfrom vig orouslycontracting ventricle (rare) Anatom y (pleasewaitforvideo to load) Surface Anatom y Valves And Surface Anatom y. L eftVentricle (L V): – V igorof contractility of underlying ventricle – if prom inent,referredto as heave orlift – S iz e of L V. Th rill– rare palpable sensation associated w/regurgitantorstenotic m urm urs (feels like sensation when kink garden hose) P alpation -T echnique. Diaph ragm ÆH igh er pitch ed sounds B ellÆ L ower pitch ed W hatAre W e L istening F or? C h estexposed (m ale)orlooselyfitted g own (fem ale) – need to see area where placing stethescope – stethescope m ustcontactskin. Stethescope w/diaph ragm (hig herpitched sounds)eng ag ed Rem em ber– Don’tE xam ine T hru C lothing! E xam O ptions When Ausculting F em ale P atients Auscultation T echnique (cont) nd 1. M urm urs □ Assess forextra heartsounds (S3,S4)w/belloverL V □ C arotid arterypalpation,auscultation □ J ug ularvenous pressure assessm ent Tim e Target:< 10 m in. Furthermore, it has been Introduction shown that non-cardiologists can safely and accurately use echocardi ography to assess cardiac function. The diameter should be obtained by measuring from inner edge to inner edge at the level of the aortic annulus (attachment of valve leaf lets). Sepsis, hypotension, pancreatitis and Passive Leg Raise many other pathologic states require rapid volume repletion. How ever, overzealous administration of fluid can be detrimental, particu larly in patients with known congestive heart failure. The “eyeball” technique for assessing ejection fraction when this measurement should be made 1cm apically from the septal performed by experienced sonographers is as good as quantita aortic attachment and perpendicular to the long axis of the heart in tive methods. It requires a cardiac package on your ultrasound machine and adequate views of the apical 4 chamber and apical 2 chamber with traced endocardial borders in both systole and dias tole for each. Its specific description is be yond the scope of this book, but more information can be found here. Mitral E point septal separation: a reliable index of left ventricular performance in coro nary artery disease. Quantitative estimation of left ventricular ejection fraction from mitral valve E-point septal separa tion and comparison to magnetic resonance imaging. As this chapter will discuss, how ever, the right ventricle is sensitive to changes in pulmonary and sys temic pressure and volume, which may affect a patient’s hemody namic status and acute management. When the apex is hypertrophied, thick trabeculations may be mistaken for intra-cardiac tumors or thrombus. Three measurements are taken during dias tole; two transverse diameters and one longitudinal (Movie 2. Early freeze the image; calipers are then used to measure the annular dis detection may assist in the diagnosis, as well as monitoring response placement (Movie 2. If available on your machine, the Abnormal appropriate cardiac package should then be opened. In these cases, prior echocardiograms should be reviewed and compared to the cur rent echocardiogram for any changes. B-mode ultra sound and Doppler, however, can be used to non-invasively estimate right heart pressures. Right atrial systolic collapse fusion, as well as assist with ultrasound-guided pericardiocentesis. Right ventricular diastolic collapse Pericardial tamponade is the physiologic state in which increasing c. Over time, this may result in reduced cardiac filling, cardiac output, and hemodynamic collapse. As a result, critical intra-pericardial pres side Ultrasound Volume 1 for additional information. On the other hand, rapidly accumulating effusions are not well tolerated, and small but rapid effusions can acutely result in cardiovascular col lapse. Whether an effusion develops acutely or chronically, there is a critical point where the rising intra-pericardial pressures exceed the pressures within the right side of the heart; this results in a reduction in cardiac filling and subsequently cardiac output. This creates a negative pressure within the right side of the heart, leading to increased venous return and right-sided cardiac filling. Of note, the previous description is the physiologic tamponade (40%), it has good sensitivity (97%). This measurement is some times made with a respirometer to determine the phase of respira tion, although not mandatory. Bedside echocardio phological and functional changes during early septic shock: a graphic evaluation of hemodynamics in sepsis: is a qualitative transesophageal study. Guidelines for the echocardio graphic assessment of the right heart in adults: a report from the 13. American Society of Echocardiography endorsed by the Euro Quantitative assessment of pulmonary hypertension in patients pean Association of Echocardiography, a registered branch of the with tricuspid regurgitation using continuous wave Doppler ultra European Society of Cardiology, and the Canadian Society of sound. Use of transthoracic echo cardiography combined with clinical and electrocardiographic 23. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmo 24.
The above mentioned practical considerations rather than bioelectric ones determined the Einthoven lead system menstruation 8 weeks postpartum order fertomid master card, which is an application of the 10 leads of Waller women's health clinic westmead hospital discount fertomid 50mg visa. The Einthoven triangle is an approximate description of the lead vectors associated with the limb leads womens health 3 day cleanse buy discount fertomid online. One can show that if the position of the right arm women's health clinic in el paso tx purchase fertomid line, left arm, and left leg are at the vertices of an equilateral triangle, having the heart located at its center, then the lead vectors also form an equilateral triangle. A simple model results from assuming that the cardiac sources are represented by a dipole located at the center of a sphere representing the torso, hence at the center of the equilateral triangle. With these assumptions, the voltages measured by the three limb leads are proportional to the projections of the electric heart vector on the sides of the lead vector triangle, as described in Figure 15. The figure is divided into four cases, where both the depolarization and repolarization fronts propagate toward both positive and negative electrodes. In various cases the detected signals have the following polarities: Case A: When the depolarization front propagates toward a positive electrode, it produces a positive signal (see the detailed description below). Case B: When the propagation of activation is away from the positive electrode, the signal has the corresponding negative polarity. Case C: It is easy to understand that when the repolarization front propagates toward a positive electrode, the signal is negative (see the detailed description below). Although it is known that repolarization does not actually propagate, a boundary between repolarized and still active regions can be defined as a function of time. Case D: When the direction of propagation of a repolarization front is away from the positive electrode, a positive signal is produced. The positive polarity of the signal in case A can be confirmed in the following way. First we note that the transmembrane voltage ahead of the wave is negative since this region is still at rest. What is important here is that the orientation of the double layer, given by the negative spatial derivative of Vm, is entirely to the left (which corresponds to the direction of propagation). Because the dipoles are directed toward the positive electrode, the signal is positive. The signal produced by the propagating activation front between a pair of extracellular electrodes. In this case the direction of repolarization allows us to designate in which regions Vm is negative (where repolarization is complete and the membrane is again at rest) and positive (where repolarization has not yet begun, and the membrane is still in the plateau stage). In this highly idealized example, we show repolarization as occurring instantly at the to + interface (repolarization wavefront). But the source associated with this spatial distribution of Vm is still found from Equation 8. Application of that equation shows that the double layer, given by the negative spatial derivative, is zero everywhere except at the repolarization wavefront, where it is oriented to the right (in this case opposite to the direction of repolarization velocity). Since the source dipoles are directed away from the positive electrode, a negative signal will be measured. For the case that activation does not propagate directly toward an electrode, the signal is proportional to the component of the velocity in the direction of the electrode, as shown in Figure 15. This conclusion follows from the association of a double layer with the activation front and application of Equation 11. Note that we are ignoring the possible influence of a changing extent of the wave of activation with a change in direction. Special attention should be given to cases A and D, marked with an asterisk (*), since these reflect the fundamental relationships. As a consequence, activity in one cell is readily propagated to neighboring cells. It is said that the heart behaves as a syncytium; a propagating wave once initiated continues to propagate uniformly into the region that is still at rest. We have quantitatively examined the electrophysiological behavior of a uniform fiber. Now we can apply these results to the heart if we consider it to be composed of uniform fibers. These equivalent fibers are a valid representation because they are consistent with the syncytial nature of the heart. In fact, because the syncytium reflects connectivity in all directions, we may choose the fiber orientation at our convenience (so long as the quantitative values of conductivity assigned to the fibers correspond to those that are actually measured). Much of what we know about the activation sequence in the heart comes from canine studies. The earliest comprehensive study in this area was performed by Scher and Young (1957). More recently, such studies were performed on the human heart, and a seminal paper describing the results was published by Durrer et al. These studies show that activation wavefronts proceed relatively uniformly, from endocardium to epicardium and from apex to base. One way of describing cardiac activation is to plot the sequence of instantaneous depolarization wavefronts. Since these surfaces connect all points in the same temporal phase, the wavefront surfaces are also referred to as isochrones. An evaluation of dipole sources can be achieved by applying generalized Equation 8. If we assume that on one side cells are entirely at rest, while on the other cells are entirely in the plateau phase, then the source is zero everywhere except at the wavefront. Consequently, the wavefront or isochrone not only describes the activation surface but also shows the location of the double layer sources. After the electric activation of the heart has begun at the sinus node, it spreads along the atrial walls. The resultant vector of the atrial electric activity is illustrated with a thick arrow. The projections of this resultant vector on each of the three Einthoven limb leads is positive, and therefore, the measured signals are also positive. The ventricular depolarization starts first from the left side of the interventricular septum, and therefore, the resultant dipole from this septal activation points to the right. In the next phase, depolarization waves occur on both sides of the septum, and their electric forces cancel. However, early apical activation is also occurring, so the resultant vector points to the apex. Because the left ventricular wall is thicker, activation of the left ventricular free wall continues even after depolarization of a large part of the right ventricle. Because there are no compensating electric forces on the right, the resultant vector reaches its maximum in this phase, and it points leftward. The depolarization front continues propagation along the left ventricular wall toward the back. Because its surface area now continuously decreases, the magnitude of the resultant vector also decreases until the whole ventricular muscle is depolarized. Because there is no longer a propagating activation front, there is no signal either. Ventricular repolarization begins from the outer side of the ventricles and the repolarization front "propagates" inward. This seems paradoxical, but even though the epicardium is the last to depolarize, its action potential durations are relatively short, and it is the first to recover. Although recovery of one cell does not propagate to neighboring cells, one notices that recovery generally does move from the epicardium toward the endocardium. The inward spread of the repolarization front generates a signal with the same sign as the outward depolarization front, as pointed out in Figure 15. Because of the diffuse form of the repolarization, the amplitude of the signal is much smaller than that of the depolarization wave and it lasts 396 forrás: BioLabor Biofizikai és Laboratóriumi Szolg. The deflections in this signal are denoted in alphabetic order starting with the letter P, which represents atrial depolarization. But how is one to achieve this in the volume conductor of the size of the human body with electrodes already placed at the extremities? In several articles on the subject, Wilson and colleagues (Wilson, Macleod, and Barker, 1931; Wilson et al. This was formed by connecting a 5 k resistor from each terminal of the limb leads to a common point called the central terminal, as shown in Figure 15. Wilson suggested that unipolar potentials should be measured with respect to this terminal which approximates the potential at infinity.
The main reasons for these good news is a change in nutrition breast cancer 5k chicago best fertomid 50 mg, in par ticular the avoidance of salt for meat and fish preservation women's health garcinia cambogia order 50 mg fertomid with visa, the lowering of salt intake from other sources menstrual 5 days late purchase fertomid australia, and the availability in many countries of fresh fruits and vegetables throughout the year womens health 8 week workout cheap 50 mg fertomid visa. Mortality has been further dercreased by significant advances in the early detection of stomach cancer. Infection with Helicobacter pylori appears to play an important additional aetiological role since it leads to chronic atrophic gastritis with intestinal metaplasia as an important precursor lesion. The stomach is the main gastrointestinal site for lymphomas and most of these are also pathogenetically linked to H. If there is perforation of the visceral peritoneum covering the gastric ligaments or omenta, the tumour is classified as T3. There is about a 20-fold dif frequently has hereditary characteristics, A malignant epithelial tumour of the ference in the incidence rates when com perhaps modulated by environmental stomach mucosa with glandular differen paring the rates in Japan with those of influences {1738, 1633}. Ascorbic acid, Diffuse type 8145/3 been observed worldwide over the past carotenoids, folates and tocopherols are Papillary adenocarcinoma 8260/3 several decades, but the absolute num considered active ingredients. Salt intake Tubular adenocarcinoma 8211/3 ber of new cases per year is increasing strongly associates with the risk of gas Mucinous adenocarcinoma 8480/3 mainly because of the aging of the pop tric carcinoma and its precursor lesions Signet-ring cell carcinoma 8490/3 ulation . The intestinal type Eastern Asia, the Andean regions of rises faster with age than the diffuse Bile reflux South America and Eastern Europe. Low type; it is more frequent in males than in the risk of gastric carcinoma increases rates (< 15/100,000) are found in North females. The higher the replication rate, the Apoptosis Repair Mutation greater the chance that replication errors become fixed and expressed in subse quent cell generations. The latter is better explained by the presence of external or Helicobacter pylori infection cinogenic cascade. Proliferation is the most important development in the frequent cause of chronic gastritis. Ammonia, independent prospective cohort studies dominantly occur in the mucus layer a substance stimulating cell replication, reporting a significantly increased risk in overlying normal gastric epithelium. They is abundantly liberated by the potent ure subjects who 10 or more years before the are absent in areas overlying intestinal ase activity of H. At the patho are exerted from a distance, via soluble with increased production of oxidants logical level, H. The mechanism involves epithe reactive nitrogen species dinitrogen tri sequential steps: chronic gastritis, multi lial production of interleukin 8 via a oxide (N2O3), a potent nitrosating agent focal atrophy, intestinal metaplasia, and nuclear factor KappaB pathway. There is that forms nitrosothiols and nitrosamines intraepithelial neoplasia . Nitrosated compounds are recog and atrophy alter gastric acid secretion, a cag positive H. This increased replica malignancies detected by such screen scopically according to the growth pat tion is balanced by increased cell death. The risk of deep and multifocal pen apoptotic rates in patients infected with mately 50% of all gastric cancers in etration into the submucosa and the risk the virulent cagA vacA s1a H. Infiltration occurs via desquamation in patients Imaging and endoscopy of the gastric wall (linitis plastica) may not infected by toxigenic H. The dants attenuates the degree of apoptosis slight changes in colour, relief, and archi depth of invasion of the tumour is staged and peroxynitrite formation . Radiology with barium meal is still used this process is chronic, the opportunity Even with these procedures, a substan in mass screening protocols in Japan, for random hits to the genome to occur at tial number of early gastric cancers can followed by endoscopy if an abnormality critical sites increases dramatically. For established gas Localization the most frequent site of sub-cardial stomach cancer is the distal stomach, i. Carcinomas in the body or the corpus of the stomach are typically located along the greater or lesser curvature. Clinical features Symptoms and signs Early gastric cancer often causes no symptoms, although up to 50% of A B patients may have nonspecific gastroin Fig. C, D Deep ulcer scar surrounded by superficial early gastric cancer infil and (B) diffusely infiltrative type. Tumour stag (difficult to detect on conventional endo Duodenal invasion occurs more fre ing prior to treatment decision involves scopy, but apparent on dye-staining quently than expected based on gross percutaneous ultrasound or computer endoscopy) or polypoid growth. Therefore, resection mar ized tomography to detect liver metas ances intermediate between them gins should be monitored by intraopera tases and distant lymph node metas include a depressed or reddish or discol tive consultation. The macroscopic type of Intestinal carcinomas preferentially meta only way to exclude peritoneal seeding in early gastric carcinoma is classified using stasize haematogenously to the liver, the absence of ascites. The gross appearance metastasize to peritoneal surfaces {1273, of advanced carcinoma forms the basis 245}. When spread superficially in the mucosa and carcinoma penetrates the serosa, peri submucosa, producing flat, plaque-like toneal implants flourish. Bilateral massive lesions, with or without shallow ulcera ovarian involvement (Krukenberg tumour) tions. With extensive infiltration, a linitis can result from transperitoneal or haema plastica or ‘leather bottle’ stomach results. Tumour spread and staging the accuracy of pathological staging is Gastric carcinomas spread by direct proportional to the number of regional extension, metastasis or peritoneal dis lymph nodes examined and their loca semination. Tumours inva tumour are assessed, many cancers are ding the duodenum are most often of the classified incorrectly. Duodenal invasion may occur gland-forming malignancies composed 42 Tumours of the stomach A B C D E F Fig. Rarely, a micropapillary or they consist of a complex mixture of columnar, cuboidal, or flattened by intra architecture is present. Clear cells may also be cellular atypia and mitotic index vary; morphologies, sometimes in combination present. The with glandular, trabecular or alveolar solid varies from low to high-grade {466, invading tumour edge is usually sharply structures . A poorly differentiated variant is demarcated from surrounding structures; systems have been proposed, including sometimes called solid carcinoma. The Despite their histological variability, usu two major growth patterns are (1) glands ally one of four patterns predominates. Papillary adenocarcinomas lined by a columnar mucous-secreting the diagnosis is based on the predomi these are well-differentiated exophytic epithelium together with interstitial mucin nant histological pattern. There Tubular adenocarcinomas cuboidal cells supported by fibrovascu may also be mucin in the interglandular these contain prominent dilated or slit lar connective tissue cores. Scattered signet-ring cells, when like and branching tubules varying in tend to maintain their polarity. Some present, do not dominate the histological their diameter; acinar structures may be tumours show tubular differentiation picture. Gastric carcinoma 43 other diffuse carcinomas contain cells with central nuclei resembling histiocytes, and show little or no mitotic activity; (3) small, deeply eosinophilic cells with prominent, but minute, cytoplasmic gran ules containing neutral mucin; (4) small cells with little or no mucin, and (5) anaplastic cells with little or no mucin. These cell types intermingle with one A B another and constitute varying tumour proportions. Signet-ring cell carcinomas are infiltra tive; the number of malignant cells is comparatively small and desmoplasia may be prominent. Cyto keratin immunostains detect a greater percentage of neoplastic cells than do nomas is unreliable in tumours containing Superficially, cells lie scattered in the lam mucin stains. The term ‘mucin-produ ina propria, widening the distances signet-ring cell carcinoma including cing’ is not synonymous with mucinous in between the pits and glands. Signet-ring cell carcinomas classical signet ring cell appearance due More than 50% of the tumour consists of to an expanded, globoid, optically clear Laurén classification isolated or small groups of malignant cytoplasm. These contain acid mucin the Laurén classification has cells containing intracytoplasmic mucin. Tumours that contain approximately equal quantities of intestinal and diffuse components are called mixed carcino mas. Carcinomas too undifferentiated to fit neatly into either category are placed in the indeterminate category. A B Intestinal carcinomas these form recognizable glands that range from well differentiated to moder ately differentiated tumours, sometimes with poorly differentiated tumour at the advancing margin. The mucinous phenotype of these can cers is intestinal, gastric and gastro intestinal. D Alcian green positive They consist of poorly cohesive cells dif signet-ring cells expanding the lamina propria in this Movat stain. The cells usually Adenosquamous carcinoma Undifferentiated carcinoma appear round and small, either arranged this lesion combines an adenocarcino these lesions lack any differentiated fea as single cells or clustered in abortive, ma and squamous cell carcinoma; nei tures beyond an epithelial phenotype lacy gland-like or reticular formations.
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